The Clap

Back when I was working for a community based public health agency, we thought we were close to conquering the common sexually transmitted infections -- syphilis, gonorrhea, and chlamydia. We spent a lot of effort on HIV prevention because it's incurable, but the incidence (that means the number of new cases per given time period) was declining, and the other STIs were becoming pretty rare. The public health response to these diseases basically has two components: convince people to use condoms whenever they have risky sex, and detect new cases quickly and treat them.

Well there's bad news, and it isn't getting much attention: the incidence of STIs has exploded in recent years. We've lost all the ground we had gained and then some:

Nearly 2.3 million cases of chlamydia, gonorrhea, and syphilis were diagnosed in the United States in 2017, according to preliminary data released today by the Centers for Disease Control and Prevention (CDC) at the National STD Prevention Conference in Washington, D.C. This surpassed the previous record set in 2016 by more than 200,000 cases and marked the fourth consecutive year of sharp increases in these sexually transmitted diseases (STDs).
The CDC analysis of STD cases reported for 2013 and preliminary data for 2017 shows steep, sustained increases:

• Gonorrhea diagnoses increased 67 percent overall (from 333,004 to 555,608 cases according to preliminary 2017 data) and nearly doubled among men (from 169,130 to 322,169). Increases in diagnoses among women — and the speed with which they are increasing — are also concerning, with cases going up for the third year in a row (from 197,499 to 232,587).
• Primary and secondary syphilis diagnoses increased 76 percent (from 17,375 to 30,644 cases). Gay, bisexual and other men who have sex with men (MSM) made up almost 70 percent of primary and secondary syphilis cases where the gender of the sex partner is known in 2017. Primary and secondary syphilis are the most infectious stages of the disease.
• Chlamydia remained the most common condition reported to CDC. More than 1.7 million cases were diagnosed in 2017, with 45 percent among 15- to 24-year-old females.

So why is this happening? Some reasons are fairly apparent, others more speculative. There has been an increase in risk behavior by gay men, probably because HIV is now less scary since there is effective treatment, and also because of Pre-Exposure Prophylaxis (PrEP), that is antiretrovirals given to HIV negative people to prevent infection. Many of my colleagues are big advocates for PrEP but it does appear it makes some users more willing to have condomless sex which puts them at risk for other STIs. Since some men who have sex with men also have sex with women, that means these infections are going to become more common in both sexes.

Many suspect that hook-up apps are also encouraging more casual sex. This is my own speculation, but the opioid epidemic may also result in more women engaging in risky transactional sex. But as Julia Belluz at Vox notes, STD clinics have seen substantial budget cuts in recent years meaning reduced services. With fewer people diagnosed and treated, the infections continue to spread.

Yeah yeah, people shouldn't do all this nasty stuff. But just spouting moral disapprobation isn't going to accomplish anything. And the best opportunity to engage with people about safer sex is when you diagnose and treat them. That's your teachable moment. If we aren't willing to pay for it, we're going to continue to be less healthy.

Sunday Sermonette: Brotherly love

¹⁹ This is the account of the family line of Abraham’s son Isaac.

Abraham became the father of Isaac, ²⁰ and Isaac was forty years old when he married Rebekah daughter of Bethuel the Aramean from Paddan Aram^[c] and sister of Laban the Aramean.

Just by way of explanation, you may recall the Rebekah was from Nahor. Apparently Paddam Aram is a broader, regional designation.

²¹ Isaac prayed to the Lord on behalf of his wife, because she was childless. The Lord answered his prayer, and his wife Rebekah became pregnant. ²² The babies jostled each other within her, and she said, “Why is this happening to me?” So she went to inquire of the Lord.
²³ The Lord said to her,

“Two nations are in your womb,
    and two peoples from within you will be separated;
one people will be stronger than the other,
    and the older will serve the younger.”

²⁴ When the time came for her to give birth, there were twin boys in her womb. ²⁵ The first to come out was red, and his whole body was like a hairy garment; so they named him Esau.^{[d] 26} After this, his brother came out, with his hand grasping Esau’s heel; so he was named Jacob.^[e] Isaac was sixty years old when Rebekah gave birth to them.

²⁷ The boys grew up, and Esau became a skillful hunter, a man of the open country, while Jacob was content to stay at home among the tents. ²⁸ Isaac, who had a taste for wild game, loved Esau, but Rebekah loved Jacob.

Which of your children do you love?

²⁹ Once when Jacob was cooking some stew, Esau came in from the open country, famished. ³⁰ He said to Jacob, “Quick, let me have some of that red stew! I’m famished!” (That is why he was also called Edom.^[f])
³¹ Jacob replied, “First sell me your birthright.”
³² “Look, I am about to die,” Esau said. “What good is the birthright to me?”
³³ But Jacob said, “Swear to me first.” So he swore an oath to him, selling his birthright to Jacob.
³⁴ Then Jacob gave Esau some bread and some lentil stew. He ate and drank, and then got up and left.
So Esau despised his birthright.

1. Genesis 25:25 Esau may mean hairy.
2. Genesis 25:26 Jacob means he grasps the heel, a Hebrew idiom for he deceives.
3. Genesis 25:30 Edom means red.

 Now, there are a lot of people out there who claim to "live biblically," and to take the Bible as their guide to morality. If this story makes any sense at all, Esau must have been on the brink of starving to death. But Jacob wouldn't give his own brother a piece of bread and some lentil stew without screwing him out of his entire inheritance. I also have to say that the food shortage evidently didn't last much longer since Esau survives without any further handout.  Anyway, that's the way to live biblically -- extort everything you can from your siblings.

Too long, do read

Nils Gilman in The American Interest discusses the hollowing out of the "social modernist" state by what he calls the "twin insurgencies" of plutocracy and organized crime. It's a long essay that I won't try to fully summarize -- it will reward your patient reading.

I think he implies a false equivalence between the two insurgencies. The plutocracy is a far more important phenomenon, which really drives and enables the epidemic of financial crime, cybercrime, drug and human trafficking. But the basic notion that a class of plutocrats has arisen that sees itself as having no obligation to the population on which it leeches is certainly correct.

In the postwar era, until around the early 1970s,  the wealthy paid taxes to finance the basic infrastructure of society, that made life tolerable for the working and professional classes -- roads, schools, some modicum of retirement security. He doesn't mention amenities such as parks and public art and community centers and so on, but those were also important. Economic inequality declined, and people expected to have a better life than their parents.

By the 1980s, the trajectory changed. He doesn't really offer a single money quote, but I will give you this:

Cremated along with the corpse of Communism was the civic-minded conception of development as the central responsibility of the state and allied elites—a conception shared by communists and liberals alike during the Cold War. It wasn’t just that the state “retreated” from the “commanding heights” of the economy, to use Daniel Yergin’s terms, but also that the very ambition of the state receded. Many states stopped even pretending they wanted to create a more egalitarian society and instead sought to legitimate themselves by claiming they were maximizing individual opportunity. For proponents of this perspective, the rise of new plutocrats counted not as a defeat, but as a success for the new model of governance. . . .

This transformation of the role of the state in the wake of the Cold War has dramatically increased the precariousness of the lives of the middle classes within most societies. On a material level, it has generated unprecedented new forms of insecurity. From above, middle classes find themselves threatened by a global financial elite, in league with ultra-wealthy compradors, both of whom seek to cut social services and the taxes that pay for them—taxes that these elites depict as a form of illegitimate expropriation. From below, the middle classes find themselves exposed to a new resurgence of criminality, which has discovered in their plight a business opportunity.

This of course, is not sustainable. Socialism had little appeal in the post-war social modernist state, but it is making a comeback. Manipulating racial resentment will only keep the plutocracy entrenched for so long. Eventually, people will  demand that the state again serve their interests.

As Michael Tomasky puts it, What are capitalists thinking?He tells essentially the same story, more succinctly.

Every once in a while in history, cause and effect smack us in the face. The conditions under which the czars forced Russians to live gave rise to Bolshevism. The terms imposed at Versailles fueled Hitler’s ascent. The failures of Keynesianism in the 1970s smoothed the path for supply-side economics. And so it is here. . . .

End-of-life care and spending

I think I last addressed this issue quite a few years back. Ashish Jha in JAMA provides an opportunity to return to it.

'Tis oft observed that about 1/4 of all medicare spending is on people in the last year of life. Many people argue that much of this spending must be wasteful. The alternative fact, which is the true one, is that it's much more difficult to reduce spending in the last year of life than you might think.

The main difficulty is that contrary to the magical powers often ascribed to physicians, predicting life expectancy is very difficult. The obvious reason why so much is spent on the last year of life is that most health care spending is on people who are sick, and people who are very sick, and therefore in many cases very expensive, are likely to die within a year. But some of them don't -- because we spent all that money on them.

In fact, Jha demonstrates a seeming paradox. In a place where out of 200 sick people, 100 die in a year, and average spending per person is $10,000. Well, if you look at the 100 who died, their average spending was $10,000. But you have ignored the 100 who lived. Now go to another place where average spending on a similarly sick 200 people is $5,000, and 150 of them die. Now we will say that average end-of-life spending is only $5,000, and isn't that better? Not if you care about the extra 50 dead people.

So the right way to think about this is matching the care to what people want, and is best for them. Certainly people who have poor quality of life may not want to be hospitalized, and by not hospitalizing them we might save some money. They would also be more likely to die, but that's their choice. It used to be that people with end-stage dementia who couldn't eat would get feeding tubes; that's happening much less nowadays. So we might end up saving a little money by doing more of what's right for people, but don't count on it being very much.

It's still going to be expensive to treat cancer and do heart transplants, and some people will die within a year anyway. But some of them won't. Most of the reason health care in the U.S. is so expensive is actually because the price is high. Drugs are more expensive, and providers make more money. There's waste to be squeezed out for sure, but the waste isn't mostly with people who are very sick. They really do need expensive medical care.

Sunday Sermonette: censorship

Before we get on with today's lesson, here's a contemporary story. Valerie Tarico wrote a story for the on-line magazine Salon about how much of the Bible is poorly written. I actually did not know about this until after last Sunday's post, in which I made the same observation. She notes the innumerable contradictions, multiple versions of the same story, weird digressions, non-sequiturs, extremely turgid passages juxtaposed with baffling elision, incomprehensibility. . . .

Well, outraged Christians objected and Salon immediately retracted the story. Took it down. Unfortunately it's behind a paywall, but  Free Inquiry has now published an expanded version, augmented by consultation with biblical scholars. I can recommend FI, if you're interested in buying a magazine subscription.

Anyway, on with the show. Here's the beginning of Genesis 25.

 Abraham had taken another wife, whose name was Keturah. ² She bore him Zimran, Jokshan, Medan, Midian, Ishbak and Shuah. ³ Jokshan was the father of Sheba and Dedan; the descendants of Dedan were the Ashurites, the Letushites and the Leummites. ⁴ The sons of Midian were Ephah, Epher, Hanok, Abida and Eldaah. All these were descendants of Keturah.
⁵ Abraham left everything he owned to Isaac. ⁶ But while he was still living, he gave gifts to the sons of his concubines and sent them away from his son Isaac to the land of the east.
⁷ Abraham lived a hundred and seventy-five years. ⁸ Then Abraham breathed his last and died at a good old age, an old man and full of years; and he was gathered to his people. ⁹ His sons Isaac and Ishmael buried him in the cave of Machpelah near Mamre, in the field of Ephron son of Zohar the Hittite, ¹⁰ the field Abraham had bought from the Hittites. There Abraham was buried with his wife Sarah. ¹¹ After Abraham’s death, God blessed his son Isaac, who then lived near Beer Lahai Roi.

In the first place, it seemed in Genesis 24 that old Abe was on his last legs and about to cash in his chips, but no, he's got the energy for another wife (maybe, hold that thought) and an unknown number of concubines. In case you're wondering, a concubine is a sex slave.  Anyway, what's the deal with Keturah. She's supposedly his wife, and has six sons, but they don't count. Isaac gets everything. Later, in Chronicles, Keturah is referred to as Abraham's concubine, which would  make sense of this.

I must also say it was mighty sporting of Ishmael to show up for the funeral, since Abraham had cast him out into the desert to die with his mother. Twice. And he gets no inheritance. But we are treated to his begats:

¹² This is the account of the family line of Abraham’s son Ishmael, whom Sarah’s slave, Hagar the Egyptian, bore to Abraham.
¹³ These are the names of the sons of Ishmael, listed in the order of their birth: Nebaioth the firstborn of Ishmael, Kedar, Adbeel, Mibsam, ¹⁴ Mishma, Dumah, Massa, ¹⁵ Hadad, Tema, Jetur, Naphish and Kedemah. ¹⁶ These were the sons of Ishmael, and these are the names of the twelve tribal rulers according to their settlements and camps. ¹⁷ Ishmael lived a hundred and thirty-seven years. He breathed his last and died, and he was gathered to his people. ¹⁸ His descendants settled in the area from Havilah to Shur, near the eastern border of Egypt, as you go toward Ashur. And they lived in hostility toward^[b] all the tribes related to them.

Why are we supposed to care about all this? None of these people or tribes ever show up again. The bit about "hostility" may be a mistranslation. One would hope so.

Anyway, the rest of this chapter is a bit more interesting. We'll get to it next week.

More on overdiagnosis

Kale and Korenstein in BMJ give a good overview of the subject. There is a cognitive bias, not just in medicine but in people in general, I think, in favor of "doing something." We like to feel as though we're in control. We don't want to get cancer, or diabetes, or heart disease, so if we think there might be something we can do to improve our odds, we're likely to go for it.

Often, however, we can do more harm than good by our actions. But other cognitive biases make that hard to notice. Obviously, if we don't get cancer, we won't know that we wouldn't have gotten it anyway. We're likely to believe that the prostatectomy or whatever we went through saved our life because we don't like to think that all the suffering and damage we endured was unnecessary and that we made a mistake.

Another source of bias that promotes overdiagnosis is that doctors and drug companies and device manufacturers are paid for their services and goods. So naturally they tend to think that intervening is a good idea, and they'll advocate for it in general and do it for individual patients when they are parties to the decision.

K&K make a few recommendations to reduce overdiagnosis but the first issue they consider is the present topic of controversy, broadening of disease definitions. As I have tried patiently to explain, diseases are not generally entities "out there" in the world like apricots and camels that we just have to name. Rather, people decide that a test result above some threshold or a set of clinical observations qualifies you for a disease label. There are pressures to set those thresholds lower than cost-benefit analysis justifies. These thresholds are human constructions, decisions that people have made -- rather like the issue of brain death that we recently discussed. And those decisions can be changed.

And then, maybe, you don't have the disease after all. And nobody is lying to you. And you ought to be relieved.

Critical Thinking

It seems that some people don't understand the nature and purpose of diagnostic labels. While it is essentially unambiguous that you have, say, a compound fracture of the femur or infection with pathogenic E. coli, many diagnostic labels are a matter of judgment. They do not correspond to definite entities, but rather have a pragmatic function.

Think of the decision by the International Astronomical Union to declare that Pluto is not a planet. There was an outcry, I imagine because people had been taught about the nine planets in school (and there's even a symphony!) and being told that there are only 8 is very discomfiting. But the point is that there are millions of objects in the solar system. People started calling certain objects planets before they knew anything about them, in fact when people thought the whole universe revolves around the earth. The "planets" were stars that appeared to move against the background of the other stars. The name means "wanderer." But only five of them were visible. Once people started looking with telescopes they found Uranus, Neptune and eventually Pluto, then they figured out that earth was the same kind of thing and earth became a planet.

But what about smaller objects? It didn't seem like a big problem because there was such a huge gap between the biggest asteroids and Pluto. But then astronomers realized that there are many objects beyond the orbit of Pluto that are similar to it, and just as big or bigger. They are all mostly ice, unlike the other planets that are either rocky or presumably have rocky cores. (We don't know for sure what's inside the gas giants, but the leading theories of solar system formation presume solid centers.) Also, Pluto is too small to have cleared all the other junk from its orbit. So they decided to change the definition of "planet" to simplify matters. Nothing about Pluto has changed, they just moved the boundaries of the definition of a planet.

It's the same way with many medical diagnoses. In psychiatry this is most apparent, since for psychiatric disorders there aren't any objectively definable physical parameters. So you get lists of symptoms, all of which are established by subjective judgment, and if the person has three from column A and two from column B they get the label. But it's also true for, say, hypertension or diabetes. The definition of hypertension has changed over the years as evidence about levels of blood pressure that are associated with risk has changed. It used to be that 140/90 was considered the threshold, but now doctors want to get it down to 120.

Cancer is kind of like the planets. Before we had microscopes and X-ray machines and DNA tests, cancer was a bunch of  lumps that started growing in or on people. Then it became possible to detect tiny lumps that could not be seen or felt, and to look at cells under the microscope and see that they were abnormal. Physicians started calling these entities "cancer" because they presumed they would develop into malignancy in time. But then they figured out that isn't necessarily true, and we have proposals to stop calling some of these phenomena cancer. Like Pluto, they haven't changed, but our understanding of them has.

So suggesting that physicians not tell patients that certain abnormal cells are cancer is not telling physicians to lie to people. On the contrary, it's finding a way of getting closer to the truth. Science, including medical science, is not static. When ideas change, it doesn't invalidate science. It means we're making progress, that we know more now than we once did. That's a good thing, as Martha Stewart says.

Much ado about nothing

The latest obsession of the corporate media is the "alleged" existence of recordings in which Ronald T. Dump makes vile and repulsive comments. Who the hell cares?

He has made innumerable vile and repulsive comments in public. I'm quite sure he does in private as well. We already know everything about him we need to know, or care to know. He's a disgusting pig.

What's in a name?

From time to time I have commented on the controversies over cancer screening. Most people assume that screening is an unqualified good, that early detection of cancer saves lives. Whenever some panel proposes recommending less screening, we hear screaming and yelling from advocates who claim they are trying to "ration" health care to save money at the expense of people's lives.

In fact, as a bunch of Australians and a Minnesotan explain in BMJ, there are a few conditions called "cancer" that you are better off not treating, or perhaps treating very conservatively. These include what is called ductal carcinoma in situ (DCIS), which is very commonly found by mammography, whereupon women are told they have breast cancer. Another such condition is low risk localized prostate cancer. A huge problem has emerged as doctors have started screening for thyroid cancer and thousands of people are having their thyroids removed, but mortality from thyroid cancer has not decreased. It turns out that most people are found to have "thyroid cancer" on autopsy, which never caused them any trouble, just as most men are found to have "prostate cancer."

In the case of DCIS, it is possible to remove the lesion (called "lumpectomy") which doesn't cause much harm. However, many women opt for more radical treatment, sometimes including total mastectomy and often radiation and chemotherapy, with the attendant side effects. Men who have their prostates removed may end up with erectile dysfunction and incontinence. Thyroid removal can cause collateral damage, and results in the need for lifelong hormone replacement therapy.

It's difficult to persuade patients that they can just watch it and do nothing. They'll most likely be just fine, they'll avoid the pain, financial cost, and adverse effects of treatment. We'll keep an eye on it and if it looks like it's growing, then we can act. But if you've just told people they have cancer, they aren't going to hear that message. Cancer is deadly, cancer is scary. Of course, doctors make their money by doing surgery, chemotherapy and radiation so they aren't really hearing this message either in many cases.

But there's a solution. Don't call it cancer. Words can make reality. Tell people there are abnormal cells, or a lesion. This type of abnormal cell seldom causes any problem, but just in case we'll check on it every six months or so. There will be disputes about the ethically appropriate discussion to have. Many will argue that patients should be offered the option of treatment; some will perhaps feel more anxious with no treatment. But that's a function of our starting point. Since we call this cancer now and typically treat it, people will worry if we don't. As the linked essay says, it will take considerable effort and community engagement to process such a change in the culture of medicine and achieve general acceptance. But it will save a lot of suffering, not to mention money, if we make the effort.

Sunday Sermonette: Get me rewrite!

If the Bible is indeed the divinely inspired word of God, the deity is seriously deficient in literary talent. We have seen how he can't seem to keep his stories straight, he keeps mentioning characters who are irrelevant to the plot, for no apparent reason, it's often difficult to figure out what he really means. Also, there is a weird tendency to give not enough information sometimes, and to be repetitive and turgid at others. Genesis 24 is in the latter category. In the second half, the unnamed slave tells the story of the first half all over again.

²⁶ Then the man bowed down and worshiped the Lord, ²⁷ saying, “Praise be to the Lord, the God of my master Abraham, who has not abandoned his kindness and faithfulness to my master. As for me, the Lord has led me on the journey to the house of my master’s relatives.”
²⁸ The young woman ran and told her mother’s household about these things. ²⁹ Now Rebekah had a brother named Laban, and he hurried out to the man at the spring. ³⁰ As soon as he had seen the nose ring, and the bracelets on his sister’s arms, and had heard Rebekah tell what the man said to her, he went out to the man and found him standing by the camels near the spring. ³¹ “Come, you who are blessed by the Lord,” he said. “Why are you standing out here? I have prepared the house and a place for the camels.”
³² So the man went to the house, and the camels were unloaded. Straw and fodder were brought for the camels, and water for him and his men to wash their feet. ³³ Then food was set before him, but he said, “I will not eat until I have told you what I have to say.”
“Then tell us,” Laban said.
³⁴ So he said, “I am Abraham’s servant. ³⁵ The Lord has blessed my master abundantly, and he has become wealthy. He has given him sheep and cattle, silver and gold, male and female servants, and camels and donkeys. ³⁶ My master’s wife Sarah has borne him a son in her old age, and he has given him everything he owns. ³⁷ And my master made me swear an oath, and said, ‘You must not get a wife for my son from the daughters of the Canaanites, in whose land I live, ³⁸ but go to my father’s family and to my own clan, and get a wife for my son.’
³⁹ “Then I asked my master, ‘What if the woman will not come back with me?’
⁴⁰ “He replied, ‘The Lord, before whom I have walked faithfully, will send his angel with you and make your journey a success, so that you can get a wife for my son from my own clan and from my father’s family. ⁴¹ You will be released from my oath if, when you go to my clan, they refuse to give her to you—then you will be released from my oath.’
⁴² “When I came to the spring today, I said, ‘Lord, God of my master Abraham, if you will, please grant success to the journey on which I have come. ⁴³ See, I am standing beside this spring. If a young woman comes out to draw water and I say to her, “Please let me drink a little water from your jar,” ⁴⁴ and if she says to me, “Drink, and I’ll draw water for your camels too,” let her be the one the Lord has chosen for my master’s son.’
⁴⁵ “Before I finished praying in my heart, Rebekah came out, with her jar on her shoulder. She went down to the spring and drew water, and I said to her, ‘Please give me a drink.’
⁴⁶ “She quickly lowered her jar from her shoulder and said, ‘Drink, and I’ll water your camels too.’ So I drank, and she watered the camels also.
⁴⁷ “I asked her, ‘Whose daughter are you?’
“She said, ‘The daughter of Bethuel son of Nahor, whom Milkah bore to him.’
“Then I put the ring in her nose and the bracelets on her arms, ⁴⁸ and I bowed down and worshiped the Lord. I praised the Lord, the God of my master Abraham, who had led me on the right road to get the granddaughter of my master’s brother for his son. ⁴⁹ Now if you will show kindness and faithfulness to my master, tell me; and if not, tell me, so I may know which way to turn.”

 So okay, we got that. Why not just say the man recounted for the family all that had occurred?

⁵⁰ Laban and Bethuel answered, “This is from the Lord; we can say nothing to you one way or the other. ⁵¹ Here is Rebekah; take her and go, and let her become the wife of your master’s son, as the Lord has directed.”

So Rebekah doesn't have any choice in the matter.

⁵² When Abraham’s servant heard what they said, he bowed down to the ground before the Lord. ⁵³ Then the servant brought out gold and silver jewelry and articles of clothing and gave them to Rebekah; he also gave costly gifts to her brother and to her mother. ⁵⁴ Then he and the men who were with him ate and drank and spent the night there.
When they got up the next morning, he said, “Send me on my way to my master.”
⁵⁵ But her brother and her mother replied, “Let the young woman remain with us ten days or so; then you may go.”
⁵⁶ But he said to them, “Do not detain me, now that the Lord has granted success to my journey. Send me on my way so I may go to my master.”
⁵⁷ Then they said, “Let’s call the young woman and ask her about it.” ⁵⁸ So they called Rebekah and asked her, “Will you go with this man?”
“I will go,” she said.
⁵⁹ So they sent their sister Rebekah on her way, along with her nurse and Abraham’s servant and his men. ⁶⁰ And they blessed Rebekah and said to her,

“Our sister, may you increase
    to thousands upon thousands;
may your offspring possess
    the cities of their enemies.”

As usual, the NIV cleans things up a bit. King James has:

And they blessed Rebekah, and said unto her, Thou art our sister, be thou the mother of thousands of millions, and let thy seed possess the gate of those which hate them.

As usual, we get a prophecy of vast multitudes (billions in this case) of Jews. The Jews of course have never become very numerous. 

⁶¹ Then Rebekah and her attendants got ready and mounted the camels and went back with the man. So the servant took Rebekah and left.

⁶² Now Isaac had come from Beer Lahai Roi, for he was living in the Negev. ⁶³ He went out to the field one evening to meditate, and as he looked up, he saw camels approaching. ⁶⁴ Rebekah also looked up and saw Isaac. She got down from her camel ⁶⁵ and asked the servant, “Who is that man in the field coming to meet us?”
“He is my master,” the servant answered. So she took her veil and covered herself.
⁶⁶ Then the servant told Isaac all he had done. ⁶⁷ Isaac brought her into the tent of his mother Sarah, and he married Rebekah. So she became his wife, and he loved her; and Isaac was comforted after his mother’s death.

 Again, King James has " And Isaac brought her into his mother Sarah's tent, and took Rebekah, and she became his wife; and he loved her: and Isaac was comforted after his mother's death." No marriage ceremony, no vows, Isaac just boinks her and that's that. Rather creepy that he did it in his dead mother's tent. Why is it still there after two years? Anyway, we finally got all that out of the way.

It's appalling that this was even necessary

Some police-affiliated docs discuss what to do if a wackjob with a gun attacks your hospital.

Defining [active shooter] incidents as situations in which “an individual [is] actively engaged in killing or attempting to kill people in a confined and populated area,” the Federal Bureau of Investigation (FBI) has identified 160 discrete incidents that occurred between 2000 and 2013, in which 486 people were killed and an additional 557 were wounded.⁶ In the first half of that period, there were an average of 6.4 active-shooter incidents per year; the number more than doubled, to 16.4, in the latter half of the period. The most recently released FBI data reveal that the rate increased to 20 incidents per year in 2014 and 2015.

It turns out that hospitals are a fairly popular place for this to happen. And people can't just run and hide. At any given time, some people are in surgery, others are unable to get out of bed and are even tethered to machines. And their caregivers can't flee and abandon them.

These authors suggest that hospitals should at least consider restricting access, making visitors pass through metal detectors and X-ray screening, and limiting them to specific areas with color-coded wrist bands. Few hospitals do that now, I'm happy to say, and I think it would be an overreaction. These incidents aren't exactly rare -- 154 in ten years according to one cited study -- but there are about 5,500 hospitals in the U.S. so your individual risk is low. Somebody who wants to shoot one up isn't going to worry about the metal detector, it seems to me.

But their other recommendations are almost as disconcerting. They want areas within the hospital where there are patients who cannot flee to be secured with automatic barriers. "Most shooters will not be equipped with the breaching equipment, such as a battering ram or explosives, that can overcome secured entryways, and they will most likely simply move on from barricaded areas." That's comforting.

Kits containing essential supplies for hemorrhage control, including tourniquets, gauze, and gloves, should be located inside all these areas. Arguably, these kits would also be installed in all public-access areas, just as automated external defibrillators have been. Efforts should be made to train all hospital workers, whatever their area of expertise, in basic bleeding-control techniques.

And, "Facilities also need a notification system that will allow personnel at the point of initial contact to trigger an alert that is immediately disseminated to the entire facility." There's more -- pre-planning with the police, psychological first aid, on and on.

This is just incredibly sad. Do we really have to turn hospitals into fortresses because there are so many lunatics running around with guns? Yes, they have to do that in Syria, Yemen and Afghanistan -- war zones. But otherwise, only in America. Maybe the leaders of the NRA will slither back under the rocks they came from.

duh Sawx

I lived in Boston for 20 years, and was inevitably infected with Red Sox fandom. As most people know, the Red Sox were a perennially strong team during the early years of the American League, but in 1918, after winning the World Serious, owner Harry Frazee sold the services of Babe Ruth to the New York Yankees in order to get money to invest in the musical No, No, Nanette (featuring the well-known standard Tea for Two), as a result of which the team was cursed for the remainder of the 20th Century.

When I got to Boston the curse was still in effect, but in 2004, shortly after John Henry purchased the team and installed Theo Epstein as General Manager, the Sox made the playoffs but found themselves down 3 games to none against the Yankees in the ALCS, and down 4-3 in the ninth inning in game 4 against the Yankees indefatigable closer Mariano Rivera. The leadoff batter walked, he was replaced by pinch runner Dave Roberts who stole second, and scored on a single by Bill Mueller, and won the game in the 12 inning on a home run by David Ortiz. They came back to win the series and then swept the World Series against the Cardinals.

They have won two world championships since then, so the curse is clearly broken. But they have been utterly awful in between, until winning division championships in the past two years, although they bombed in the playoffs. This year, however, they are having one of the best regular seasons in major league history. They have the two best hitters in the league, the best starting rotation, the best defense  --  a lot of super athletic, multi-skilled players. Their best athlete is probably center fielder Jackie Bradley Jr., who is a very streaky hitter but seems to save a run per game with his glove and arm and is lightning fast on the bases. Right now his streak status is hot so for now, at least, he's the best baseball player in the world. When he's cold at the plate, right fielder Mookie Betts is the best baseball player in the world, and DH J.D. Martinez is vying with Betts for best bat. Everybody seems to come through in the clutch and they jump on every mistake by an opponent.

Of course, none of this matters if they fail in the playoffs.

Since I am required to make a profound philosophical observation in every blog post, the question of course is why we get so emotionally involved in the fate of a sports team. None of the individuals who was involved in the team when I got to Boston, or even in 2004, is still there. (TV color man Jerry Remy is arguably an exception. I will refrain from further discussion of Remy at the moment. He's had a recurrence of lung cancer and is on leave.) I don't even live in Boston any more. But even when I did, why did I care who won a baseball game? You know what, I'm not really sure. This is just something we take for granted.

One step forward and two steps back

I spent 15 years as the Research Director for a community-based public health agency in Massachusetts. We offered substance abuse treatment and mental health services for people at risk for HIV; broader community-based HIV prevention and counseling and testing; housing services for people with HIV; and clinical case management. All of that is about saving the lives of individuals, and also preventing HIV transmission and protecting public health. In principle, if we do all that well and work at it hard enough, we can stop the epidemic.

We were making progress. The number of new infections kept declining. The prevalence of HIV among injection drug users fell substantially, to the point where a symposium I attended a couple of years ago featured arguments that HIV transmission among injection drug users in Massachusetts was no longer a significant problem.

No longer is this true. As the linked article in the Puffington Host informs us, the presenters at the symposium might have been a bit too complacent but they weren't crazy: from 2012 to 2014, an average of just 41 cases of HIV linked to injection drug use were diagnosed per year in the entire state of Massachusetts. And now? That many cases in two cities alone, Lowell (where we had an office) and nearby Lawrence (where we did extensive outreach). 

The proximate cause is of course the opioid epidemic, and particularly fentanyl, which is shorter acting than heroin, therefore injected more frequently, thereby increasing the risk of needle sharing. 
Contributing is an epidemic of homelessness, which means that treatment is interrupted. (People who are successfully treated for HIV are not infectious). Also, complacency by providers who, perhaps having attended the symposium, stopped routinely testing injection drug users for HIV. Neither city had a formal needle exchange program prior to the outbreak.

This is really depressing. I spent nearly half of my working life trying to put an end to this, and here it comes again. Just like a lot of other bad shit we thought we'd left behind.

Sunday Sermonette: A fairy tale

Genesis 24 is another long, and very weird chapter. Here beginneth the weird longness:

Abraham was now very old, and the Lord had blessed him in every way. ² He said to the senior servant in his household, the one in charge of all that he had, “Put your hand under my thigh. ³ I want you to swear by the Lord, the God of heaven and the God of earth, that you will not get a wife for my son from the daughters of the Canaanites, among whom I am living, ⁴ but will go to my country and my own relatives and get a wife for my son Isaac.”

In case you were wondering, "Put your hand other my thigh" is a euphemism for "grab my nuts." Apparently this was the equivalent of pinky swearing. Why doesn't Abraham want Isaac to marry a Canaanite? Who knows?

⁵ The servant asked him, “What if the woman is unwilling to come back with me to this land? Shall I then take your son back to the country you came from?”
⁶ “Make sure that you do not take my son back there,” Abraham said. ⁷ “The Lord, the God of heaven, who brought me out of my father’s household and my native land and who spoke to me and promised me on oath, saying, ‘To your offspring I will give this land’—he will send his angel before you so that you can get a wife for my son from there. ⁸ If the woman is unwilling to come back with you, then you will be released from this oath of mine. Only do not take my son back there.” ⁹ So the servant put his hand under the thigh of his master Abraham and swore an oath to him concerning this matter.

Note the logic of this: it is somehow pre-determined that there is one specific woman in question here. 

¹⁰ Then the servant left, taking with him ten of his master’s camels loaded with all kinds of good things from his master. He set out for Aram Naharaim and made his way to the town of Nahor. ¹¹ He had the camels kneel down near the well outside the town; it was toward evening, the time the women go out to draw water.

Ha ha! Camels were not domesticated in the Levant until a milennium after these events supposedly happened. "Camels are mentioned as pack animals in the biblical stories of Abraham, Joseph, and Jacob. But archaeologists have shown that camels were not domesticated in the Land of Israel until centuries after the Age of the Patriarchs (2000-1500 BCE). In addition to challenging the Bible's historicity, this anachronism is direct proof that the text was compiled well after the events it describes." Note that Nahor is Abraham's brother, after whom the town is presumably named.

¹² Then he prayed, “Lord, God of my master Abraham, make me successful today, and show kindness to my master Abraham. ¹³ See, I am standing beside this spring, and the daughters of the townspeople are coming out to draw water. ¹⁴ May it be that when I say to a young woman, ‘Please let down your jar that I may have a drink,’ and she says, ‘Drink, and I’ll water your camels too’—let her be the one you have chosen for your servant Isaac. By this I will know that you have shown kindness to my master.”
¹⁵ Before he had finished praying, Rebekah came out with her jar on her shoulder. She was the daughter of Bethuel son of Milkah, who was the wife of Abraham’s brother Nahor. ¹⁶ The woman was very beautiful, a virgin; no man had ever slept with her. She went down to the spring, filled her jar and came up again.

So Abraham's (nameless) head slave tells God to set up a ritual from a bad spy novel, and God goes along with the gag. Why all this rigamarole? In order for it to work, the slave has to pick her out in the first place, BTW. Note that she is Isaac's cousin, so the incest continues. How does the slave know that she is a virgin?

¹⁷ The servant hurried to meet her and said, “Please give me a little water from your jar.”
¹⁸ “Drink, my lord,” she said, and quickly lowered the jar to her hands and gave him a drink.
¹⁹ After she had given him a drink, she said, “I’ll draw water for your camels too, until they have had enough to drink.” ²⁰ So she quickly emptied her jar into the trough, ran back to the well to draw more water, and drew enough for all his camels. ²¹ Without saying a word, the man watched her closely to learn whether or not the Lord had made his journey successful.
²² When the camels had finished drinking, the man took out a gold nose ring weighing a beka and two gold bracelets weighing ten shekels.²³ Then he asked, “Whose daughter are you? Please tell me, is there room in your father’s house for us to spend the night?”
²⁴ She answered him, “I am the daughter of Bethuel, the son that Milkah bore to Nahor.” ²⁵ And she added, “We have plenty of straw and fodder, as well as room for you to spend the night.”

No big surprise that she's hospitable -- the man has just given her more than 4 ounces of gold. We'll finish this up next time.

Is this really true?

This Washington Post-ABC News poll is actually good news. Restores my faith in humanity, it does.

On the "generic ballot" question, white women with a college degree support Democrats by a net 50 points. Fewer than 25% pick Republican:





White men without a degree are still drinking the Trumpian Kool Aid, but as Kevin Drum notes at the linked post, maybe reality will sink in for them at some point. Yeah, Trump is racist, which is what they like about him, but there's no wall, NAFTA is still in effect, their pay still hasn't gone up, and Uncle Vlad has him by the nads.

In fact, the cognitive dissonance required to continue to worship the Orange Deity is such that many of the cultists have embraced a batshit crazy conspiracy theory that explains why he only appears to be a feckless idiot and a stooge.

Despair not, fellow citizens, time is on our side.

Update: For those who may be under the misapprehension that Cheeto Benito has actually delivered for his supporters, I refer you to a couple of actually smart people.

Nomi Prins, at TomDispatch. From her introduction:

According to the Merriam-Webster dictionary, entropy is “a process of degradation or running down or a trend to disorder.” With that in mind, perhaps the best way to predict President Trump’s next action is just to focus on the path of greatest entropy and take it from there. Let me do just that, while exploring five key economic sallies of the Trump White House since he took office and the bleakness and chaos that may lie ahead as the damage to the economy and our financial future comes into greater focus.

The great Krugthulu:

Message to those in the news media who keep calling Donald Trump a “populist”: I do not think that word means what you think it means. It’s true that Trump still, on occasion, poses as someone who champions the interests of ordinary working Americans against those of the elite. And I guess there’s a sense in which his embrace of white nationalism gives voice to ordinary Americans who share his racism but have felt unable to air their prejudice in public. But he’s been in office for a year and a half, time enough to be judged on what he does, not what he says. And his administration has been relentlessly anti-worker on every front. Trump is about as populist as he is godly — that is, not at all.

You have to read the whole essays, of course. That requires a bit of an attention span.

The singularity

No doubt you have heard about the prediction of mad genius Ray Kurzweil of the singularity, when machines will be smarter than people and we'll connect our brains to the cloud.

Well, that probably won't happen, for better or for worse. However, our unquestioning love of technological advances is a serious blind spot. It's trivially obvious that there are downsides to nuclear weapons, internal combustion engines, and hydrogenated vegetable oil, to name a few. And it ought to be just as obvious that if firearms were still muzzle-loading muskets we'd have less of an argument about them and a lot less to fear.

But I haven't heard very many people worrying about a disastrous technological singularity. As a thought experiment, what if teleportation became possible? It seems to me it would be the end of civilization, possibly of humanity. Door locks would become irrelevant. Anybody could remove any object or person from any place. You could knock down skyscrapers by teleporting away part of their footings, kidnap anybody from anywhere, kill anybody by removing the head, steal all the gold from Fort Knox. And anyone who had a monopoly on the technology would have absolute, unassailable power over all humanity.

Okay, that's probably impossible. Laws of physics and all that. But sci-fi writers don't seem to have thought it through. But technology that is possible is also pretty scary. Consider 3-D printing. It's a cool way to make customizable objects, including prostheses and other good stuff. And, as German Lopez discusses at the link, guns. Plastic guns that are untraceable and don't set off metal detectors. They can be made so they don't look like guns and won't be identifiable with x-rays. Anybody can make them without worrying about a background check. As Lopez explains:

The wide release of the 3D-printed gun blueprints, however, has only become an issue now due in large part to the Trump administration. The previous administration, under President Barack Obama, had forced libertarian Cody Wilson to stop publishing these blueprints on his website, Defcad.com. Wilson sued the administration in hopes of republishing his schematics. The case seemed like an easy win for the government, with multiple courts initially ruling in the government’s favor.

But once the Trump administration came in, with its gun-friendly politics, the Justice Department abruptly agreed to a settlement — giving Wilson and his nonprofit, Defense Distributed, “essentially everything they wanted,” Andy Greenberg reported for Wired. The deal allowed Wilson to publish his blueprints starting in August, and paid him $40,000 for his legal costs.

So that was going to happen today, but a court has stopped it for now. Doesn't matter, they're already out there. Thousands of these blueprints have already been downloaded and they're being shared. And of course people can make new ones, and better ones. So yeah, you can now get on an airplane or enter a courthouse or other government building with a gun. What other capabilities will be coming along soon? People with chemistry sets making powerful neurotoxins, people gene-editing bioweapons in their garages -- this is possible right now.

I'm not sure how worried to be but we probably ought to be at least a little bit worried. Our technological capabilities have run far ahead of our wisdom.