Priorities

This has been covered elsewhere in the blogosphere, but it also deserves mention in a public health blog like this one. We have talked frequently about the public health consequences of George Bush's personal choice to take America to war in Iraq, but those effects are often invisible. But sometimes things happen to make them starkly present.

In great natural disasters like Hurricane Katrina, the National Guard is one of the important resources in managing the consequencdes. These citizen-soldiers have as their priority to protect their communities. Last October Louisianna lost a large contingent of their Guard troops, along with heavy equipment, including high water viehicles, refuelers and generators. They are now in the Iraqi desert, not the flooded city of New Orleans and its environs.

The pressure on the federal budget caused by the Iraq debacle coupled with a relentless policy of tax cutting is also having a visible effect. Last June New Orleans City Business reported that the New Orleans District of the Army Corps of Engineers suffered the largest single-year budget reduction in its history, $71.2 million. Two months ago:

I've been here over 30 years and I've never seen this level of reduction, said Al Naomi, project manager for the New Orleans district. I think part of the problem is it's not so much the reduction, it's the drastic reduction in one fiscal year. It's the immediacy of the reduction that I think is the hardest thing to adapt to.

There is an economic ripple effect, too. The cuts mean major hurricane and flood protection projects will not be awarded to local engineering firms. Also, a study to determine ways to protect the region from a Category 5 hurricane has been shelved for now.

If you won't tax those that can afford it but you still want to spend on military adventurism, there isn't enough left for important needs. That's not difficult to understand and it wasn't difficult to understand two months or two years ago. A no brainer. Unless important needs to some are not that important to Bush and his fellow congressional country clubbers.

Iraq. Not having to pay a fair share of taxes. Katrina. Pandemic flu preparedness. Education. Public health. It's all about priorities.

ET, don't phone home (if you are driving)

In the 1930s my uncle got a car that had a radio in it. The family was aghast at the foolhardiness of this recipe for disaster. Now the same arguments are being played out with mobile phones. But is it the same? I think not.

Research to be published soon in Applied Cognitive Psychology shows what a number of other studies have shown: talking on a car phone while driving is risky. On hundred students were asked to answer simple questions about the layout of buildings or verify statements about relative positions of buildings on campus while using a driving simulator.

Participants were poorer at maintaining a stable speed, or keeping a constant distance between themselves and other traffic than when only driving. Paradoxically, there was some indication that when drivers had to speak while driving, their lane control increased even though speed control decreased. (via News-Medical.net)

Either speaking or listening interfered with driving. Other research, using devices that track eye-movements, has shown that the usual "darting" gaze of an active driver reverted to a fixed straight ahead gaze when using a car phone. Coupled with actual epidemiologic data that "hands-free" devices do not mitigate the added risk of accidents from car phones (post), this research adds to the evidence that it is the cognitive aspects of talking on a phone rather than the physical act of holding it with one hand that is the problem.

Why this would be more of a problem for car phones than for talking with a passenger or listening to the radio is unclear. One could interpret this research as saying that these more usual activities are as dangerous as talking on a phone, but that isn't my experience and I doubt it is true. Clearly there is both more room for research here and also enough research to indicate that talking on a car phone while driving several tons of steel at more than 60 miles per hour (88 feet per second) isn't a very good idea. If the danger were only to the driver it would be one thing. But it is also to the passenger and everyone else that shares a road with them.

Because I had once expressed caution about health effects of electromagnetic fields, for a while I was frequently called upon for help by communities concerned about cell phone towers (transmitters) being sited in their midst. Often the sites were in really stupid places, like atop schools or daycare centers. But my concern was not so much about exposure from these tower transmitters (which was usually very low) as from the transmitter that people held in their hands, with an antenna plastered to their skulls. It was known that radiofrequency hot spots near the antenna existed within the cranium, although, since this was non-ionizing radiation whether this was harmful was debatable. My poinjt here, though, is that the siting of the cell towers, while not exposing people directly, was creating a situation where mobile phone technology was becoming pervasive and now has almost become a necessity for many people.

The vastly increased exposure of the population from handheld transmitters and now the problem of cognitive deficit of drivers careening down the highway are two consequences of the cell phone towers not related to the original concerns of residents, but possibly significantly more important.

Live and don't learn, I guess.

Where are the Dems on bird flu?

EM frequent commenter (and indefatigable contributor to the Flu Wiki) Monotreme has asked several times, "Where are the Dems on bird flu?" A pertinent question.

Monotreme points out that even Bill Frist has commented on the importance of the threat, for which Monotreme believes he deserves some recognition. Our feeling was that if Doctor Bill, who after all is the Majority Leader of the Senate, thought it important he could make something happen, which obviously he hasn't. But that still leaves Monotreme's original question, "Where are the Dems?"

Democratic Senator Barak Obama writing with his Republican colleague Richard Lugar had a decent (for the time) Op Ed some months ago, but except for that we have heard almost nothing. We remind everyone that the Chairman of the Democratic National Committee is also a physician. Where is Doctor Dean? In fact, where is anyone in the Opposition Party? In other countries (e.g., Australia) the political opposition has made it a point to criticize the lack of preparation for a pandemic by the right wing government of John Howard. In the US, the opposition is apparently only interested in subjects they think will win some political points, and since no one else has made preparation for a pandemic a political issue, they won't either. This is a self-fulfilling prophecy if there ever was one. But even if there were so obvious political points here, there is some obligation to call attention to a major failing of the Bush Administration, just as a matter of principle.

So maybe that explains it. The only thing this has going for it is that it is a matter of principle. Apparently not a salient fact for the DNC. These guys make me retch. I vote democrat because the alternatives are almost always even more odious. But if they want me to respect them, they have to do it the old fashioned way: they have to earn it.

Sunday Sermonette: Gedanken experiment

On Sunday we usually give the pulpit over to a personage of note, someone whose pronouncement on a subject of interest to Freethinkers strikes our fancy. But this Sunday we take the lectern ourselves to ask a religious question in the form of a thought experiment. We mean this as a serious question, not a facetious one.

Suppose I were to maintain there was a tiny man, invisible and undetectable, inside my wristwatch, who was master of the universe. I could elaborate on the theme of time, Eternity, write a scripture or cathechism extolling the virtues of punctuality and the sin of tardiness and procrastination and it would not be hard to construct an “origins” story. I could also make as a special a target the teaching of Special Relativity in school, because Einstein’s theory denies any standing for the notion of simultaneity and the universal time of Newton. Relativity would be my “evolution,” a scientific theory that strikes at the heart of my religious system. I don’t think I have to elaborate much to make a case that a plausible religion along these lines could be devised. And I could almost certainly find a dozen or more people who believe it and would proselytize for it. Think of some of the things people already believe. I have purposely not made a claim I believe this myself, because I plainly don’t.

Here is my very serious question. What distinguishes this from any existing religion and why isn’t it a bona fide religion? Does it make any difference whether I believe it or not, and if it does, why? I ask these questions with a sense of genuine puzzlement. It is not meant to ridicule.

Finland?

If this is Friday, this must be Finland. Or so H5N1 might muse, on its way to Europe via the northern route. Or not.

Yesterday Finland's Agriculture Ministry was looking into possible bird flu in seagulls in a country with an 800 mile border with Russia on one side and borders with Sweden, Norway and the Baltic on the other.

"As a result of a monitoring programme in Finland, we have now made an initial finding of a possible bird flu virus in a seagull," the ministry said in a statement. "The studies are ongoing and a final result will come in three weeks." (Reuters via Eircomnet)

At the moment, the Finns are assuming it is not Highly Pathogenic Avian Influenza (HPAI) H5N1 but a Low Pathogenic variety (LPAI), not uncommon in wild birds. Based on prior probabilities, the assumption that it is LPAI is reasonable, while based on the downside risk that it is H5N1, making an announcement and taking immediate steps is also reasonable.

Despite the Thursday pronouncement in Brussels by EU veterinarians that the presence of H5N1 in Central Asia was "not a direct threat for Europe and there is no need for general emergency actions", most knowledgeable observers believe the virus is almost certain to make its way to Europe. Sooner or later.

Revere bloggerview at PSoTD

Wayne over at Political Site of the Day (PSoTD) has interviewed "Revere" and is posting it this weekend. If you haven't had enough of my cant here, you can get some more over there.

Civet surprise(?)

The H5N1 virus has once again revealed something about the extent of its species range. Three Owston's palm civets, cat-like animals being raised in captivity in a Vietnamese national park, are now confirmed to have died in June from bird flu. No obvious source of the infection has been found, although some of the keepers came from provinces where bird flu is endemic. However Reuters reports "tests did not find the H5N1 virus." Exactly what tests were done is not stated.

Civet cats are also suspected of being a reservoir and vector for SARS in southern China, where they are considered a delicacy. Civets are among an expanding list of animals now shown to be capable hosts for H5N1, a list that includes ostriches, sea mammals, large cats (tigers and leopards), ferrets, rodents and of course birds and humans.

It's interesting to note the differing responses of Scott Roberston, technical adviser for the civet conservation program at the park. (AP)

"It's another good example of how dangerous this thing is," Roberton said. "No animals are ill, no people are ill. We're still trying to figure out where the source was."

Compare this to the WHO response:

Peter Horby, an epidemiologist for the WHO in Hanoi, said the development would not make people more susceptible to bird flu because humans have less contact with civets than poultry.

"The interesting thing is that it's a new species," he said. "It continues to surprise.

I would think that the more speicies this thing reproduces in the more chance of an efficient mammal-adapted virus we would have. So it is not just someone "getting infected" via a palm civet, but what that someone would be infected with. Hey, but what do I know?

The "interesting thing" to me is that this continues to surprise WHO. Because, frankly, this is no surprise. This happened back in June and we are just finding out about it now. I guess that's no surprise either.

What else has already happened that we haven't been told about or they don't know has already happened?

The un-American Legion

At the top of the page where the story I am reporting here ran in the venerable industry publication, Editor and Publisher, is a banner ad for Garrison Keillor's new column in Tribune News Services. It says, "I think the most un-Amerian thing you can say is, 'You can't say that.' " By that token, the most un-American organization in this country today is The American Legion.

Melanie at Just a Bump in the Beltway alerted us to their most recent assault on the Constitution, announced yesterday. Here is how Editor and Publisher reported it:

The American Legion, which has 2.7 million members, has declared war on antiwar protestors, and the media could be next. Speaking at its national convention in Honolulu, the group's national commander called for an end to all “public protests” and “media events” against the war, even though they are protected by the Bill of Rights.

"The American Legion will stand against anyone and any group that would demoralize our troops, or worse, endanger their lives by encouraging terrorists to continue their cowardly attacks against freedom-loving peoples," Thomas Cadmus, national commander, told delegates at the group's national convention in Honolulu.

The delegates voted to use whatever means necessary to "ensure the united backing of the American people to support our troops and the global war on terrorism."

Whatever means necessary. Reichsfuhrer Cadmus explains further (followed by a wry editorial comment by E&P):

In his speech, Cadmus declared: "It would be tragic if the freedoms our veterans fought so valiantly to protect would be used against their successors today as they battle terrorists bent on our destruction.”

He explained, "No one respects the right to protest more than one who has fought for it, but we hope that Americans will present their views in correspondence to their elected officials rather than by public media events guaranteed to be picked up and used as tools of encouragement by our enemies." This might suggest to some, however, that American freedoms are worth dying for but not exercising.

Politburo Chairman Cadmus then goes on to take a swipe at Cindy Sheehan, the Gold Star Mother who has symbolically confronted Bush over the Iraq disaster, although Chairman Cadmus does it indirectly by raising the image of Jane Fonda gamboling with the North Vietnamese 35 years ago.

"We had hoped that the lessons learned from the Vietnam War would be clear to our fellow citizens. Public protests against the war here at home while our young men and women are in harm's way on the other side of the globe only provide aid and comfort to our enemies."

The Representatives of the Fatherland then went on to pass a resolution (vote 4000 to 0, just like your average rigged election in a Banana Republic) voicing platitudes about supporting our troops, from old men who won't have to fight in this criminal debacle.

I just wanted to say this while I am still allowed.

Addendum (courtesy Phila from Bouphonia in Comments): The American Legion demanded complete withdrawal from Kosovo in 1999, and issued a public statement saying that troops should never be sent into war without a valid cause and a clear exit strategy.

Geographic spread of H5N1

On August 18, WHO issued a statement calling attention to what we have become accustomed to hearing from the daily bird flu news feed: H5N1 has greatly expanded its geographic range. Starting in 1996 in southern China, it moved to Hong Kong in 1997, where it infected a number of people. After a hiatus where no infections were reported, it reappeared in 2003 in Hong Kong, swept into southeast asia where it has infected over a hundred people killing half of them, become entrenched in western China and eastern Russia and Kazakhstan, been found in wild birds in Mongolia and is poised to enter Europe (if it hasn't done so already).

Despite Draconian measures which have involved killing over 100 million birds, the geographic spread of H5N1 has been inexorable and unstoppable. WHO's statement goes on to mouth their usual platitudes about how most human cases to date have involved close contact with poultry, the need for continued surveillance, etc., etc., but finishing with the real bottom line:

The expanding geographical presence of the virus is of concern as it creates further opportunities for human exposure. Each additional human case increases opportunities for the virus to improve its transmissibility, through either adaptive mutation or reassortment. The emergence of an H5N1 strain that is readily transmitted among humans would mark the start of a pandemic.

If it hasn't already started somewhere. All previous pandemics have had a subterranean prologue of smoldering human infection, below the radar screen, followed by sudden explosive spread. Given the relative inability most of the countries where the disease is now endemic in poultry to mount effective surveillance efforts, I wouldn't be too confident.

The petition from hell

I should have known better. After all, I lived through the McCarthy years and the Reagan years. But I guess it's huiman nature to think things can't get any worse. Today, the right wing whores at the American Council on Science and Health (ACSH) filed a petition with the EPA to "eliminate 'junk science' from the process by which it determines whether a substance is likely to cause cancer in humans." (if you have a strong stomach, you can read this 1984ish statement on their press release)

The "junk science" they are referring to is the long-standing and well-confirmed practice of identifying chemicals likely to cause cancer in humans by testing them in animals. The animals (rodents) are a standard model for biological processes of relevance to humans (which is why drug companies and medical researchers have been using them for a century). They are well understood and are the only sentinels for detecting carcinogenicity of any use to public health. Since chemically induced cancer has a latency period of decades (typically 20 years or more), waiting for it to appear in human populations would meant that once detected, even if exposure would cease instantly (which can never happen), it would take another 20 or more years to eliminate the cancers from exposure (all the cancers induced in the 20 years exposure prior to detection). But even then, the chances of detecting any but the most powerful carcinogens in human populations (via epidemiology) is small. Epidemiology is a very insensitive tool. I say this with some authority, as I am a cancer epidemiologist specializing in chemical exposures and have authored numerous peer reviewed studies in that area over many years.

The main rhetorical lever ACSH employs is the use of high doses in the animal studies, doses that are much higher than usually faced by humans. But as ACSH knows well (but didn't divulge) there is a technical requirement for using these doses. If one were to use doses in animals predicted to cause cancer at a rate we would consider a public health hazard, we would need tens of thousands of animals to test a single dose, mode of exposure and rodent species or strain. This makes using those doses infeasible. Thus a Maximum Tolerated Dose is used, one that causes no other pathology except possibly cancer and doesn't result in more than a 10% weight loss. The assumption here is that something that causes cancer at high doses in these animals will also do so at low doses. This is biologically reasonable. It is a (surprising) fact, that most chemicals, given in no matter how high a dose, won't cause the very unusual and specific biological effect of turning an animal cell cancerous. Cancer cells are not "damaged" cells in the individual sense but "super cells," capable of out competing normal cells. It is only in the context of the whole organism that there is a problem. It is not surprising, then, that very few chemicals would have be ability to turn a normal cell into a biological super cell of this type. Estimates are that is far less than 10%, perhaps only 1% of all chemicals that have this ability. Thus western industrial civilization doesn't have to come to a screeching halt if we eliminate industrial chemical carcinogens from our environment.

We know of no false negatives with this process. Every chemical we know that causes cancer in humans also does so in rodents (with the possible exception of inorganic trivalent arsenic, which is equivocal). The reverse question, whether everything that causes cancer in animals also is a human carcinogen, is not testable without doing the actual natural experimen: waiting to see if people get cancer on exposure, an experiment ACSH is only too happy to conduct on the American people to make their corporate sponsors happy.

If ACSH executives want to be exposed to chemicals that cause cancer in animals that biologically are very similar to humans, that's their choice. But I don't want them to make it for me. This ACSH petition is so outlandish and outrageous one wouldn't think it would have a chance of passing scientific muster. But science means nothing to the Bush Administration.

And I thought things couldn't get any worse!

The Bird Flu Game: Who's on First?

One of a small handful of good flu reporters, Maryn McKenna of the Atlanta Journal Constitution and her colleague Jeff Nesmith, are reporting today that pandemic flu "plans" in the US call for the lead agency to be:

Drum roll . . .

The Department of Homeland Security.

The head of the Department of Homeland Security said Tuesday that his agency --- and not the federal health establishment --- would manage the nation's response if a deadly new strain of bird flu evolved into a human pandemic.

Public health officials expressed dismay at the assertion by Homeland Security Secretary Michael Chertoff.

"They don't have the infrastructure at Homeland Security, or the technical expertise, to handle" a pandemic, said Dr. Georges Benjamin, executive director of the American Public Health Association, who was Maryland's health officer during the 2001 anthrax attacks.
The Department of Health and Human Services, which includes the U.S. Public Health Service, the Centers for Disease Control and Prevention and other health agencies, has described itself as the "primary federal agency" in a national health emergency.

But at a meeting with reporters in Washington, Chertoff said his department expected to have overall responsibility for managing a national pandemic response.

Chertoff said the government would depend heavily on the health expertise within HHS, "but we would manage the incident ... to make sure that all of the other pieces that could flow from the pandemic would be properly addressed." (Atlanta Journal Constitution)

And I bet you thought it would be the Department of Health and Human Services where all the health expertise resides, didn't you. Not a chance. Those guys aren't even in the same room anymore, much less at the table. And CDC Director Gerberding has her nose so firmly fixed to GWB's behind, he can hardly ride his dirt bike anymore.

The Atlanta Journal notes that most public health and medical authorities they interviewed were dismayed by this news. But one prominent expert who has been concerned for years about the lack of preparedness in the US, Dr. Michael Osterholm, saw no problem. In our view, this is more a measure of Osterholm's complete exasperation with the total disorganization evident in the federal health establishment's response to the bird flu threat. His more relaxed view of this news, in essence, is a repudiation of CDC and DHHS's ability to handle a pandemic.

But who will really be in charge? DHHS still claims priority, based on Presidential directives. So does DHS. Again from the Atlanta Journal's excellent article:

HHS has been under pressure from Congress for months to finalize a response plan in case the deadly bird flu virus begins human-to-human transmission.

The plan --- in preparation at the CDC since 1993 --- was finalized at the beginning of this month and turned over to HHS Secretary Michael Leavitt, but it has not been made public.

A draft document released last August states, "HHS will be the primary federal agency responsible for public health and medical emergency planning, preparations, response and recovery."

The Department of Homeland Security asserts its authority to manage a pandemic response under a National Response Plan released in December that covers "incidents of national significance," including pandemics.

Both documents use similar language to assert their authority.

HHS said it would take charge when "the resources of state, local or tribal public health and/or medical authorities are overwhelmed and HHS assistance has been requested by the appropriate authorities."
Homeland Security would assume authority when "the resources of state and local authorities are overwhelmed and federal assistance has been requested by the appropriate state and local authorities."
To shore up their claims of legal authority, the two agencies cite a variety of presidential directives, executive orders and laws such as the Homeland Security Act and the Public Health Service Act.
Chertoff's claim of authority is based on a presidential directive issued Feb. 28, 2003.

The same presidential directive is cited in the plan under which HHS claims to be the federal agency primarily responsible for pandemic response.

The HHS plan also notes an executive order signed by Bush in April 2003 giving the secretary of health and human services sweeping quarantine authority, even including the right to order the arrest and detention of individuals to prevent the spread of diseases.

The order was amended in April to add to the list "influenza caused by novel or re-emergent influenza viruses that are causing or have the potential to cause a pandemic."

There is no mention of the Department of Homeland Security in that order.

This is a bunch of Keystone Cops, unable to get their act together for a real national security threat. So if the strong suit of Department of Homeland Security isn't public health, what is it? Maybe keeping public order? Which might be necessary when people figure out how thoroughly this administration blew preparing for a pandemic.

But they had better things to do. Terry Schiavo, Iraq. Social Security, Valerie Plame, smearing Cindy Sheehan, . . . And because George's Pat Robertson constituency doesn't believe in evolution, the fact that influenza A/H5N1 is a negative sense RNA virus that mutates readily is of no particular concern. Since it was Intelligently Designed, it will only kill Unbelievers and Infidels. A Smart Virus.

EU plans, and the US . . . ?

It's a good thing bird flu can't come to the US or we'd have to be doing what the EU is doing, plan for it. The Dutch and Germans are going to move their domestic poultry industry inside to reduce the risk of infection by wild migratory birds. Italy is talking about tightening import restrictions and heightened surveillance. The French, the UK and the Ausrians are apparently imitating the US, i.e., doing very little about protecting poultry from migratory birds, despite the fact that they have a large free range poultry populations.

Tomorrow (Thursday, August 25) EU veterinary expects meet in Brussels to discuss whether the Union should go further.

“If there is a majority of member states in favour of doing more, we will look at doing more,” said a commission spokesman on Monday.

[snip]

The European Commission is pushing national capitals to speed up public health contingency measures and to stockpile anti-viral drugs.

EU member states are not required to notify Brussels of plans to cope with a deadly new human flu outbreak triggered by the bird virus and some have yet to do so.

“We are engaged in discussions with members states and industry so that all members states are as prepared as possible for a pandemic,” said the commission spokesman.

“It is not our business to blame, the great majority have put in action plans. Our job is to encourage them if they do not have plans.” (via EUPolitix.com)

Well, we here at EM don't have any restrictions on not blaming governments. So we say, to George Bush and his federal health establishment, as politely and quietly as we think appropriate: WHAT THE FUCK ARE YOU WAITING FOR? GET YOUR ASS IN GEAR!

Public health, religion, war, blog: Part V

[Last of a multipart series exploring the relationship between these topics. Part I. Part II. Part III. Part IV.]

Public health is a global enterprise. Modern threats to the well-being of populations like climate change or pandemic infectious disease know no political borders. The obstacle of nationalism and the Westphalian notion of "national sovereignty" are now bearing bitter fruit in the inability of the World Health Organization to impose on its member nations responsible standards of conduct concerning timely and accurate surveillance and notification of disease outbreaks within their borders. Thus, even without national conflict, nationalism is a public health problem. But war does exist. By the choice of political leaders.

If something demonstrably and predictably results in widespread disease, malnutrition, disease and loss of life by violence and accident, it would be natural it attract the attention of public health, especially when it is the result of alterable government policy. This is undeniably a description of virtually every policy use of coercive violence to achieve a political goal. Yet, with few exceptions, public health has been silent on the issue (the exceptions are a few public health leaders like Victor Sidel and Barry Levy who have persistently and cogently raised war as a public health issue).

There is currently vigorous debate about the wisdom of the US invasion of Iraq, its motives, its justification, its ultimate consequences. It has clearly had public health consequences, both for the civilian population in Iraq, and in the US, in terms of the distortion in public health priorities, civilian opportunity costs, the creation of new threats from the way the biodefense effort has been prosecuted and the potential destabilization of the biological arms race.

The progressive political movement has not been shy of criticizing this from many different perspectives. It would seem odd that a progressive public health movement would refrain from doing so. This blog will not refrain.

So we conclude where we began, on the role of a blog in all this. The ability to put one's ideas into the great "marketplace of ideas" of the blogosphere is an important development. We are no longer constrained by the daunting economics of print and broadcast publishing. Ideas, including seemingly controversial and unpopular ones, can accrue a market not previously open to them. At least so we imagine.

Imagine there's no heaven,
It's easy if you try,
No hell below us,
Above us only sky,
Imagine all the people
living for today...

Imagine there's no countries,
It isn't hard to do,
Nothing to kill or die for,
No religion too,
Imagine all the people
living life in peace...

Imagine no possesions,
I wonder if you can,
No need for greed or hunger,
A brotherhood of man,
Imagine all the people
Sharing all the world...

You may say I'm a dreamer,
but I'm not the only one,
I hope some day you'll join us,
And the world will live as one.

Lyrics, courtesy John Lennon; sentiments, courtesy hundreds of millions the world over

Chickenhawk rag

As usual, Lindsay at Majikthise has them nailed. The "them" in this case are those who support the war in Iraq but won't lift a finger (except on a keyboard) to fight it. Here is her reconstruction of the hypocritical logic of the chickenhawk (the carrier of the hypocrisy virus, not bird flu virus):

1. A chickenhawk supports the war and could volunteer to fight.

2. Moreover he [or she; Lindsay seems to have a specific target, one Ben Shapiro, in mind, but there are plenty of others] recommends the war enthusiastically, and tries to convince other people that the war is worthwhile. He may have exhorted us to invade Iraq in the first place. Maybe he even attacks critics of the war for being "weak" or "unpatriotic."

3. He knows that there aren't currently enough troops to fight the war properly.

4. He understands that if the war is not fought properly, we will lose. He can't advocate the status quo, because that would be hypocritical. After all, he says he supports the war. He also claims to support our troops, and he wouldn't want any unnecessary deaths for lack of reinforcements.

5. The chickenhawk realizes that in the event of a troop shortage, we can do one of the following: a)Withdraw, b)Institute a draft, c)Induce more people to volunteer.

6. A chickenhawk can't advocate a draft because that would involve forcing someone to fight in his place. That would be hypocritical.

7. A chickenhawk must therefore support some alternative plan for recruiting more volunteers. The traditional free market solution would be to increase military pay until enough people join up to fight the war properly.

8. Obviously, we're going to need a lot of extra money. A chickenhawk can't urge us to simply borrow the money because that would be pawning off his financial obligation onto future, unconsenting generations.

9. The chickenhawk can either advocate raising taxes or cutting non-military spending. If the chickenhawk supports the Bush tax cuts, he's a hypocrite, unless he proposes raising other taxes to make up the shortfall. We need that money to recruit soldiers to fight his war.

10. If the chickenhawk urges us to cut non-military spending, he's got to explain why other people should lose their benefits just because people like him don't feel like fighting the war. After all, he could just volunteer at the current rates and save the government the expense of recruiting him later.
So, no matter how you look at it, a war supporter who won't join up is a hypocrite unless he's got a plan to encourage other people to volunteer and a willingness to pay his share of the cost.

This kind of hypocrisy is not new, obviously. In the Vietnam days we even celebrated it in song.

From Phil Ochs:

DRAFT DODGER RAG

I'm just a typical American boy, from a typical American town
I believe in God and Senator Dodd [hawkish Senator from CT, father of the current Sen.Dodd]
and keeping old Castro down

And when it came my time to serve: I knew better dead than red
But when I got to my old draft board, buddy, this is what I said:

Chorus: Sarge,

I'm only eighteen, got a ruptured spleen
And I always carry a purse
I got eyes like a bat, my feet are flat, and my asthma's
getting worse
O think of my career, my sweetheart dear, and my poor old
invalid aunt
Besides, I ain't no fool, I'm a goin' to school, and I'm
working in a defense plant


I've got a dislocated disc and a racked up back
I'm allergic to flowers and bugs
And when bombshells hit, I get epileptic fits
And I'm addicted to a thousand drugs.

I got the weakness woes, I can't touch my toes
I can hardly touch my knees
And if the enemy came close to me
I'd probably start to sneeze.

[Chorus]

I hate Chou En Lai, and I hope he dies,
but one thing you gotta see,
That someone's gotta go over there,
but that someone isn't me

So I wish you well, Sarge, give 'em Hell
Yeah kill me a thousand or more
And if you ever get a war without blood and gore
Well I'll be the first to go

Constitutional Law

In an earlier post, I invited people to reflect on the tension that often arises in public health between individual liberties and the public good (however defined). I particularly placed this problem in the context of possible government responses to a public health emergency such as a massive killer flu epidemic.

I was not asking for a legal opinion – I principally expected people to respond on the basis of ethical and pragmatic considerations. Indeed, one of the key points I made, in linking to an essay by David Fidler, is that the ordinary legal regime is likely to seem inadequate and to be suspended under such circumstances. While federal constitutional doctrine is somewhat tangential to my original question, I thought people might appreciate a brief summary of how it might apply.

Nobody can deny that constitutional law is an argumentative field. Although there is always a prevailing regime of constitutional interpretation (albeit with many unresolved areas), many people disagree vehemently with various elements of it, and it changes continually over time. Changes are driven by the cultural and political context, by technological change and changes in the order of society, and of course simply by the personnel on the Supreme Court and their own initial proclivities and personal intellectual evolution. Most important for our present problem, in times of national emergency – which in the real world has mostly meant war – the rights people have come to expect are commonly curtailed, and the courts have been quite tolerant of this, ex post facto, even where there was no preceding authority. Before I get to that, let me briefly summarize the doctrine of rights as it may be relevant to public health emergencies, and public health more generally.

Most people are familiar with the rights enumerated in the Constitution, and it has long been held that these to some extent go beyond the literal words on the page and have some implicit content. (E.g., people have a right to travel freely throughout the U.S. as a consequence of it being one country. "Speech" includes writing and symbolic communication. Etc.) In the mid-20^th Century, the court began to expand individual rights beyond those enumerated specifically in the Constitution in a novel manner. The evolution began with the case of Skinner v. Oklahoma (1942), in which a man deemed a habitual criminal objected to the plans of the State of Oklahoma to sterilize him. Although this may appear repugnant on any number of grounds, Skinner’s legal argument concerned the Equal Protection Clause – some categories of offenders were to be sterilized, but not others. The Court, led by Chief Justice Douglas, identified a basic “civil right” to marriage and procreation. This new “fundamental right,” not specifically guaranteed by the Constitution, required the court to impose strict scrutiny on the Oklahoma statute, and the Court found it indeed violated the equal protection clause even though the legislature could, conceivably, have had a “rational basis” for it.

Contrary to anything you may have read elsewhere, Skinner’s “fundamental rights” had nothing to do with “bodily integrity,” a concept of no salience in federal constitutional jurisprudence. Fundamental rights ultimately deemed to be protected by the Due Process and Equal Protection clauses include the right to vote, to marry (the opposite sex), and eventually, to use contraception, to have an abortion, and most recently to have consensual sex in private. While violations of these rights require “strict scrutiny,” the state may violate them if “necessary to promote a compelling government interest.”

In Washington v Gluckberg (1997), a case involving physician assisted suicide, Chief Justice Rehnquist denied any “fundamental right” to suicide, but noted that most states have allowed competent people to refuse medical treatment, which he called a “tradition.” It appears that the court tacitly assumed this tradition defined a fundamental right, although it did not bear directly on the decision in question. It remains to be seen what impact, if any, this acknowledgment will have on future jurisprudence.

In any event, if such a new fundamental right ultimately is reified in some future Supreme Court ruling, it will scarcely matter in time of emergency, when a “compelling government interest” may be asserted, and any judicial review of the government’s actions, if any, will not take place until years later.

At the beginning of the Civil War, Lincoln imposed martial law in parts of the U.S., by suspending the writ of Habeas Corpus (a power given to Congress by the Constitution in time of war, but not to the Executive). This action effectively nullified the Fifth Amendment. He also ordered various military actions, and spent federal funds, all without Congressional authorization or a declaration of war. A man arrested by the army, named John Merryman, went to Chief Justice Roger Taney seeking a writ of Habeas Corpus, which Taney granted, saying that Lincoln had no power to suspend it. Lincoln defied the ruling, and ordered the military to ignore it. That was effectively the end of the matter. Subsequent events, such as the Japanese internment during WWII and the recent indefinite confinement of U.S. citizens deemed “enemy combatants,” without charges or any judicial accountability, would seem to confirm that constitutional rights mean little when the president perceives an emergency.

People who are interested in these issues will enjoy reading The Dynamic Constitution, by Richard Fallon (Cambridge University Press, 2004). Yeah, it's published by some durn foreigners, but he is 100% American, I guarantee it.

Public health, religion, war, blog: Part IV

[A multipart series exploring the relationship between these topics. Part I, Part II, Part III, Part V]

We conclude our attempt to clarify why we have made a point of criticizing organized religion on a public health blog, by pointing out one other feature we consider particularly harmful, the natural tendency of the teachings of each organized religion to set itself apart from others, in essence, to erect artificial barriers between itself and other people. Our approach to public health is not just population based but community based.

Our solutions to public health problems advocate people helping each other. Again, the Flu Wiki is the example. It is based on the idea that the way to cope with the consequences of epidemic infectious disease is not to retreat from others but to equip everyone to pitch in and lend a hand. It is an ideal of service also embraced by some religious institutions (the ones that don't put self-reliance as the highest Good), and to that extent there is no conflict with public health. But to do so these institutions must ignore or run counter to another tendency, the one that identifies people by their professed faith.

No one "is" a Jew or a Christian or a Muslim in the same sense that they are a member of the species Homo sapiens, or tall or short, or have phenylketonuria or are diabetic. For most people, "being" a member of a faith is an accident of birth, like being born in Scranton or Istanbul. For those who convert because they "see the light," that is, they experience some kind of inner conversion, it may remain a matter of individual faith. But often the nature of the conversion turns people away from empathy and rationality.

Accidents of birth have consequences, as do individual professions of faith that become organized to exert political power. In Bosnia, where people lived side by side for decades, had intermarried, had cried and laughed together, suddenly started to kill each other in the name of religion. The only thing that had changed was a policy of cynical manipulation of religious belief by political and religious leaders. It is likely religious beliefs are so often a convenient lever because they are disconnected from any tests of rationality. The only other explanation is to hold that these kinds of conflicts are an inevitable part of "Human Nature" and hence unavoidable, not the underlying fault of religion or other doctrines that produce and exploit artificial differences.

This last view has been a persistent theme in some of the comments to this blog. Yes, inter-ethnic violence has been a constant theme in recorded history, as has inter-racial violence. So has slavery and disease and exploitation. But these historical facts alone have not prevented societies (and public health scientists) from trying to address them and meliorate them as much as possible. We know it can be done. It is not a matter of eliminating ethnic and racial prejudice completely, any more than it is a matter of eliminating disease completely. It is a matter of trying to make things better on this earth, here and now, not wait for some other promised world, there and later.

Why have we singled out religion for attack, as opposed to other kinds of artificial differences of the same sort, like race, nationalism or ethnic "diversity." We don't separate them. All these forms of tribalism, to the extent they divide people, are also harmful. A man who is "Proud to be an American" would be "Proud to be an Italian" if he had been born in one place rather than another. The "pride" of oppressed groups is understandable as a means of empowerment or a way to enhance a self-respect that has been destroyed, but it is ultimately self-defeating when it separates them from others. The two institutional mechanisms most pervasive and most harmful in this respect are organized religion and nationalism (or its older equivalent, ethnic tribalism). All are threats to the health and well-being of populations.

Hence the need to address them by a progressive public health movement.

Next: Last in the series, nationalism and war.

Sunday Sermonette: the way we were

It was only forty-five years ago, but the difference from today couldn't be much starker,

Monday, September 12, 1960, Democratic Presidential candidate John F. Kennedy faced the Southern Baptists at the Greater Houston Ministerial Association on the subject of religion in American politics. Kennedy was the first candidate who was also a Catholic since the 1928 campaign of Democrat Al Smith. Smith had been astonished, then dismayed, at the vicious anti-Catholic campaign waged by the Protestant churches of the day. It looked as if the scenario was to be repeated. Kennedy had decided to take on the issue directly.

Here's some of what he had to say that day. The contrast with current candidates -- not just George Bush, the most flagrant and cynical, but also Al Gore and John Kerry -- couldn't be greater:

[B]ecause I am a Catholic, and no Catholic has ever been elected President, the real issues in this campaign have been obscured -- perhaps deliberately, in some quarters less responsible than this. So it is apparently necessary for me to state once again -- not what kind of church I believe in, for that should be important only to me -- but what kind of America I believe in.

I believe in an America where the separation of church and state is absolute; where no Catholic prelate would tell the President -- should he be Catholic -- how to act, and no Protestant minister would tell his parishioners for whom to vote; where no church or church school is granted any public funds or political preference, and where no man is denied public office merely because his religion differs from the President who might appoint him, or the people who might elect him.

[snip]

Finally, I believe in an America where religious intolerance will someday end -- where all men and all churches are treated as equals, where every man has the same right to attend or not to attend the church of his choice, where there is no Catholic vote, no anti-Catholic vote, no bloc voting of any kind, and where Catholics, Protestants, and Jews, at both the lay and the pastoral levels, will refrain from those attitudes of disdain and division which have so often marred their works in the past, and promote instead the American ideal of brotherhood.

That is the kind of America in which I believe. And it represents the kind of Presidency in which I believe, a great office that must be neither humbled by making it the instrument of any religious group nor tarnished by arbitrarily withholding its occupancy from the members of any one religious group. I believe in a President whose views on religion are his own private affair, neither imposed upon him by the nation, nor imposed by the nation upon him¹ as a condition to holding that office.

I would not look with favor upon a President working to subvert the first amendment's guarantees of religious liberty. Nor would our system of checks and balances permit him to do so. And neither do I look with favor upon those who would work to subvert Article VI of the Constitution by requiring a religious test, even by indirection. For if they disagree with that safeguard, they should be out openly working to repeal it.

I want a Chief Executive whose public acts are responsible to all and obligated to none, who can attend any ceremony, service, or dinner his office may appropriately require of him to fulfill; and whose fulfillment of his Presidential office is not limited or conditioned by any religious oath, ritual, or obligation.

This is the kind of America I believe in -- and this is the kind of America I fought for in the South Pacific, and the kind my brother died for in Europe. No one suggested then that we might have a divided loyalty, that we did not believe in liberty, or that we belonged to a disloyal group that threatened "the freedoms for which our forefathers died."

[snip]

I do not speak for my church on public matters; and the church does not speak for me. Whatever issue may come before me as President, if I should be elected, on birth control, divorce, censorship, gambling or any other subject, I will make my decision in accordance with these views -- in accordance with what my conscience tells me to be in the national interest, and without regard to outside religious pressure or dictates. And no power or threat of punishment could cause me to decide otherwise.

You can read--and hear--the whole speech here, complete with its obligatory Cold War rhetoric. Kennedy was a Cold Warrior of the Old School, something for which I give him low marks. I am not a fan of JFK's. But these views represent the best of American democracy on the subject of religion. What we have today--primarily from Republicans but in no small measure from cowardly Democrats as well--represents something so much worse.

Of course we have seen worse, still, in our history. But it is disheartening to see that at the beginning of the 21st century we have not gone forward but backward.

Public health, religion, war, blog: Part III

[A multipart series exploring the relationship between these topics. Part I. Part II, Part IV, Part V.]

Public health practice is built on science, so it must confront the problem of science vs. faith. Our perspective may not be a sophisticated philosophy of science, but it does represent a widely shared “spontaneous philosophy” of practicing scientists:

• there is a real world out there;
• it exists independently of our perception of it;
• we can know something about it and how it works;
• and science is our method of acquiring that knowledge.

This leaves open the question of other ways of "knowing the world" (religion, art, music). We are in philosophically deep waters when it comes to the definition of "knowledge," but we hope to sidestep it by only considering one decisive difference between scientific knowledge and whatever might be called religious knowledge. Scientific knowledge is not certain, but it is public. Scientific explanations can be stated, displayed and tests of their reasonableness and validity performed. With time comes consensus, even if that consensus later breaks down and is replaced by a new consensus.

No such thing is true of religious knowledge. Religious knowledge cannot explain how the world works (one of the goals of science and a necessary condition for practicing rational public health), not because it can't explain anything, but because it can explain everything. But those explanations cannot be tested. When the Twin Towers came down, a catastrophe that no one thought possible, jihadists had a ready explanation: it was God's will. President Bush had another. It was God's test of American commitment to fighting the Forces of Evil. Take your pick. Whatever your choice, there is no possibility of deciding which is true knowledge or if either are. Indeed the explanation that there is an invisible person inside my wristwatch who rules the world is an explanation of the same sort. All are qualitatively different than a scientific explanation. If there is such a thing as religious knowledge, it is of a different kind and character than scientific knowledge and more pertinently, it is not "public." This is not to disparage anyone’s experience of personal, private spirituality. But that kind of reality cannot be shared.

All of this matters because what is shared and taught by religious institutions has public health implications. Organized religious institutions of all major sects, historically and currently, have often had a baneful influence on the health and well-being of populations, whether in the form of sectarian violence, coerced conversion, oppression of minorities or women, or the mere teaching that other people are unworthy because of their race or beliefs. Religions have been major opponents of countless human advances: abolition of slavery, emancipation of women, reproductive freedom, opposition to war, equal legal rights for gays and lesbians, civil rights.

Not every Catholic is responsible for the Vatican's position on abortion; not every Jew is responsible for Jewish settler abrogation of human rights in the occupied territories of Palestine; not every Muslim is responsible for jihadist invective and violence; not every Protestant is responsible for the extreme rightwing evangelical Christian policies so willingly adopted by the Bush Administration. Neither is every Republican or Democrat responsible for what its party does, or every American responsible for what its country does. That doesn't mean the Republican or Democratic Parties or our government shouldn't be roundly and strenuously criticized--even ridiculed--when their policies are threats to the health and well-being of populations.

If organized religion were a type of government (like a dictatorship) responsible for the same harm to populations, we would have no difficulty condemning it. But in this country there is a reign of "religious correctness" that says one cannot criticize the source of so much misery in this world. To the contrary, we believe a rational and progressive public health strategy cannot ignore it.

The next post deals with other aspects of religion.

(Some) docs to get alerted about bird flu

I just read that all general practitioners are being sent information on bird flu, both to educate them on the topic and to raise awareness and urgency of one of the most serious public health threats in many years. Seems like a sensible thing to do. One wonders why the government hasn't done it much sooner.

A spokeswoman said: "GPs will be the first point of call for many members of the public so it is important they know what advice to give.

"It is all part of the process of being prepared in case of an outbreak."

[snip]

The government has already announced it will be stockpiling antiviral drugs and vaccines to combat flu and could place restrictions on the gathering of large crowds and travel.

Under the guidance, family doctors are being told to encourage patients to take basic precautions during an outbreak such as hand-washing, covering mouths when sneezing and avoiding crowded places.

[snip]

"Some people may see this as alarming, but what it is is making sure we are properly prepared.
"GPs are probably not that clear about what their role would be if there is a pandemic, so if this helps it will be welcome."

The information will come via post in a 50-page technical guide, "Explaining Pandemic Flu," and will include 50 copies of a leaflet for patients. Very sensible indeed -- of the UK.

Too bad the American government is not [correction] doing it, too. Could it be because American doctors and the public are all fully aware of the danger, unlike those dunderheads in the UK? Could it?

Correction: Missing "not" added in first sentence of last para. Jeez. Of course it didn't make sense the way it was originally. Thanks to Aunt Deb and Dylan.

Public health, religion, war, blog: Part II

[A multipart series exploring the relationship between these topics. Part I. Part III., Part IV. Part V.]

We'll take the more difficult problem first: public health and religion. Some readers have been dismayed at posts they viewed as ridiculing "matters of faith," although our target was not individual beliefs but organized and institutionalized religion. For the record we state clearly we are atheists. But our personal beliefs are not the issue here.

Clinical medicine deals with individuals, but public health with populations. Medical training is individual-oriented, so to acquire the tools needed to deal with populations the Reveres underwent additional post graduate training in epidemiology, biostatistics, environmental health, etc. Population thinking is the essence of our perspective. The difference between a concern with individuals and populations is crucial. Things important at a population level may not be important at an individual level. A risk of one in ten thousand per year to an individual might warrant little attention in a clinical setting but the same risk in a 3 million person metropolitan area would amount to 300 cases a year, enough to fill every bed in a typical community hospital. Whether I, as an individual, drive an SUV makes little difference to climate change, but public policies that affect how populations make vehicle choices does.

This is the principal reason that organized religion is at issue for public health, not matters of individual faith. Organized religion is the population counterpart of individual faith. Questions of individual faith are only relevant when those with similar views blend them with ideology and political power, as they have done countless times in history. When that happens, great harm can result. The most vicious resistance to the abolition of slavery, the emancipation of women, civil rights, civil liberties, reproductive rights and now the teaching of rational science in secular education, has come from organized religion. The claim that churches (except for those in the black community) were the bulwark of the civil rights movement conveniently forgets that most mainstream white churches were either silent, neutral or viciously and violently racist during this period. On the other hand, the participation of “freethinkers” (agnostics, atheists, the non-observant) was disproportionately large. This historical pattern is a result of a persistent anti-Enlightenment, anti-rationalist -- indeed anti-humanist — orientation of most organized religions, based on a belief that a power higher than human reason and aspirations guides our destinies. It is an orientation that mixes poorly with science and even more poorly with democracy, where political power derives from the citizenry, not some supernatural source.

It is predictable our anti-religious positions have provoked a reaction. In the course of American history tolerance for people who question or criticize organized religion has waxed and waned. In the Revolutionary period, when many of the Founders were Freethinkers, there was substantial tolerance, allowing the framing of a Constitution which contains not a single mention of the Deity. Not one. Modern liberals didn’t remove God from the Constitution. God has never been in the Constitution. No ever. A period of religious backlash and intolerance followed, only to be succeeded by a Golden Age of Freethought at the end of the nineteenth century (we have quoted in our Sunday Sermonettes Robert Ingersoll, "The Great Agnostic," who was also a major Republican Party activist and gave the nominating speech for James G. Blaine's presidential candidacy at the Republican Convention in 1876). We are again in a period of intolerance and reaction. Any general criticism of religion is considered inappropriate, impolite and un-American. Atheists and agnostics are marginalized and many great figures denied their proper place in our history (for example Thomas Paine, Robert Ingersoll, the feminist Ernestine Rose; see Susan Jacoby’s wonderful book, Freethinkers: a history of American secularism for many more). No matter that religious institutions propagete the grossest lies about "liberals" and others they disagree with or those who try to block attempts to extend their beliefs as mandatory for everyone. Fighting back is not allowed.

In our view, fighting back is not only allowed, but required. In the next post we begin to explain why we consider a secularist agenda essential to a progressive public health strategy.

Long hours

The US economy has done reasonably well although the American worker hasn't. The explanation is the dramatic increase in "productivity," i.e., the amount of a worker's output. So businesses have done extremely well, producing more for less but not selling it for less. Some of this has been a result of more efficiency, but a distressing amount has been purely piling more on the backs of workers. Not just manufacturing workers, but workers of all kinds. We now work longer hours and longer workweeks and enjoy our diminishing time off less because we aren't in as good a shape as before. Because we work longer and harder.

Research done at the University of Massachusetts Medical School has now documented the obvious (via Edinburgh News). If you work a lot of overtime you are over 60% more likely to suffer work related injury or illness compared to those who don't. To come to this conclusion they examined over 100,000 work records and over 5000 work-related injuries and illnesses. Half or more of the injuries and illnesses were in jobs with extended hours or overtime. If you worked at least 12 hours a day you had a 37% increased risk, compared to those who worked fewer hours. Duh.

Twelve hours a day. To make ends meet. Like the candle burning at both ends.

Public health, religion, war, blog: Part I

[First of a multipart series. Part II. Part III. Part IV. Part V.]

The Reveres began this blog over eight months and more than 500 posts ago. There has been at least one, usually two posts per day, sometimes more, everyday since Thanksgiving 2004. Our objective was to jump start a process that has been allowed to lie fallow too long in the progressive wing of the public health movement, the intellectual labor of working through and clarifying our thinking. Too many have relied on formulaic thinking and empty slogans. It was time to get back to work. And not just in a left wing echo chamber. There were too many good ideas from those who didn't identify with the left and too few new ones from those who did. We were not abandoning progressive ideas and values in public health. We wanted to re-invigorate them.

And while we were determined not to "chase traffic," i.e., placate feelings and interests for the sake of increasing readership, we wanted to be open to new ideas. We have taken note of each and every comment, although we have only been able to reply to some. So in that vein, we believe we should address directly the sharp criticism of some commenters that our remarks directed at religion and war were peripheral to our public health focus, especially the strong interest many readers have in bird flu.

Bird flu is not the theme of this site, although sometimes it must seem so considering the amount of space we have given it. At the outset we began blogging without a specific plan, selecting topics that interested us, as the masthead announces. Early on, the subject of preparing for a possible threat from avian influenza seemed a convenient opportunity to discuss the sorry condition of public health, which is leaderless, marginalized and demoralized. Initially, few were interested in bird flu, a topic that has now become widely discussed. At each step of the way we tried to say what we thought important and relevant to public health. Sometimes, we were simply trying to goad public health authorities into doing something. We knew from our logs the blog was read at CDC, NIH and WHO. But clearly it didn't work. It appears you can't goad leaders to do something when they aren't leaders but followers, and the Administration they follow has its attention elsewhere. Eventually we helped start a parallel effort, the Flu Wiki.

But the topic here remains public health, writ large. Many issues have been discussed in that context, but three in particular have attracted critical comment from readers These are guns, religion and war. For some readers, religion and war seem far afield from public health, and they have made it clear they don't want to read about them here. The suggestion has been made that we are turning off people who would otherwise be allies. But we have persisted, and thus we at least owe those readers, whom we value, an explanation.

That explanation is not short, nor is it complete. We hope to begin to spell it out over several posts and advance things with your help. We leave open the possibility that "advancing" might mean a change of direction, since the main objective is not to convince you we are right and you are wrong but to clarify thinking on the matter. Firm commitments, whether about religious skepticism or belief, or the permissibility or not of coercive violence as a policy option, do not imply clear ideas about their relationship to public health. For us, writing is thinking. And thinking is needed to clarify.

We start the process of trying to clarify in the next post.

Crossing the threshold to Europe

The bird flu situation in Russia continues to deteriorate, despite optimistic (and fatuous) claims by WHO's representative in St. Petersburg that the epidemic among poultry would be over in 10 - 15 days. The originally reported focus in Siberia has spread south and westward and this week reached the Urals, the traditional line separating Asian from the more densely populated European Russia. At the start of the week the westernmost region known to be infected was in Chelyabinsk, about 1000 km (600 miles) from the initial detection in Novosibirsk (Reuters), on the very doorstep of Europe:

Russia’s public health chief warned in a letter to regional health officials that the virus — believed to be transmitted by migratory wild birds — could nonetheless reach the Black Sea and Caspian Sea regions this autumn.

And in spring next year, bird flu could spread “to the entire European part of Russia,” Gennady Onishchenko wrote. A separate order by Onishchenko issued on Aug. 11 and made public Monday called for accelerated efforts to combat the spread of the outbreak.

He also asked the Interior Ministry to provide personnel to help quarantine affected areas and instructed the Health Ministry’s regional offices to compile lists of people and their families who have come into contact with infected birds. (Mosnews)

This last instruction is particularly revealing in the light of repeated statements that there have been no human cases. Clearly the correct statement (accepting it at face value) is that there are no known cases, but that the ability to detect cases is poor.

And yesterday came word that apparently the threshold has been crossed. Via ProMed:

Russian health workers have found mass bird deaths in a region to the west of the Ural mountains, in what could become the 1st case of the deadly bird flu virus spreading to Europe, officials said on Wednesday [17 Aug 2005].

The Russian state health watchdog, in a statement posted on its Web site, said the bird deaths occurred on a farm in the Caspian region of Kalmykia, 2000 km (1200 miles) from the region where Russia's 1st flu outbreak was reported. It was unclear whether bird flu had caused those deaths.

"This case is being investigated," the Federal Consumers' Rights and Welfare Watchdog said, adding that no cases among humans had been confirmed in Russia.

Kalmykia is 1800 km south of Moscow and is the only Buddhist region in Europe.

These reports are as yet unconfirmed by laboratory diagnosis. But I doubt anyone is expecting good news on that score.

The wide geographic area with endemic poultry infection is a sure recipe for further genetic changes of unknown effect in this rapidly mutating virus. Even if we assume it never mutates to allow efficient human to human transmission (and we have no basis for assuming such an optimistic scenario), the virus is capable of doing enormous economic and ecological damage to wild bird and domestic poultry populations. Yet despite all that has happened, the UN continues to put a good face on things:

The scenario of a bird flu outbreak in Europe would be very different from that in Asia, said Juan Lubroth, an animal health expert with the U.N.'s Food and Agriculture Organization, one of the agencies responsible for tracking the virus.

It would not only be detected more quickly, he said, but people don't live in close quarters with animals, as they do in much of southeast Asia.

The European poultry industry also is better able to shelter its birds from contact with the wild ducks blamed for the disease's spread. Italy and the Netherlands have previously stamped out outbreaks of bird flu.

Also, experts noted the health care system is better able to deal with human exposure to bird flu and other animal-produced diseases.

"Theoretically, because it's going to be stopped in its tracks, it's not going to infect humans because of the quick detection, and therefore it would have less of a chance to become adapted to humans," Lubroth said. (AP via ABC News)

All I can say is, these guys must be living in some weird, parallel universe.

What to do? Hang onto your hats for a wild ride and cross your fingers for luck? That seems to be US government policy. Other things to worry about, you know.

My liberties or yours . . .

(Apologies for double posting: Revere invited something on this subject.)

Competent adults in the United States have the right to refuse any medical treatment, for any reason or no reason . . . ah, err, no, they don't. In most places, people with tuberculosis can be detained and medicated against their will, as Lawrence O. Gostin discusses here.

Then there is the question of immunization. Children may not attend school without demonstrating that they have undergone a schedule of vaccinations, although most states allow exceptions for religious reasons. Not everyone is happy about this, including these folks, who describe themselves as:

Vaccination Liberation is part of a national grassroots network dedicated to providing information on vaccinations not often made available to the public so that one can make the only informed choice, complete avoidance and refusal.

Then there is the question of quarantine. This has come up in the past in the U.S., but it's gotten new life with all the hoo hah about bioterrorism. I'm not sure why we are only permitted to think about this in terms of a deliberately introduced plague, as opposed to a non-intentional epidemic, but that seems to be the fashion. David B. Fidler, writing in Clinical Infectious Diseases, says:

Neither public health law nor the law on emergency management has ever (fortunately) been implemented in a real biological weapons attack. Tabletop exercises and simulated bioterrorism incidents, such as the May 2000 TOPOFF exercise in Denver, Colorado, demonstrate that neither public health law nor emergency management law could currently support an effective response to a major biological weapons incident [2]. The ineffectiveness of existing legal frameworks in a real bioterrorism crisis would exacerbate pressure on governments to take drastic actions that might sweep away the rule of law in the midst of panic or uncertainty.

Of course, as we have seen in the run-up to the Iraq war, panic and uncertainty can be manufactured based on false information. We may indeed confront compelling reasons -- or apparent reasons -- for authorities to ban travel out of or into certain parts of the United States; to confine law abiding people to their homes or to institutions; to close businesses that are in compliance with the law; to seize private property; to enter people's homes unbidden; to vaccinate or medicate people against their will.

Should the federal government have such powers? If so, how can we trust them to use them only for the right reasons, in the right way, on the right occasions; and to stop when necessity has passed? (And keep in mind that we know the President of the United States does not always tell us the truth.) How can such powers be granted, yet constrained and made accountable? Or are such powers of government simply unacceptable?

If so, how can we protect you against people who refuse to do the right thing voluntarily? After all, we use compulsion against people who would drive while intoxicated, operate unsanitary restaurants, build unsafe houses, etc. Lately we use it in more and more places against people would expose us to their exhaled tobacco smoke. What's the difference?

I'm just asking. As usual, I reserve any opinions of my own.

What, me worry?

Global warming? No problem. Mercury in power plant emissions? No problem. Mad cow disease. Ummmm.

Idaho officials on Friday confirmed one case of naturally occurring Creutzfeldt-Jakob disease (CJD) and are investigating five other suspected cases, but said none are believed to be caused by eating infected animals. (Reuters)

No problem. I guess. Except:

Naturally occurring CJD is found at a rate of about one case per 1 million population annually, according to the U.S. Centers for Disease Control. Yet in a state with only 1.4 million people the fact that Idaho has so many suspected cases of the rare disease has sparked concern.

Shanahan said researchers at Case Western Reserve confirmed that brain tissue from one woman showed CJD caused her death and that the state was waiting for results from two other tests. All the deaths occurred this year, beginning in February, he said.

"We actually are real concerned because we have never had more than three cases in a year and they are in one geographic area," Shanahan said.

Well, since they seem to be sure it is "naturally occurring" CJD. Because they said so. Of course Idaho officials are still looking into it, checking such things as the victims' diets. But they're already sure it isn't from meat. And meat experts agree with them:

"We are confident in the accuracy of the assessment of the Idaho Health Department that these cases of CJD have absolutely nothing to do with BSE," said American Meat Institute President J. Patrick Boyle. "Beef has been, and remains, safe to eat."

Of course. And since there are less than 300 cases of CJD reported per year in the US, and populous Idaho is one of 50 states, why shouldn't it have 1/50 the cases in one small geographic area? No problem.

Like New Jersey:

Last year, health officials found a cluster of 13 deaths due to naturally occurring CJD in New Jersey between 1988 and 1992. All of those people either attended or worked at a racetrack in Cherry Hill, New Jersey, according to investigators.

Another fluke. No problem.

Well, maybe one small problem. The distinction between "sporadic" or "normal" CJD and variant CJD doesn't seem to be as hard and fast as we once thought. Experiments in transgenic mice suggest that BSE (mad cow) prions can produce "sporadic" CJD prions (Asante et al., EMBO Journal)

Oh, and this one:

Inspectors have found more than 1,000 violations of rules aimed at preventing mad cow disease from reaching humans, the Agriculture Department said Monday. No contaminated meat reached consumers, the agency said.

The rules, created in 2003, require that brains, spinal cords and other nerve parts--which can carry mad cow disease--be removed when older cows are slaughtered. The USDA said it had cited beef slaughterhouses or processing plants 1,036 times for failure to comply. (Chicago Tribune)

Small problem. No problem. Big deal. Same thing.

Reason and reasonableness

Last flu season (2004) Virginia Mason Medical Center announced it would require nurses to receive flu vaccinations, the nation's first hospital to do so. Sounds pretty reasonable, considering nurses are both at risk from contracting flu from infectious patients and if themselves contagious, could put patients at risk. But the Washington State Nurses Association asked U.S. District Court in Seattle to bar the requirement after the hospital refused to negotiate. Both sides entered into binding arbitration. Last week the Seattle Post-Intelligencer reported the outcome, a complete victory for the nurses union.

This seemed counter-intuitive, the union flexing its muscle over an issue it should not have fought. Voluntary programs usually do not work, often producing less than 50% participation. So the hospital's requirement seemed reasonable. Indeed the union doesn't oppose but encourages vaccination. So what's the deal?

It sounds like a familiar story. An employer dealing with its employees in a high-handed and what seems an arbitrary manner. Indeed, the memo sent to staff read:

"Staff must be vaccinated by Jan. 1, 2005; staff who cannot document vaccination by that date will face termination if they are not taking influenza prophylaxis."

And the union's response was predictable:

The union encourages its members to receive the vaccination, said Anne Tan Piazza, a spokeswoman for the Washington State Nurses Association.

But it's another matter when the company threatens termination to those who refuse, she said.

The association is pleased with the precedent set by the arbitrator's award, she said. "In the future, if the hospital wants to have a policy requiring vaccination, they must first come to the table and negotiate with the association," she said.

The arbitrator agreed. And indeed it is reasonable and appropriate to work with employees to ensure a reasonable outcome to a reasonable policy.

The reason for a reasonable request shouldn't be, "Because we said so." That's true even when there isn't a union to protect workers.

People are beginning to notice

George (El Presidente). Julie (Director of CDC). Wake up. People are beginning to notice.

While researchers furiously pursue defenses against the expected outbreak of a deadly international flu, the U.S. policymakers remain amazingly passive about pandemic preparations.

This Editorial in the The Philidelphia Inquirer (reg. required) also takes the administration to task in its tardy and insufficient efforts at getting a vaccine ready. The recent announcement that a vaccine has passed its first tests is now the subject of furious backtracking as everyone realizes the tests revealed the dose needed was so large there was no hope of adequate manufacturing capacity for some time--even supposing the vaccine works, which is not yet established, nor if it does work for the strain it was designed for, whether that will be the strain that eventually is the source of a pandemic.

Over the years the government has left the task of developing a vaccine to the drug companies, who, it turns out, weren't actually doing it because they could make so much more money selling impotence drugs or pain medications with serious side effects. The Inquirer notes this but then goes on to suggest that better incentives are needed.

Not true. We need a better Administration. One that would recognize that if the market doesn't work (and everyone agrees in this case it hasn't) we would have taken the necessary steps to do the research, development and manufacture of an influenza vaccine (an ongoing need) with public funds and for an overriding public purpose: the safety and security of our citizenry. The President doesn't mind spending incredibly large amounts of our money for what he thinks is necessary in that regard. Let him do it with a far smaller sum for what everyone else recognizes is necessary.

Sunday Sermonette: the Equal Time Provision

This Sunday we pause to consider the Equal Time Provision, championed by our President for the case of Intelligent Design (of course some Times are more equal than others, but that's what the debate is not all about). So let me make a rare demur from this public health observation from the wonderful Richard Dawkins:

"I do think the Roman Catholic religion is a disease of the mind which has a particular epidemiology similar to that of a virus... Religion is a terrific meme. That's right. But that doesn't make it true and I care about what's true. Smallpox virus is a terrific virus. It does its job magnificently well. That doesn't mean that it's a good thing. It doesn't mean that I don't want to see it stamped out."

Richard Dawkins (Interviewed in: Sceptic vol 3, no 4, 1995) (via Positive Atheism)

I don't think this is quite fair. Under the Principle of Equal Time I would prefer to rewrite this:

"I do think the [X] religion is a disease of the mind which has a particular epidemiology similar to that of a virus... Religion is a terrific meme. That's right. But that doesn't make it true and I care about what's true. Smallpox virus is a terrific virus. It does its job magnificently well. That doesn't mean that it's a good thing. It doesn't mean that I don't want to see it stamped out."

where X = Judaism, Protestantism, Islam, Hinduism, Buddhism, Sikhism, . . .

(see also last week's Sunday Sermonette for a similar Dawkinsism)

Why Bush hates Chavez

Venezuela's President Hugo Chavez acts inappropriately for a President. This offends W, who is a real President. Not a President of a two-bit banana-republic. Bananas. Jeez. Bush is President of an Oil-Republic. And of course Oil Republicans don't like people who nationalize oil companies. But that's not the main thing. The main thing is Chavez's odious behavior. Consider this.

On August 1 Chavez appeared on national television to announce he was deeply disappointed about the failure to meet the government's goal of constructing 120,000 new housing units. Only 43,000 had actually been built. So whose fault was that? In this country we know how to handle things like this. Whose fault? Someone else's. Not this nutcase Chavez. He blamed himself! From the excellent new blog, UnCapitalist Journal:

Chavez made the comments yesterday during his weekly television program Aló Presidente, where he also announced that his government is investing $2.8 billion in the housing program.

[snip]

Chavez said, “This will not do, with all due respect, this is not the way. … at this speed we will not even reach the corner.”

Chavez went on to say that the most common letters the president’s office receives are requests for housing. “I am supremely disappointed with myself and my government on this subject and the first responsibility is mine. I am giving time to see the results, but the signs are bad,” said Chavez.

One can sympathize with Bush's exasperation at this kind of behavior. It sets an incredibly bad example for citizens, who will come to expect assumption of responsibility whenever things go the least bit wrong (no preparation for an influenza pandemic, Iraq, Enron, Plame-scandal, Abu-Ghraib, Schiavo debacle, etc.). This is a slippery-slope. If a Chief Executive starts apologizing for mistakes, there will be no end to it. And that would be bad.

Because we all want an end to it.

Corrected link: This is the correct link to the Uncapitalist Journal.

Saturday Prayer

Dear Intelligent Designer:

I hope you don't mind getting mail from your designees, I figure a little feedback is always healthy. When I first heard that evolution wasn't just a natural process, but was actually all done on purpose, I was kind of pleased by the idea. It was nice to know there was somebody out there looking out for us. Or well, I guess you're not a person, but a being, anyway. I try to think the best of beings.

So, I appreciate all the good stuff you've done. Flowers, songbirds, sex, all very nice. Or, mostly nice. But the more I thought about it, the more I started to get, I don't know how to say this any more nicely, kind of disappointed in a few things. So if you'll just give me a moment of your time, here are some things you might want to reconsider.

Are you really looking out for us after all? For one thing, you really ought to stop intelligently designing those bacteria to be resistant to antibiotics. Evidently you originally designed the bacteria to kill us and make us sick, and I'm sure you had your reasons. Intelligent doesn't have to mean nice. So now you're probably a little annoyed with us for coming up with ways to kill the the bugs first, but give us a break! It seems to me if we start to figure out how to stay alive for a while, you should just accept that. We get to design things too, okay? Same goes for HIV. What's that all about anyway? It was bad enough you intelligently designed it in the first place, now you keep redesigning it so the drugs don't work. Enough already. And then there's the flu virus. Don't get me started with that one. Don't you have anything better to do?

Then there's the whole question of the human body. It has a lot of great features, but a few of them just seem -- sorry to have to say this, but it's true -- not very intelligent. To begin with, there's that stupid appendix, that doesn't seem to do anything except get infected. Then there's the birth canal. It's not a problem for me personally but it is for at leat half of my friends. It's too small for the baby's head, causes no end of trouble. I could go on and on with that. The lower back. I don't expect perfection, everything has to wear out and break down eventually, but there are some pretty obvious improvements you could make there.

Then, as if an appendix isn't bad enough, you made it even worse by giving me a solitary cecal diverticulum. Damn near killed me, for no good reason that I can see. Then there are allergies. Multiple sclerosis. Schizophrenia. Huntington's disease. Neurofibromatosis. These appear to be manufacturing defects, rather than design flaws per se, but shouldn't you exercise better oversight? (By the way, can you give me the name and phone number of the being in charge of manufacturing? Or at least the mailing address? I promise I'll be civil.) The quality of the product is a reflection on you, after all, and I'd think you'd take more pride in it.

Next, I don't want to call you a hypocrite, but I hear that you get really, really angry when people kill those innocent preborn babies. But then I read that you do it yourself! Specifically, out of 100 zygotes, about 50 fail to implant in the uterus and uhh, well, there goes a Sacred Human Life down the toilet. Of the remaining 50, 30% (that's 15) are simply sloughed off in what appears to be a normal, perhaps late, menstrual cycle and the woman probably will never know that she was preganant. The remaining 35 embryos will last at least 35 days, after which pregnancy may be recognized. Of these, 25% will die in utero, perhaps recognized as a miscarriage. That leaves about 26 of the original 100 innocent preborn babies unslain by you. So why is it okay for you, and not for us? Just asking.

Now, there are some things that bother some people that are okay with me. For instance, I have nothing against beetles. You're entitled to your obsessions. It's kind of ridiculous that the whales keep stranding themselves on the beach but it's not my problem. And kudzu is a major pain but I guess it's our own fault for putting it where it doesn't belong. (That's still no excuse for poison ivy.)

Anyhow, just a few thoughts, I hope you don't mind. I know I've mostly been pretty critical, but I hope you'll take it professionally, not personally. If you're interested, I have some more ideas.

Your artifact,

Cervantes