On inequality and disease.

On inequality and disease.

I should preface these remarks by stating that my political views qualify as “extremely liberal” in the United States.

I’m a well-trained economist – I completed all but the residency requirement for a masters at Northwestern – but I don’t give two shits about the “damage we’re doing to our economy,” except insofar as financial insecurity causes psychological harm to people in poverty.  Our economy should be slower, to combat climate change and inequality.

One of my big fears during this epidemic is that our current president will accidentally do something correctly and bolster his chances of reelection.  The damage that his first term has already caused to our environment and our judiciary will take generations to undo – imagine the harm he could cause with two.

And yet, in arguing that our response to the Covid-19 epidemic is misguided, I seem to be in agreement with our nation’s far right. 

As far as I can tell, the far right opposes the shutdown because they’re motivated by philosophies that increase inequality.  Many of them adore Ayn Rand’s “Who will stop me?” breed of capitalism, as though they should be free to go outside and cough on whomever they want.  They dislike the shutdown because they think our lives are less important than the stock market.

By way of contrast, I care about fairness.  I care about the well-being of children.  I care about our species’ future on this planet.  It’s fine by me if the stock market tanks!  But I’ve written previously about the lack of scientific justification for this shutdown, and I’m worried that this shutdown is, in and of itself, an unfair response.

#

Quarantine could have prevented this epidemic from spreading.  If we had acted in December, this coronavirus could have been contained.  But we did nothing until several months after the Covid-19 epidemic began in the United States. 

Then schools were closed: first for two weeks, then a month, then the entire year.

Stay-at-home orders were issued: first for two weeks, then extended to a month.  No data supports the efficacy of these orders – haphazard, partial attempts at social distancing, from which certain people, like my buddy doing construction for a new Amazon facility, have been exempted.  And no metrics were announced that might trigger an end to the shutdown.

Currently, the stay-at-home orders last until the end of April.  But, as we approach that date, what do people expect will be different?  In the United States, we still can’t conduct enough PCR tests – and even these tests yield sketchy data, because they might have false negative rates as high as 30%, and they’re only effective during the brief window of time — perhaps as short as one week — before a healthy patient clears the virus and becomes invisible to testing.

Based on research with other coronaviruses, we expect that people will be immune to reinfection for about a year, but we don’t know how many will have detectable levels of antibody in their blood.  As of this writing, there’s still no serum test.

#

In the United States, New York City has the largest concentration of risk – densely populated elderly people with constant exposure to unclean air. But even the New York Times has begun to print articles describing the folly of our response to Covid-19.

The Italian government is considering the dystopian policy of drawing people’s blood to determine if they’ll be eligible for a permit to leave their homes.  If you were worried about the injustice that the virus itself imposed on people who are elderly or immunocompromised, this is worse!

We can’t evaluate our response without tests.  Missteps by the CDC (which was gutted by the Trump administration) have left us blind to the progression of the epidemic.  And we can’t evaluate our response if we have nothing to compare it to – we will have to end the shutdown to see what happens next (with the option of resuming these safety measures if our test shows they were necessary).

We know, clearly, that the shutdown has been causing grievous harm.  Domestic violence is on the rise.  This is particularly horrible for women and children in poverty, trapped in close quarters with abusers.  The shutdown is creating conditions that increase the risk of drug addiction, suicide, and the murder of intimate partners.

We don’t know whether the shutdown is even helping us stop the Covid-19 epidemic.  And we still don’t know whether Covid-19 is scary enough to merit this response.  As of this writing, our data suggest that it isn’t.

Covid-19 is a rare breed, though: a communicable disease where increased wealth correlates with increased risk.

And so we’re taking extreme measures to benefit the most privileged generation to ever walk the face of this Earth, at the cost of great harm to vulnerable populations.  This is why I feel dismayed.

Hopefully I can present some numbers simply enough to explain.

#

Many diseases are more likely to kill you if you’re poor.

Malaria kills between 400,000 and one million people every year.  The vast majority are extremely poor, and many are children – the World Health Organization estimates that a child dies of malaria every thirty seconds.

Wealth protects against malaria in two ways.  Wealthy people are less likely to live in parts of the world with a high prevalence of malaria (most of the deaths each year occur in Africa and India), and wealthy people can buy effective anti-malarial medications. 

I took prophylactic Malarone when I visited Ecuador and India.  Lo and behold, I did not get sick. 

I believe Malarone costs about a dollar per day.  I am very privileged.

HIV kills between 700,000 and one million people every year.  Again, the vast majority are poor.  HIV is primarily transmitted through intimate contact – exposure to blood, needle sharing, or sex – so this virus rarely spreads across social boundaries in stratified communities. 

In the United States, HIV risk is concentrated among people living in our dying small towns, people without homes in inner cities, and people trapped inside the criminal justice system. 

It seems that these people are all easy to ignore.

Wealth will protect you even if you do contract HIV.  We’ve developed effective anti-retroviral therapies.  If you (or your government) can pay for these pills, you can still have a long, full life while HIV positive.  About 60% of the people dying of HIV happen to have been born in Africa, though, and cannot afford anti-retrovirals.

Even the myriad respiratory infections that plague our species – of which Covid-19 is but one example – are more likely to kill you if you’re poor.  The World Health Organization lists the top causes of death for people living in low-income versus high-income countries.  The death rate from respiratory infections is twice as high for people living in low income countries.

The second-highest cause of death among people in low-income countries is diarrhea.  Diarrhea kills between one million and two million people each year, including about 500,000 children under five years old.

These deaths would be easy to treat and even easier to prevent. 

Seriously, you can save these people’s lives with Gatorade!  (Among medical doctors, this is known as “oral rehydration therapy.”)  Or you could prevent them from getting sick in the first place by providing clean water to drink.

We could provide clean water to everyone – worldwide, every single person – for somewhere between ten billion and one hundred billion dollars.  Which might sound like a lot of money, but that is only one percent of the amount we’re spending on the Covid-19 stimulus bill in the United States.

We could do it.  We could save those millions of lives.  But we’re choosing to let those people die.

Because, you see, wealthy people rarely die of diarrhea.  Clean water is piped straight into our homes.  And if we do get sick – I have, when I’ve traveled – we can afford a few bottles of Gatorade.

Instead, wealthy people die of heart disease.  Stroke.  Alzheimer’s.  Cancer.

If you’re lucky enough to live past retirement age, your body will undergo immunosenescence.  This is unfortunate but unavoidable.  In old age, our immune systems stop protecting us from disease.

Age-related immunosenescence explains the high prevalence of cancer among elderly people.  All of our bodies develop cancerous cells all the time.  Usually, our immune systems kill these mutants before they have the chance to grow into tumors.

Age-related immunosenescence also explains why elderly people die from the adenoviruses and coronaviruses that cause common colds in children and pre-retirement-age adults.  Somebody with a functional immune system will get the sniffles, but if these viruses are set loose in a nursing home, they can cause systemic organ failure and death.

#

I haven’t seen this data presented yet – due to HIPAA protections, it can’t easily be collected – but Covid-19, on average, seems to kill wealthier people than influenza.

On a personal level, wealth will protect you from Covid-19.  We know that early treatment saves lives, which is a reason why Germany’s death rate is so low, and wealthy people are less likely to postpone going to the hospital.  Wealthy people can afford the medications that might keep you out of the ICU. Wealthy people are less likely to experience the stresses, sleep loss, and discrimination that have caused disproportionate numbers of Black people in the United States to succumb to Covid-19.

But on a population level, wealth is correlated with increased risk.

Part of this wealth gap is due to age.  Currently we don’t have enough data to know exactly where the risk curves for seasonal influenza and Covid-19 intersect, but it seems to be around retirement age.  If you’re younger than retirement age, seasonal influenza is more deadly.  If you’re older than retirement age, Covid-19 is more deadly.

And in the United States, if you’re older than retirement age, you’re more likely to be wealthy.

Covid-19 is also more dangerous if you’re already sick.  A study of Covid-19 deaths found that 97% of the people killed were already sick with at least one serious medical condition.  The average person killed by Covid-19 had 2.7 other serious diseases.

Because these people were receiving expensive medical care, they were able to survive despite their other diseases.  Imagine what would have happened if these people had chanced to be born in low-income countries: they would already be dead. 

This is a tragedy: all over the world, millions of people die from preventable causes, just because they had the bad luck of being born in a low-income country rather than a rich one.

We don’t have data on this yet, but it’s likely that Covid-19 will have a much smaller impact in Africa than in Europe or the United States.

When my father was doing rounds in a hospital in Malawi, his students would sometimes say, “We admitted an elderly patient with …”  And then my father would go into the room.  The patient would be 50 years old.

Covid-19 is particularly dangerous for people in their 80s and 90s.  Great privilege has allowed so many people in Europe and the United States to live until they reached these high-risk ages.

#

Our efforts to “flatten the curve,” in addition to increasing many people’s risk of death (from domestic violence, suicide, and the lifelong health repercussions of even a few months of sedentary living), will save relatively few lives, even among our country’s at-risk population.

The benefit of this shutdown is simply the difference between how many people would die if we did nothing, compared to how many people will die if we “flatten the curve.” 

Assuming that our efforts to flatten the curve succeed – and neglecting all the other risks of this strategy – we’ll be able to provide ventilation to everyone.  But there will still be a lot of deaths.  The shutdown will not have helped those people.  The shutdown is only beneficial for the small number who would be treated in one scenario, would not be treated in another, and who actually benefit from the treatment.

The Lancet reported that in the initial wave of the Covid-19 epidemic, 97% of patients receiving invasive ventilation died.  Later on, the death rate among people receiving ventilation was still over 80%

Their lives matter, too.  Many of us have a friend or relative whose life was cut short by this. But something that we have to accept is that we all die.  Our world would be horrible if people could live forever.  Due to immunosenescence, it becomes increasingly difficult to keep people alive after they reach their late 70s and 80s.

And the priorities of elderly people are different from mine.  I care deeply about the well-being of children and our planet’s future.  That’s why I write a column for our local newspaper discussing ways to ameliorate our personal contribution to climate change.  That’s why my family lives the way we do.

These priorities may be quite different from what’s in the short-term best interests of an 80-year-old.

Schools are closed.  Children are suffering.  Domestic violence is on the rise.  All to protect people who have experienced such exceptional privilege that they are now at high risk of dying from Covid-19.

Our national response to Covid-19 is being directed by a 79-year-old doctor.  I haven’t gotten to vote in the presidential primary yet, but if I get to vote at all, I’ll be allowed to choose whomever I prefer from a selection of a 77-year-old white man or a 78-year-old white man.  Then comes the presidential election, where there’ll be an additional 73-year-old white man to choose from.

It makes me wonder, what would our national response be like if we were facing a crisis as risky as Covid-19, but where elderly people were safe and children were most at risk?

And then I stop wondering.  Because we are facing a crisis like that. 

It’s climate change.

And we have done nothing.

On AIDS and drought in Malawi.

On AIDS and drought in Malawi.

Nobody wants to be bitten by a wild animal.  Even my former housemate, who is exceedingly likely to wrestle raccoons or be chased up a tree by a flock of angry turkeys each time she visits her ancestral home, would prefer not to be bitten.  But let’s say you slip up.  Make a wrong move and let some critter sink its teeth into your wrist.  In the United States, there are limited consequences to your mistake.raccoon.JPG

Maybe you’ve heard that the rabies vaccine is scary, but it’s not so bad.  A series of four; none hurt; none made me feel sore.  It did hurt when the nurse injected human-anti-rabies immune serum directly into my wound.  I began a long, loud diatribe – I know this is for the best, and I know that it hurting is not your fault, but I am decidedly unhappy right now – that went on for the entire twenty minutes it took for the nurse to inject ten milliliters.  All the children screaming in the ER at four a.m. sudden became very quiet; because the hospital was overcrowded that night, I was on a gurney just outside their ward.

Still, I didn’t suffer much.  By five thirty I was home, snoozing contentedly.

I’m not saying that health care in the United States is great.  I was a graduate student at Stanford.  We had fancy coverage.  I could drop by a fantastic hospital for free.  Others are less lucky.  People go broke from medical bills in this country.

I am saying that health care in the United States is pretty great compared to the standard fare on offer in Malawi.

malawiMalawi is a very poor country.  We – meaning not you & I personally, but rather the people who engendered the prosperity of the United States, from whom the contemporary beneficiaries inherited both wealth and blame – are responsible for the poverty of Malawi.  Throughout Africa, resources were plundered.  Europeans brought horrific violence to the continent.  And, because wealth begets wealth, the repercussions of these sins have grown more severe over time.  Unless there is a conscious effort to repair past economic wrongs, they won’t vanish on their own.

This same principle underpins lingering individual inequality in the United States.  Some wounds, time does not heal.  A rising tide only lifts those comfortably ensconced in boats.  The world’s plundered nations are still struggling, sinking farther and farther behind.

In addition to dire economic circumstances, Malawi has been ravaged by an HIV epidemic.  Ten percent of the population, approximately 1 million people, are living with HIV.  30,000 or more die of HIV-related illnesses each year.  This public health crisis is tragically self-perpetuating.  Poverty exacerbates epidemics by reducing access to medication and pushing people toward riskier lifestyles.  And then it’s hard to escape poverty since young people are dying daily and huge numbers of children are orphaned by disease.

In the United States, we often discuss the curtailed economic prospects for children raised in single-parent households.  Those children have it hard.  Now picture all the Malawian children in zero-parent households.

My father, who has worked with sick patients in HIV clinics in the United States for many years, is now practicing medicine in Malawi.  It’s grim.  For instance, the reason I began this piece with a description of rabies vaccination?  Those vaccines are not available in Malawi.  Instead of four relatively painless shots, those who get bit face death.

After four decades of practice as an infectious disease doctor, my father has obviously seen patients die.  But a sign like the one below is new for him.

image1 (1).JPG

“Dying from rabies is a terrifying experience for both the patient and their relatives,” it says, before admonishing, “Don’t forget to ask about spiritual needs!”  Nothing drives home privilege like the thought that someone else’s son would die from the sort of bite that simply sent your own to a hospital for a late night.

It feels even worse knowing that his doctoring – and my sister’s, who will be traveling to Malawi with her newborn child to practice pediatric medicine starting this fall – is a meager staunch against whelming calamity.  People are dying now.  They can’t make effective long-term plans when the short-term outlook is so bleak.

And yet.  Poverty there is so deep, and infrastructure so quickly deteriorating, that many people have been chopping down the country’s few remaining forests to produce charcoal.  For many, charcoal production is the only source of income.  For others, in circumstances only slightly less dire, it’s necessary to buy charcoal to weather the frequent blackouts.  Even those responsible for protecting the forests buy illegal charcoal.  There’s no winning.

Without the forests, there will be drought.  When the drought comes, people will starve.  Climate change – caused primarily by the nations responsible for plundering our world’s currently-impoverished nations, yet which will beleaguer those plundered nations first – will exacerbate this problem.  New tragedies are coming.

I’ve obviously benefited from the prosperity of the United States.  I have a computer.  I have access to the internet.  When I turn the tap, there is clean water.  When I flick a switch, the room is instantly (and always!) illuminated.

But this means that the blame for the current plight of our world’s plundered nations – which brought my prosperity – falls on me, too.  I’m glad that my family members are doing what they can to help.  I wish it were enough.

On how human different humans happen to be (hint: equivalently human).

CaptureI finally read some of the initial papers (circa 1981) describing an outbreak of opportunistic infections among previously-healthy homosexual men in the United States.  The case studies are harrowing — a dispassionate litany of suffering, ending with death.

And, yes, these are papers from before I was born.  I should’ve read them already, or at least know enough about them that they’d have no impact.  To someone like my father, for instance, who has worked with HIV patients for most of my life, the old case studies would not seem shocking — I recently read Henry Marsh’s Do No Harm, which carries a beautiful epigraph from Rene Leriche (I’m not sure who translated this from the French — if somebody knows, please tell me!): “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray — a place of bitterness and regret, where he must look for an explanation for his failures.” — my father, like most medical doctors, can surely close his eyes to summon up memories more bleak than the case studies I’ve been reading.

But to me, a medical naif, the papers remind me of the horrifying violence against women section of Roberto Bolaño’s 2666.  Personal tragedy and heart-wrenching suffering condensed into clinical prose.  Not fun.

But I had a reason for subjecting myself to this!  A recent NPR news investigation alerted me to Susan Smith’s article “Mustard Gas and American Race-based Human Experimentation in World War II.”

To put these experiments in perspective, I think it’s worth considering how mustard gas works.  Luckily, I took a medicinal chemistry class with Rick Silverman where we discussed the mechanism of both mustard gas and the early mustard-gas-esque chemotherapy drugs known as nitrogen mustards.  It was a cool topic, so I still remember it: I’ve drawn out the mechanism (with some helpful notes!) below.

mechanism001

And, looking back on this, there are a few things worth noting.  One is, yeah, it’s perhaps obvious why I was emotionally leveled by reading those AIDS case studies — most of what I know is massively abstracted.  It’s very different to hear the words “mustard gas” and envision a lines-and-letters mechanism  versus seeing a image of Rollins Edwards juxtaposed with another depicting a jarful of his own skin (which appears halfway down the page for the NPR story).

Capture
See the NPR article here.

I’d like to think that the scientists who originally designed these experiments were picturing everything on that same level of abstraction.  Not that this excuses what they did, but it’s slightly less awful to imagine that they were simply oblivious to the human harm they were causing.

The second is, well, look!  Mustard gas crosslinks DNA!  How different from black or Puerto Rican or Japanese soldiers did those white scientists imagine themselves to be to think that mustard gas would show differential efficacy?

And that’s why I was looking up the AIDS papers.  Because I attended a symposium in 2002 where Lane Fenrich read excerpts from those original papers.  His message was that the authors of those original papers implied that homosexuals are distinct on a cellular level.

I no longer remember which passages he chose to read, but here are two quotes that convey his point.  The first is from the paper by Gottlieb et al.:

Depression of T-cell numbers and of proliferative responses to the degree observed in our patients has not been reported to occur in ctyomegalovirus-induced syndromes in normal persons.

Should I be doing something cheeky with font to add emphasis to the words “normal persons” at the end of that sentence?  Naw, I think you probably get the point.

The second quote I thought I’d include is from a 1982 Center for Disease Control report:

Infectious agents not yet identified may cause the acquired cellular immunodeficiency that appears to underlie [Kaposi’s sacroma] and/or [Pneumocystis cainii pneumonia] among homosexual males.

Again, the message being sent is that there are cellular differences.  An infectious agent targets basic human biology among homosexual males.  Which is a crazy message to send.  Sure, they only had a small data set — they didn’t have any evidence yet that the same infectious agent might cause immunodeficiency in heterosexuals, or in women.  But, wouldn’t that be a reasonable assumption to make?  You have to presume pretty extreme levels of otherness to think that would not be the case.

ZPp_fotx0TiwtLE3nEBnVw_sharegeneswmeReading these papers made me pretty happy that a friend sent us a copy of 23andMe’s board book You Share Genes with Me shortly after N was born.  With corny rhymes the book celebrates how similar we are to organisms ranging from grasses, flies, fish, up to chimpanzees and our (presumed) human friends.  With numbers, too — if N could speak, perhaps she could let you know that chimpanzees share ca. 96% of her DNA sequence, and another human baby ca. 99.5%.

Which is a nice message to send.  Human brains are so good at presuming otherness; it’s charming to have a book for her that makes clear how similar we all are, people, animals, and even plants.

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

p.s. Maybe you’ve read reports about pharmaceuticals with race-based differential efficacy.  And, yes, despite over 99% DNA sequence identity between any two human beings, there are some differences that correlate with ethnicity.

Appearance, for one — many people assume they can assess ethnicity well from photographs.  Lactase persistence is another, and that seems to have developed recently (as far as evolutionary timescales go).  It’s not so unreasonable to imagine differences in drug metabolism between humans of differing genetic ancestries, and that can have a big impact on efficacy: two people taking the same dose of a medication might experience significantly different concentrations of the active ingredient.

I’ll include more about these issues when I finally get around to posting that essay on the evolution of skin color, but on the whole these seem to be pretty minor differences, and nothing that would affect sensitivity to mustard gas, which takes a baseball bat to your DNA long before you’d have a chance to metabolize it.  And the only big news story about race & pharmaceuticals that I know about is for that heart medication, BiDil.  In that case, it seems most likely that their rationale for claiming race-based efficacy was to help them file a new patent.  If you’re curious, you could read Dorothy Roberts’s article chastising the race-based claims; here I’d like to highlight just these three lines:

In the past, the FDA has had no problem generalizing clinical trials involving white people to approve drugs for everyone.  That is because it believes that white bodies function like human bodies.  However with BiDil, a clinical trial involving all African Americans could only serve as proof of how the drug works in blacks.