The Age of the Superbug

With all of the media hullaballoo about Hillary Clinton’s pneumonia, Donald Trump’s physical exam, Brangelina’s impeding divorce, and poisoned Skittles, you may have missed one of the biggest and most important health stories of this year.

Just yesterday, the United Nations General Assembly held a day-long meeting in New York City to discuss one of the most deadly threats to human health since the bubonic plague: antibiotic-resistant bacteria. This is only the fourth time in history that the General Assembly has met to address a health issue, having met twice in 2011 to talk about HIV/AIDS and chronic diseases, respectively, and again in 2014 to discuss the West African Ebola outbreak.

Antibiotic-resistant bacteria pose an even greater threat than Ebola, HIV/AIDS, and heart disease combined. According to the US Centers for Disease Control and Prevention (CDC), antibiotic-resistant forms of common bacteria like E. coli, Staphylococcus aureus, Streptococcus pneumoniae, and Mycobacterium tuberculosis – among others – infect nearly 2 million people a year in the United States, killing at least 25,000.

Worldwide, the number of people infected is several magnitudes greater; an estimated 750,000 people died from antibiotic-resistant infections in 2015. Within just a couple of decades, that number is expected to increase by nearly 1500%, yielding over 10 million “superbug”-related deaths annually by 2050.

Antibiotic-resistant infections will soon account for one-third of all deaths globally, a startling turnabout from 1967. That year, thanks to the widespread use of antibiotics and still effective public immunization programs, then Surgeon General William Stewart famously stated that, “the time has come to close the book on infectious diseases. We have basically wiped out infection in the United States.”

However, it turns out that it was the very successes that Dr. Stewart was touting –including copious use of antibiotics – that resulted in the grave crisis that we face today. It was the overprescribing and misuse of antibiotics over the past 50 years that allowed these superbugs to emerge.

Commonly used antibiotics like amoxicillin, cephalexin, azithromycin and ciprofloxacin still kill most bacteria, but a small percentage of these microorganisms are naturally resistant. Naturally occurring resistance has been seen for every antibiotic that has ever been developed. Thus, whenever an antibiotic is used, the drug-sensitive bacteria die off but the resistant bacteria survive. Eventually, if a particular antibiotic is used enough, the resistant bacteria take over. This is why antibiotics should only be used sparingly.

Unfortunately, we haven’t been so thoughtful in our use of these drugs. Ever since the first antibiotics were prescribed to treat serious infections among the soldiers fighting in World War II, we have used them more and more liberally.

It is not uncommon, for example, for a physician to prescribe an antibiotic like azithromycin to a patient with the flu, even though these drugs do not work on viruses like influenza. They may do so because they are hurried, because they misdiagnosis the illness, because they want to prevent potential secondary infections, or (most likely) because their patients expect them to.

We also use antibiotics for non-medical purposes. Nearly 80% of the antibiotics produced annually in the US are not used to treat infections, but instead are used by farmers as growth promoters. Antibiotics are routinely added to the feed or water of agricultural livestock – cattle, pigs and poultry – in order to make these animals fatter.

Given the high-dosages used, many of these drugs pass through the digestive system un-metabolized and are thus present in animal waste. This waste eventually enters the ecosystem through agricultural run-off or sewage spills, contaminating the ground, local streams and rivers, and underground aquifers. In agriculturally intensive regions of the world, pharmaceutically active concentrations of antibiotics are routinely found in soil and water samples. One study of the Yangtze and Pearl Rivers in China, for example, detected more than 60 different antibiotics in those waterways, often at levels that were 10,000 times greater than the normal human treatment dose.

As a result, the world is quickly running out of effective antibiotics. Despite this, there are few new antibiotic drugs in development. This is not because the need isn’t there, but it is simply too expensive and too difficult for pharmaceutical researchers and drug manufacturers to develop, test and market new antibiotics when the bacteria adapt so quickly.

Unless we change our current practices, we will soon be entering a post-antibiotic era. We need to stop prescribing antibiotics for every little cold. We need to stop using these drugs to satisfy our desire for cheap meat, milk and eggs. We need a global effort to develop new drugs and treatments for the myriad of drug-resistant bugs we already face. And we need to do it before it is too late.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on September 22, 2016, and is available on the WAMC website.]

Posted in Clinical Care, Disasters, Drugs | Leave a comment

How to Die in California

Late last month, Betsy Davis died at her home in Ojai, California. The 41-year-old performance artist was suffering from ALS, a progressive neurodegenerative disorder, also known as Lou Gehrig’s disease, which had already robbed her of the ability to stand, to walk, and to speak clearly. Facing the prospect of a slow and lingering death as she lost her capacity to move, to eat and, eventually, to breathe, Ms. Davis took her own life by taking a lethal dose of barbiturates.

In doing so, Betsy Davis became the first terminally ill patient to die under California’s End of Life Options Act. That law, which went into effect in June of this year, allows a terminally ill resident of California to be prescribed a lethal dose of drugs so long as they meet certain medical criteria, make two oral and one written request for physician aid-in-dying, and have the ability to take the drugs without assistance.

In passing the End of Life Options Act, California became the fifth state to legalize physician aid-in-dying. Oregon was the first state to legalize the practice by popular referendum, implementing it in 1998. Washington and Vermont followed suit in 2008 and 2013, respectively. Montana is the only other state where the practice is allowed, the result of a Montana Supreme Court ruling that nothing in that state’s laws prevents the practice.

California’s Act was passed largely thanks to the efforts of two advocacy groups. The first is Compassion and Choices, a national organization that has been working to expand end-of-life treatment options (including physician aid-in-dying) for the past 30 years. The other organization involved, and the one that has been the most instrumental in changing public opinion about physician aid-in-dying, was the Brittany Maynard Fund.

The Fund was established in 2014 following the death of Brittany Maynard. Earlier that year, the then 29-year-old Californian was diagnosed with astrocytoma, a rare and aggressive form of brain cancer. Despite treatment, which included a partial craniotomy and the removal of part of her temporal lobe, Brittany’s cancer continued to progress and she was given a terminal diagnosis.

Facing a brief future filled with pain as she slowly lost her memory, her vision, and her ability to walk and to speak, Brittany sought to end her life on her own terms. Unfortunately, at that time physician aid-in-dying was not available in her home state of California. In response, she and her husband left their family, friends and home behind and moved to the neighboring state of Oregon. It was there, on November 1, 2014, that Ms. Maynard ended her life peacefully by taking a lethal overdose of drugs that was prescribed to her under that state’s Death with Dignity Act.

In going public with her story, Ms. Maynard became one of the most visible faces of the right-to-die movement. A young, beautiful and talented woman, she presented to the public an image that was very different from what most pictured when thinking of the terminally ill: she wasn’t old, she wasn’t depressed or suicidal, and she wrote and spoke bluntly but eloquently about her terminal diagnosis and her desire to die on her own terms and in her own way. She also had the support of her husband of three years, Dan Diaz, who founded the Brittany Maynard Fund in honor of her memory.

In one of those rare coincidences, earlier this month I had the good fortune to meet Dan Diaz. Purely by chance, my husband and I happened to be dining in a bar-restaurant in New York City’s Little Italy when Mr. Diaz sat on the stool next to us. He was in town briefly as part of his unceasing efforts to lobby for expanded end-of-life options in New York and the other 44 states where physician aid-in-dying is still illegal.

Over the next two hours, we talked openly and honestly about Brittany, her experience, the arguments for and against aid-in-dying, and whether or not New Yorkers would be open to making the practice legal in this state.

Neither he nor I know the answer to that last question. The arguments for legalizing physician aid-in-dying are compelling, but so too are many of the concerns raised by critics. For example, physicians opposed to the practice believe that hastening death run counter to the moral duties outlined in the 2500-year-old Hippocratic Oath. Others fear that terminally ill patients will be pushed into ending their lives because of the emotional and financial burden placed upon their loved ones. Disability rights advocates worry that legalizing physician aid-in-dying devalues the lives of those living with physical or mental limitations, and point to the recent legalization of euthanasia for severely disabled children in the Netherlands as proof that we are but one step away from legitimizing their murder.

These are all valid concerns, and ones that need to be respected and addressed as we begin to debate the issue of physician aid-in-dying more and more publicly. Moreover, we need to bluntly discuss the issue of death itself, by talking with our friends, families and physicians about what a ‘good death’ means for each of us, by planning for the inevitable with our loved ones and our lawyers, and by exploring and expanding alternative end-of-life treatment options like hospice and palliative care. That is the true legacy of women like Brittany and Betsy: not the hastening of death but the celebration of life, no matter how short.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on August 25, 2016, and is available on the WAMC website.]

Posted in Cancer, Celebrities, Disability, End-of-Life, Physician Aid-in-Dying, Policy, Uncategorized | Leave a comment

Blame It On Russia … and Rio

Tomorrow marks the mid-point of the 2016 Summer Olympic Games in Rio de Janiero, Brazil. Despite my concerns about the threat posed by the Zika virus – shared by a significant majority of scientists, infectious disease physicians and public health experts but largely ignored by the World Health Organization and the International Olympic Committee (IOC) – the Games have gone on as scheduled. Whether or not that is a blunder of epidemic proportions remains to be seen, but in the meantime I’ve been enjoying the international spectacle that is the Olympics.

In addition to enjoying the athletic competition, I’ve been following the other various dramas, scandals and controversies surrounding the Games closely. This includes the acrimonious rivalries between different athletes and different countries (sometimes descending into less-than subtle threats of physical harm on social media), the rampant sexism of sports journalists and correspondents, and the public protests by Rio’s citizens over bribery, crime, corruption and waste. But what is most interesting to me personally is the controversy surrounding the presence (and exclusion) of Russian athletes at this year’s Games.

Late last month, despite evidence of an extensive state-sanctioned doping program, the IOC decided against imposing a blanket ban on Russian athletes in Rio. Rather, over the complaints of organizations like the World Anti-Doping Federation and the Institute of National Anti-Doping Organizations, the IOC shifted that burden to the 28 individual sports federations that make up the summer Olympics. A mere twelve days before the official start of the Rio Games, those ill-equipped and over-burdened federations were asked to take on the complicated task of scrutinizing the individual anti-doping histories of nearly 400 Russian athletes.

A few federations, like the International Association of Athletics Federations, cleared only a handful to compete; of 62 Russian track and field competitors, only two were cleared (including Yuliya Stepanova, a middle-distance runner who blew the whistle on Russia’s doping program after she herself was caught using performance-enhancing drugs). By contrast, the Fédération Internationale de Natation, which oversees all aquatic competitions, cleared over 60 Russian athletes and banned but a few. All told, over 70 percent of Russia’s Olympic team was belatedly and hastily cleared for competition.

That some athletes will resort to using performance-enhancing drugs to gain an edge over their rivals is nothing new. Athletes competing in the original Olympic Games in Ancient Greece would use so-called ‘magic’ potions in order to improve their performance. As far back as then, the practice was prohibited and those caught cheating were banned and publicly shamed. However, it was only after the death of Danish cyclist Knud Jensen at the 1960 Summer Games in Rome that a concerted effort to ban the use of performance-enhancing drugs in international sport began. Mr. Jensen died as a result of injuries sustained in a crash, and the autopsy revealed that he was under the influence of amphetamine at the time of the accident. In response, the IOC banned the use of performance-enhancing drugs in 1967.

Testing of Olympic athletes for drugs began the following year at the 1968 Mexico City Games, with Swedish pentathlete Hans-Gunnar Liljenwall being the first to test positive for a then banned substance (alcohol). Since then, over 200 Olympic athletes have tested positive for otherwise prohibited drugs. The actual number of competitors using performance-enhancing drugs is likely much higher, calling into question the integrity and credibility of Olympic competition and even the Games themselves.

As I’ve written about before, organizations like the World Anti-Doping Agency face a daunting and thankless task. While random drug tests can (and are) be used to test athletes for the use of performance-enhancing drugs, such tests are usually performed on the day of competition. But most performance-enhancing drugs are used only during training, leaving plenty of time for the drugs to wash out and become undetectable. More frequent out-of-competition testing could combat this, an approach that is very expensive and time-consuming.

Similarly, many athletes use novel drugs for which anti-doping tests do not yet exist. The only way to combat this is to store and reanalyze samples as new drug tests become available. But this does little to combat the problem in real time, and the legality of stripping someone of a title when they test positive for a drug that wasn’t on the list of prohibited substances at the time of competition is questionable. For example, Russian tennis star Maria Sharapova recently received a two-year ban after testing positive for the drug meldonium. While she’d been using that performance-enhancing drug for over ten years, its use was only banned by the World Anti-Doping Agency at the end of 2015. She has not been stripped of her previous titles, and corporate sponsors like Nike have yet to drop her.

Finally, as the still unfolding Russian scandal suggests, poorly funded and over extended anti-doping agencies are competing with state-sanctioned doping programs. Of the 33 Olympic medals won by Russia at the 2014 Winter Games in Sochi, over a third were awarded to individuals whose names appear on lists maintained by that government’s clandestine doping program. None of these athletes tested positive for banned substances during the Games, demonstrating just how effective Russia’s doping program is. Other countries likely have similar programs, including competitive powerhouses like China (if the claims of dissent Chinese athletes are to be believed).

Don’t get me wrong: most of the athletes at the Rio Games are honest. For every one using performance-enhancing drugs, there are hundreds more who are clean. This includes many of the Russians who are competing under a cloud. Moreover, I don’t blame the athletes who were caught up in that country’s systematic doping program; it is hard to refuse to participate in a program that is run by a non-democratic, authoritarian government like Putin’s.

Rather, I blame the IOC for failing to take a strong if controversial stance against doping by banning the entire Russian team. I also blame a culture of competition that emphasizes winning at all costs rather than celebrating the more important cultural and communal values promoted by sports. Until we stop treating winning athletes as commodities, lauding and rewarding the success of gold medal winners like Michael Phelps while ignoring the tenacity and spirit of those he outswam, we will never truly solve the doping problem.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on August 11, 2016, and is available on the WAMC website.]

Posted in Athletics, Celebrities, Drugs, Enhancement, Media, Politics, Uncategorized | Leave a comment

The Invisible Woman

As I watched the opening days of the Democratic National Convention in Philadelphia, I was struck by the stark contrast in tone between it and last week’s Republican National Convention in Cleveland.

Despite the sometimes-acrimonious conflict between Clinton’s delegates and Sander’s supporters, a sign of vibrant and democratic debate regardless of what the various pundits might suggest, there was still strong evidence of unity among the Democrats of all levels. You only need contrast, for example, the unequivocal endorsement of Hillary Clinton by Bernie Sanders and his various lieutenants with the openly contemptuous speech of Republican also-ran Ted Cruz to see the difference.

Of course, just like the Republican Convention, many of the speeches were full of hyperbole, half-truths, or outright distortions. One need only read the analyses of independent organizations like Politifact to see that. Nevertheless, the opening night of the convention made for good entertainment.

The star power on display the first night of the convention was also impressive, with powerhouse progressives like Cory Booker and Elizabeth Warren giving rousing speeches that outlined the Democratic Platform and its policy goals while condemning the fear-mongering and divisiveness of the Trump campaign.

However, while many in the media swooned over the powerful and positive message given by First Lady Michelle Obama, there was one speech in particular that stood out to me: the speech given by disability rights advocate Anastasia Somoza.

Diagnosed with cerebral palsy and spastic quadriplegia at birth, Ms. Somoza first rose to national prominence in 1993 when, at the age of nine, she appeared on television with then-President Bill Clinton to call for integration of children with disabilities into general education classrooms. As a result of her advocacy and President Clinton’s intervention, Anastasia and her twin sister Alba (who suffers from the same condition) were the first significantly disabled students to be enrolled in a mainstream New York City public school.

Since then, Ms. Somoza has graduated with degrees from such top universities as Georgetown and the London School of Economics, taken a position with Shield Institute (an organization that supports those with intellectual and developmental disabilities to live independently), and worked with the Clinton Foundation on efforts to provide parents in low- and middle-income countries with the education and resources they need to care for disabled children.

Although she was speaking on the 26th anniversary of Americans with Disabilities Act, the landmark civil rights law that prohibits public discrimination against anyone with a physical or mental disability, Anastasia described some of the challenges of living, “in a country where 56 million Americans with disabilities so often feel invisible.”

I’m not sure whether or not Ms. Somoza’s complaint was a direct allusion to Ralph Ellison’s Invisible Man, the mid-century novel about race whose protagonist is similarly invisible because of the refusal of others to see him, but the social invisibility of which she speaks is but one example of the overt and covert discrimination which those with disabilities experience every day.

Ask any of your friends or colleagues living with a disability and they will undoubtedly tell you of illegally occupied handicapped parking spaces, quotas on the number of wheelchairs allowed onto buses, airplanes or concert venues, and the quickly averted gaze of store clerks or taxi cab drivers who do not know how to deal with those with special needs. Businesses often refuse to hire the disabled for similar reasons. Nearly 80% of those living with disabilities do not participate in the workforce. When they do, they face a wage gap that exceeds that faced by women or ethnic minorities.

Many well-intentioned able-bodied individuals are often guilty of this social blindness, be it the result of misguided respect, embarrassment, repugnance or fear. Others are outwardly dismissive or hostile towards those with disabilities, including GOP Presidential Candidate Donald Trump, who openly mocked a disabled New York Times reporter at a campaign rally last November. Mr. Trump has yet to apologize for his infantile mockery, and few in the Republican Party have taken him to task for this behavior (including former Alaska Governor Sarah Palin, who is herself the mother of a disabled son and who has publicly admonished political opponents for similar insults in the past).

When we allow people to get away with things like this – by looking the other way when they make fun of someone’s disability, by failing to speak up when someone uses a racial epithet or calls someone a queer or a faggot – we are equally guilty in creating a social climate that values the lives of some people more than it values the lives of others. And we’ve already seen through millennia of history what that can lead to.

And for those of you who do not think that atrocities like the Holocaust, the Armenian and Rwandan genocide, or the Cherokee Trail of Tears can happen again, you need only open today’s newspaper. The very morning after Ms. Somoza spoke on the floor of the Democratic National Convention, 19 people at a facility for the disabled in Japan were stabbed to death by a man who claimed that, “I envision a world where a person with multiple disabilities can be euthanized … I believe there is still no answer about the way of life for individuals with multiple disabilities. The disabled can only create misery.”

Treating those living with disabilities respectfully isn’t about political correctness, it’s about human decency. It’s about publicly recognizing the dignity of everyone and the value of each and every life, and celebrating the tenacity and courage of women and men like Ms. Somoza. There is no shame in being disabled … the shame lies only with those who fail to recognize that.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on July 26, 2016, and is available on the WAMC website.]

Posted in Disability, Discrimination, Media, Policy, Politics, Uncategorized | Leave a comment

Welcome to Cleveland. Please Set Your Watch Back 100 Years.

As anyone who listens to my commentaries or reads some of my opinion pieces likely suspects, I tend to fall on the liberal side of the political spectrum. That said, next week I will definitely be watching the political three-ring circus that is the Republican National Convention.

This election cycle has been one for the history books, with the Grand Old Party of Lincoln, Eisenhower and Reagan bucking tradition and defying expectations by selecting opinionated billionaire Donald Trump as the presumptive nominee. More importantly, the 112 members of the Republican National Committee Platform Committee have drafted a staunchly conservative political platform that outlines their vision for America. This platform will now be presented to the delegates of the Republican National Convention for approval on Monday.

That the platform itself is politically conservative should come as no surprise, particularly as the Republican Party has become increasingly beholden to right-wing ideologues and organizations like the Tea Party, the Family Research Council, and the National Rifle Association. I expect the Democratic Party Platform to be equally progressive, particularly as the Clinton campaign struggles to recruit the disaffected supporters of Bernie Sanders.

What’s surprising about the GOP’s 2016 platform is this: it is an ultra-reactionary platform that runs counter to a century of progress in civil rights, ignores some of the basic premises of our Nation’s founding and previous Republican philosophies, and outwardly ignores conclusive data on public health and climate change.

Consider, for example, the numerous and tone-deaf provisions that target the LGBT community. Coming exactly one month after a single gunman killed 49 people at a gay club in Orlando, and despite claims by the Platform Committee that it didn’t not want to engage in “identity politics”, social conservatives who were still bristling over Supreme Court rulings like United States v. Windsor and Obergefell v. Hodges were able to include a number of discriminatory provisions in the platform documents.

Included among these discriminatory provisions was a reaffirmation of marriage as the legal union of one man and one woman, a call for a Constitutional Amendment to ban same-sex marriage, a requirement that transgendered individuals use the bathroom or changing room that aligns with the sex on their birth certificates, and support for state- and federal-level legislation that would allow any person or company to legally discriminate against the LGBT community on the basis of religious freedom.

Worse yet, the GOP Platform also expresses support for so-called “conversion” or “reparative” therapy, psychiatric treatment that aims to change an individual’s sexual orientation. In pushing that political plank, the members of the Platform Committee – which includes the head of an anti-gay organization described by the Southern Poverty Law Center as an official hate group – ignored decades of medical research. In 2009, for example, the American Psychological Association engaged in a comprehensive review of all of the then-available research on reparative therapy. They reviewed all studies on gay conversion therapy conducted between 1963 and 2007, and concluded that a person’s sexual orientation could not be changed with therapy. That review also found that individuals who underwent reparative therapy were likely to have higher rates of anxiety, depression and suicide than other members of the LGBT community.

So compelling are these data that the American Psychological Association, the American Psychiatric Association, the American Counseling Association, the American Academy of Pediatrics, and the National Association of Social Workers have all condemned reparative therapy. The American Psychiatric Association goes even further, calling the practice unethical and stating that, “the potential risks of reparative therapy are great, including depression, anxiety and self destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self hatred already experienced by the patient.” Five states have also banned the practice. It should not be surprising then that the even the Log Cabin Republicans – a group of LGBT conservatives that frequently ignore the anti-gay rhetoric of their own party – have spoken out against the platform, calling it “the most anti-LGBT Platform in the Party’s 162-year history.”

Lest you think the GOP’s 2016 platform only targets the LGBT community, however, consider these other planks. Ignoring the spate of gun violence, particularly crimes committed using legally obtained semi-automatic weapons, the Platform Committee passed an amendment opposing any law that would restrict magazine capacity. The traditional anti-abortion language was also strengthened to exclude abortion even when the pregnancy is the result of rape, incest or threatens the health of the mother. Contrary to the opinion of most military experts, and the experience of the Israeli Defense Force, the members of the Platform Committee continue to oppose women occupying combat positions in the US military. Finally, and in direct contravention of the Establishment and Free Exercise Clauses of the First Amendment, the GOP platform demands that lawmakers use religion as a guide when legislating by stating that, “man-made law must be consistent with God-given, natural rights.”

Despite dubious claims by Donald Trump and his supporters that he would be better for women, for minorities and for the LGBT community than Democratic-nominee Hillary Clinton, this platform (which the Trump campaign has already endorsed) seeks to overturn the hard won civil rights of all Americans. For a party that condemns so-called ‘identity politics’ and claims to offer a ‘big tent’ that welcomes all people regardless of race, ethnicity, gender, religion, sexual orientation, or political views, the proposed 2016 platform suggests the exact opposite.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on July 14, 2016, and is available on the WAMC website.]

Posted in Discrimination, Homosexuality, Human RIghts, Policy, Politics, Uncategorized | Leave a comment

No Forgiveness for Florida

Like so many others around the world, this past weekend my husband and I watched in disbelief as the deadliest mass shooting in American history unfolded in Orlando. What started out for many as a joyous evening of drinking and dancing turned into a horrifying morning of chaos and mayhem after a deranged gunman used a legally obtained semiautomatic rifle to kill 49 people and wound 53 others at a popular gay nightclub called Pulse.

In the four days since the shootings in Orlando, we still know little about the gunman’s motives. However, the opportunistic motives of so many others capitalizing on this tragedy are clear.

Consider the motives of the radical terror group ISIS, which has been quick to claim credit for the assault. In chilling calls to 911 and a local television station during the attack, the gunman pledged allegiance to that militant organization. While there is no evidence that the shooter was acting on direct orders from ISIS leaders, the virulent homophobia of ISIS is well known. In the regions of Iraq and Syria that group still holds, those suspected or accused of the crime of being gay are put to death. So routine are these executions, in which men hurled from the tops of five-story buildings as bloodthirsty crowds watch from below, that they scarcely make the news anymore.

As sickening as that sounds, imprisoning or executing people simply because they are gay is commonplace. According to a 2016 report by the International Lesbian, Gay, Bisexual, Trans and Intersex Association, more than 70 countries worldwide criminalize homosexuality. In 13 of those countries, it is a crime punishable by death. There are also many right here in the United States would probably support the passage of similar laws in our country, as suggested by the vitriolic rhetoric, odious Facebook posts and hateful tweets of conservative activists and evangelical preachers in support of the Orlando shooter. So intense is their hatred of the LGBT community that they openly praise a deranged man claiming allegiance to a terror group that would gleefully put these so-called “Christians” to death as well.

Consider the motives of politicians on both sides of the aisle. Those on the left are already demanding gun reform, with Democratic senators seizing control of the Senate floor in a filibuster-style takeover until Congress acts to close the gun-show loophole. Similarly, those on the right have been quick to use the shooter’s alleged but unproven links to the foreign terror group ISIS to call more stricter immigration laws and intensified military action in the Middle East. Both sides have expressed compassion for Orlando’s victims and their families, with those on the left calling for greater social tolerance and increased legal protections for LGBT individuals while those on the right have cynically avoided any mention of the gay community or their continuing efforts to block or overturn anti-discrimination ordinances and statutes.

Consider the motives of the news media. As with many other recent tragedies, including Newtown, Paris and Belgium, they have used the shooting in Orlando to boost sagging ratings. As communication experts will tell you, news producers ascribe to the simple mantra of, “If it bleeds, it leads.” There was a lot of blood on the dance floor of the Pulse nightclub, and the media has since been locked in a twenty-four hour cycle of consisting of graphic descriptions of the tragedy from on the ground reporters, speculation about the shooter’s intentions from armchair pundits (including salacious suggestions that he was a closeted gay man himself), and promises to prevent similar tragedies from self-serving politicians.

Finally, consider my motives in writing this commentary. I am not saddened by the tragedy, although I have great sympathy for those directly affected. Instead, as the tone of my words suggests, I am angry. I am furious, and that rage will spur me to action.

For example, although it may seem like a tiny thing to do, I will now and forever refuse to speak the gunman’s name. People who commit atrocities like this deserve to be forgotten. They should not be remembered. They should not be forgiven. Rather, they should be relegated to the dustbin of history and cursed with eternal anonymity. It is the victims of the attacks who should be honored, named and remembered through stories, pictures, and songs.

Likewise, I refuse to pray for Orlando, despite the social media hash tag calling for me to do so. My prayers may give me solace, but they will do nothing for the victims and their families. I don’t want solace. I want action.

If we are truly members of a civilized society, we must use tragedies like this to act, to move forward, to progress, and to create an increasingly just and compassionate world where horrors like this become less rather than more frequent. This will require a thoughtful and bipartisan response by our politicians to problems of terrorism, gun violence and public safety. This will require conservative groups and evangelical organizations to practice the Christian values that they espouse rather than use Scripture to condemn those with whom they disagree. This will require Americans from all walks of life to recognize the humanity and dignity of everyone, regardless of their race, their religion, their gender, or their sexual orientation.

Sadly, I doubt that any of this will happen … and that is the ultimate tragedy.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on June 16, 2016, and is available on the WAMC website.]

Posted in Disasters, Homosexuality, Human RIghts, Military, Policy, War on Terror | Leave a comment

Five Ring Circus

In a mere 65 days, almost 10,000 athletes from 204 countries will gather in Rio de Janeiro for the start of the 2016 Summer Olympic Games. An additional 500,000 spectators are expected to file into Rio’s athletic venues, walk its crowded streets, tour its famous monuments and seamy favelas, and frolic on its fabled beaches. Over a hundred thousand more – athletes, staff and tourists – will visit Rio the following month for the 2016 Paralympic Games.

I love watching the Olympic Games. I will likely spend those two weeks in August with every free hour glued to the television watching the world’s greatest athletes compete in sports from archery to wrestling. I also love Rio de Janeiro, a city that rightfully deserves the Portuguese-language nickname Ciudad Maravillosa, or Marvelous City. That said, I worry that these games will be an unmitigated disaster.

There are a lot of reasons to be worried about these Games. There is, for example, the fact that many of the athletic venues being built for South America’s first Olympics are not yet finished; it will require a herculean effort by the Rio Games organizers to complete them in time. There is also the current political crisis unfolding in Brazil, with populist President Dilma Rousseff recently impeached and placed on trial for corruption in what many of her supporters are calling a bloodless coup.

There is also the ongoing and still unfolding doping scandal, with Russia fighting claims that it engaged in systematic efforts to hide evidence of widespread abuse of performance enhancing drugs by Russian athletes at the 2014 Sochi Winter Olympic Games. So serious are the claims that the International Association of Athletics Federations has suspended Russia’s eligibility to compete in international track and field competitions, including the Rio Games, until that country shows that it is compliant with the doping rules established by the World Anti-Doping Agency. That doping scandal, however, has again raised questions about corruption among national and international athletic organizations like the International Olympic Committee (IOC), including investigations into the decision to award to 2016 Games to Rio.

Surprisingly, none of those problems, crises or scandals matters to me. The same concerns or claims have been raised about nearly international competition in modern history, yet most of those games have gone off without a hitch. What worries me about the Rio Games is something that I have been thinking, writing and talking about a lot of late: Zika.

If you listed to my radio commentary just a couple of weeks ago, you already know about the threat that Zika poses. A mosquito-borne virus that is now epidemic in Brazil (as well as nearly every other country in the Western hemisphere), Zika is associated with any number of serious diseases. Children born to Zika-infected mothers, for example, are at elevated risk for a serious birth defect known as microcephaly. Older adults infected with this virus may also develop a serious neurological condition known as Guillain-Barré Syndrome, which can result in muscle weakness, paralysis and even death. So serious is the Zika outbreak that the US Centers for Disease Control and Prevention has recommended that Americans “consider delaying travel to areas with active Zika virus transmission.”

As many as 1.5 million Brazilians have already contracted Zika. Rio de Janeiro and the surrounding state is one of the hot spots of viral transmission in that country, with nearly 1 in 500 Cariocas (as residents of Rio are known) having been infected to date. The spread of that disease also remains unchecked, with Rio’s own officials reporting a three-fold increase in the spread of mosquito borne diseases like Zika and dengue this past year. This is largely a result of Rio’s crumbling public infrastructure and recent cuts to its existing public health programs (including a 20% cut to mosquito control programs), and something that cannot be easily fixed. This makes the coming influx of foreign competitors and tourists a ticking time bomb.

Should current rates of transmission remain unchanged, we can predict that thousands of Olympic athletes and spectators will be infected. Many (if not most) of those afflicted will likely return home before they even begin to show symptoms, spreading the Zika virus to all corners of the globe in just a few weeks time. While not all of those cases will spark local outbreaks, some might (particularly in warmer regions of the world where mosquitos capable of spreading the virus already exist).

So serious is this concern that last week nearly 200 physicians, researchers, and public health experts (myself included) wrote a letter to World Health Organization (WHO) Director General Margaret Chan calling for the Rio Olympics to be moved or delayed. Not surprisingly, given the economic impact that moving or delaying the Games would have on Rio and its travel industry, on the IOC, on the national teams and athletic delegations, and (most importantly) on the many multinational corporate sponsors who benefit from free advertising during the Olympics, our call for prudence and caution was rejected.

Economic shortsightedness has once again ruled the day, placing millions (and even billions) of people at risk. Moreover, the WHO has abrogated its responsibilities to protect the public health in favor of maintain its financially lucrative (and largely secret) economic partnership with the iOC. It’s not a question of if but when Zika becomes a global crisis. But at least we will know whom to blame … that competition has already been won.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on June 2, 2016, and is available on the WAMC website.]

Posted in Athletics, Politics, Public Health | Leave a comment

Zeroing in on Zika

Every year I spend one to two weeks visiting the Caribbean island nation of Grenada. I don’t go for vacation, despite the allure of that country’s white sand beaches, but rather for work. I spend most of my time in windowless classrooms teaching clinical and research ethics to a number of graduate, medical and professional students from across the region.

One of the worries often voiced by family and friends when I travel to the tropics is about my health and safety. In recent years there have been a number of outbreaks of mosquito-borne diseases across Latin America and the Caribbean, including dengue, Chikungunya and (most recently) Zika. I myself caught Chikungunya during a visit to Grenada a year-and-a-half ago. Despite having a relatively mild case of what the locals call ‘Chick-V’, I still suffer from some lingering aftereffects, including intermittent arthritis-like joint pain in my right hand.

Despite all hullabaloo about Chikungunya in past years, public concern about that disease has largely faded in both the US and in the Caribbean. Most of the people I work with or teach in Grenada caught and recovered from ‘Chick-V.’ While the disease is now endemic in that part of the world, the number of new cases is relatively small since most people are now immune. Moreover, the long-term health impacts of Chikungunya are relatively mild.

Instead, and rightfully so, it is the rapid spread of the Zika virus across the Western hemisphere that is raising so many concerns. Zika, as you undoubtedly know, was first identified as a serious health threat during an outbreak of that virus in Brazil. Although most of the people who became sick with Zika only developed a mild illness – characterized by fever, headache and joint and muscle pain – at the same time Brazilian health authorities also noted a sudden increase in the number of children born with a rare birth defect known as microcephaly. Similar increases were also seen in other Zika hotspots, including El Salvador and Jamaica.

Microcephaly is a neurological condition in which an infant is born with a smaller-than-usual brain. Some children born with microcephaly develop normally, but most will experience lifelong symptoms that include developmental delays and disabilities, difficulties with coordination and movement, hyperactivity, and seizures.

So serious is the problem that some government officials in the region recommended that women avoid getting pregnant until the Zika outbreak is contained. Other (largely Catholic) countries in the region are reconsidering laws that currently outlaw abortion. Health authorities in the US and elsewhere are similarly recommending that pregnant women avoid traveling to Zika-affected areas. Some have even called for Brazil to cancel the 2016 Summer Olympic Games in Rio because of the potential threat that the virus poses to competitors and spectators.

Experts are also raising concerns about the possibility of an outbreak of Zika in the United States and Southern Europe. To date, over 500 cases have been reported in 35 states, including 48 cases involving pregnant women [Update: One day after writing this, the US Centers for Disease Control and Prevention increased these figures to include 279 pregnant women]. While none of these cases were locally acquired – all of these patients were infected while traveling in a Zika-afflicted region of the world – Aedes aegypti, the mosquito that most commonly transmits the virus, is abundant throughout the southern tier of the US. Nearly 700 cases of Zika have also been reported in the American territories of Puerto Rico, Samoa and the Virgin Islands; almost all of those cases were locally acquired.

So convinced are American public health experts that an outbreak of Zika in the US is imminent that doctors at the Children’s National Health System in DC, the Texas Children’s Hospital and the Baylor College of Medicine in Houston, have established specialized programs for diagnosing and treating people with the virus. Similarly, the US Centers for Disease Control and Prevention and the National Institutes of Health have already invested nearly $600 million to study the disease and to develop a vaccine.

Despite this, and despite a $1.9 billion request by the White House to combat the Zika crisis, Congress has largely failed to act. While the Democratic-controlled Senate has authorized $1.1 billion in funding, the Republican-controlled House of Representatives has proposed spending a paltry $600 million. Most of those House-authorized funds would also come from existing public health programs, including $350 million that would be stripped from a program designed to develop a vaccine for Ebola. The only House Republican who supports the Obama’s Administration request for nearly $2 billion? That would be Congressman Vern Buchanan of Florida, whose state has already (and will continue to be) the hardest hit by Zika.

During an election cycle where the most newsworthy candidates are decrying “politics as usual,” our leaders in Congress are nevertheless doing just that. They are risking the nation’s health because they don’t want to be seen as spendthrift politicians who spend taxpayer’s dollars willy-nilly. Only when we have a full-fledged outbreak, when our pregnant sisters and daughters are infected with a dangerous virus, when our children are born with a largely preventable birth defect will they likely act. Unfortunately, as our response to AIDS, to Ebola, and to other public health crises has shown, by then it will be too little too late.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on May 19, 2016, and is available on the WAMC website.]

Posted in Clinical Care, Health Care, Human RIghts, Policy, Politics, Prenatal, Public Health | Leave a comment

Half-and-Half Wits

I lost a friend last week. I didn’t lose her in the physical sense. She didn’t pass away or move to the other side of the globe. Rather, after a disturbing online exchange, I made the decision to, in the words of Gwyneth Paltrow, ‘consciously uncouple’ myself from her.

What happened was this: on her Facebook page she posted a popular Internet meme that read, “If Caitlyn Jenner went missing, would her picture appear on the back of a carton of half-and-half?” While some people might find a celebrity-mocking joke like this funny, I found it in exceedingly bad taste.

I was also surprised that this joke was posted by someone who is herself a member of the LGBT (lesbian, gay, bisexual and transgender) community. I asked her to take the post down, explaining my concerns about the type of message that a joke like that sends. She refused and our online conversation quickly went downhill. I finally ‘de-friended’ her.

Now anyone who knows me well should know that I rarely take offense at jokes. I enjoy sarcastic, self-depreciating and (often) inappropriate humor, particularly of the type that skewers celebrities and politicians, or that calls out some of the absurdities of modern life. My snarky comment about Gwyneth Paltrow is proof of that. So what was it about this joke that got me so riled up?

The problem with a joke like the one about Caitlyn Jenner is it perpetuates ugly stereotypes about the transgender community. It makes light of the real struggles of a highly marginalized and stigmatized segment of the population. It contributes to the continued victimization of a group of individuals whose only mistake was to be born into the wrong body.

Because of their fame, transgendered celebrities like Caitlyn Jenner, award-winning actress Laverne Cox, and musician Chaz Bono are easy targets for jokes like this. However, their wealth and prestige means that they are largely insulated from the discrimination and harassment that other transgendered men and women deal with on a daily basis.

If Caitlyn Jenner heard us laugh at a joke that implies that she is somehow half a man or only half a woman, she would probably roll her eyes, climb into her limo, and head off to her next photo shoot or red carpet gala. But when a young man or woman who is struggling with their gender identity hears us laugh, it sends a very different and very powerful message. It reinforces the idea that they are somehow damaged or defective. It denies them of their basic humanity and strips them of their dignity.

Add to this the fear-mongering rhetoric of politicians in states like North Carolina, Mississippi and Tennessee – where conservative lawmakers have promoted the idea that transgendered individuals are sexual predators in order to gain support for laws that deny them access to basic services, including the use of public restrooms – and it should come as no surprise that transgendered men and women have some of the highest rates of drug addiction, alcohol abuse, domestic violence and suicide.

For example, the National Transgender Discrimination Survey, a study of over 6,000 people conducted by the National Gay and Lesbian Task Force and National Center for Transgender Equality, found that over 40% of transgendered men and women attempt to take their own lives. This is a rate of suicide that is more than 10-times the national average.

That same 2011 study also found that transgendered individuals are very likely to be bullied in school (55 percent), to experience discrimination at work (59 percent), to be refused services by a health care provider (60 percent), to be harassed by law enforcement officers (61 percent), to be homeless (69 percent), and to be the victim of physical violence and sexual assault (78 percent). Most frightening is the fact that murder of transgendered women has hit an all time high, with one transwoman killed every 29 hours. Few of these murders are solved; of all of the transgender murders that occurred from 2013 to 2015, not a single one was prosecuted or even reported as a hate crime.

All of this can be directly attributed to the rampant transphobia that permeates American society. While a single ill-conceived joke about Caitlyn Jenner might not seem like a big deal, when we suggest that transgender men and women are to be laughed at we ourselves contribute to the internalized self-loathing and externalized stigmatization that results in the tragic death of so many of our brothers, sisters, sons and daughters.

Suicide, murder, physical violence and sexual assault are no laughing matter. If you think that they are, then you’re a half-and-half wit.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on May 5, 2016, and is available on the WAMC website.]

Posted in Discrimination, Human RIghts | 1 Comment

The Weight of the World

When I was a young child, I was a very picky eater. I would often refuse to eat the meals my parents put before me, even if it was something that I’d eaten and enjoyed before. Some kids are so-called “selective” eaters because of a medical problem like gastroesophageal reflux disease, gluten intolerance, or some other nutritional or sensory disorder, but my picky eating was a result of sheer stubbornness.

Like most mothers, mine resorted to all sorts of inducements, incentives and threats to get me to eat, including using the age-old remonstration about starving children in India or Ethiopia. My usual retort was to offer to pay the postage out of my allowance so that she could send the food there.

What a change 40 years can make. The rebellious five-year-old boy who would go a whole month eating nothing but buttered noodles is now a very adventurous eater. I have even sampled such exotic foods as snake, spiders, jellyfish and grasshoppers while traveling overseas. Even more surprising, although there is still a massive problem of hunger and malnutrition in India, Ethiopia and even in the United States – as many as 1 in 7 Americans go to bed hungry – there are now more people who are obese than who are malnourished globally.

According to a new study published in the medical journal The Lancet last week, the number of people in the world who are clinically obese has increased six-fold over the last four decades. Using a measure of body fat composition known as the body mass index (or BMI, which is calculated as an individual’s weight in kilograms divided by their height in meters squared), researchers compared historical rates of obesity among 20 million people from 186 different countries.

Clinically, a person is usually considered to be obese if they have a body mass index of 30 or higher. By this standard, an American man who is an average 5’10” in height and weighs 210 pounds would be obese. While the use of BMI as an individual measurement of body fat does have its flaws – it doesn’t distinguish between fat and lean muscle, for example, so an extreme body builder might also be classified as “clinically obese” despite a body fat level of less than 5% – the body mass index does works well when examining obesity at the population level.

What the study in The Lancet reported was this: the number of people worldwide who are clinically obese has increased more than 600% during the past 40 years, from 100 million in 1975 to almost 650 million in 2014. Globally, ten percent of men and 15 percent of women are now considered to be obese, the bulk of whom (pun intended) live in industrialized countries like the United States, Great Britain and China. By contrast, only 450 million people worldwide are considered to be malnourished. Most of those individuals live in impoverished regions of the world.

Should this trend continue unabated, over one-fifth all adults worldwide will be obese by 2025. Another two-fifths of the world’s adult population will be considered overweight. The public health and economic implications of this are staggering.

According to the World Health Organization (WHO), obesity is linked to as many as 60 life-threatening and costly illnesses, including heart disease, high blood pressure, stroke, cancer, and diabetes. Nearly 3 million people each year die as a result of preventable weight-related illnesses, making obesity directly responsible for about 5 percent of all deaths worldwide.

The human toll aside, obesity-related health care expenses total approximately $2 trillion annually. As a relatively fat nation, both in terms of our waistlines and our wallets, we Americans shoulder about one-tenth of these costs: about $200 billion a year in medical bills alone. Only war and smoking make bigger but equally preventable dents in the world economy.

Small wonder then that the WHO has set the ambitious goal of reversing rates of obesity by 2020. This is, however, a goal that the World Health Organization and other public health agencies will never be able to meet. This is because obesity is not a medical problem. Rather, it is a social problem with medical consequences.

It’s not that so many people worldwide are deliberately eating unhealthy foods. Rather, they increasingly lack access to healthier choices. For example, the urban poor have some of the highest rates of obesity globally. This is in part because they do not have the money or opportunity to buy healthy foods. In many urban communities, from New York’s Spanish Harlem to the Kibera slum in Nairobi, the only stores that sell food are often small corner bodegas that stock little in the way of fresh and affordable produce.

Similarly, our growing urban and suburban cityscapes are rarely designed to provide residents safe opportunities for exercising out-of-doors, whether by providing sidewalks on busy streets, by building walking and biking trails, or by creating and maintaining public facilities like parks and basketball courts.

Quite simply, the global obesity epidemic is a complex social problem with no single quick fix solution. The various public health proposals that have been proposed — free and healthy school lunches for all students, nutritional labels on restaurant menus, taxes designed to reduce the consumption high-calorie foods and drinks, government-sponsored wellness programs, and educational campaigns – all have their merits. Taken alone, however, each of these efforts will be largely ineffectual in reversing current trends.

This isn’t to say that we shouldn’t try, but we need to do more than set lofty goals and promote quick fix policies. This crisis didn’t happen overnight, and it won’t be resolved overnight. We need to develop a holistic and concerted plan that addresses all of the factors contributing to the obesity epidemic, be they medical, psychological, social, political or financial. Only then can we hope to achieve a happier, healthier and lighter future.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on April 21, 2016, and is available on the WAMC website.]

Posted in Health Care, Obesity, Uncategorized | Leave a comment