Friday, December 12, 2008

The Blagojevich complaint: hospitals and political corruption

The news about Governor Blagojevich's alleged corrupt behavior has focused, understandably, on his scams to try to get payback for Obama's Senate seat. Intrigued by some incidental details about a shakedown of a children's hospital CEO, I searched for the word "hospital" in the affidavit. It appears 22 times, with two separate incidents, the first being about a "Certificate of Need" for another hospital and the other being the Children's Memorial incident. The "Certificate of Need" saga will be familiar to those who were already following the Tony Rezko trial, but since I hadn't realized how deeply the Rezko trial was entangled in hospital construction, I include this along with the Children's Hospital CEO.

It's just a reminder that healthcare, perhaps the largest segment of our GDP, is just another industry, immune neither to shakedowns by the corrupt, or corruption of its own.

Here are the appearances of the word "hospital" in the affidavit.


The first group of references concerns a small hospital which a planning board staff felt was unnecessary because there were already plenty of hospitals in the area. The hospital chain wanted to build a hospital anyway. Imad Almanaseer, who provided the crucial vote from the planning board to overrule the staff recommendation not to allow the hospital to be built, is a physician. It was his vote that allowed political corruption to overrule any semblance of the sensible allocation of healthcare resources. For handy reference I've inserted the title "Doctor" before his name, although the affidavit does not do this in the original.

35. As described more fully in the following paragraphs, Mercy Hospital, which sought permission from the Planning Board to build a hospital in Illinois, received that permission through Rezko’s exercise of his influence at the Planning Board after Rezko was promised that Mercy Hospital would make a substantial campaign contribution to ROD BLAGOJEVICH. Rezko later told a member of the Planning Board that Mercy Hospital received the permit because ROD BLAGOJEVICH wanted the organization to receive the permit.

36. Levine’s criminal activities included his abuse of his position on the Planning Board to enrich both himself and Friends of Blagojevich. The Planning Board was a commission of the State of Illinois, established by statute, whose members were appointed by the Governor of the State of Illinois. At the relevant time period, the Planning Board consisted of nine individuals. State law required an entity seeking to build a hospital, medical office building, or other medical facility in Illinois to obtain a permit, known as a “Certificate of Need” (“CON”), from the Planning Board prior to beginning construction.

37. Levine, as well as Planning Board members Thomas Beck and [Dr.] Imad Almanaseer, testified under oath at the Rezko Trial. Beck testified that he asked Rezko to reappoint him to the Planning Board and that Beck thereafter followed Rezko’s directions regarding which CON applications Rezko wanted approved. Beck testified that it was his job to communicate Rezko’s interest in particular CONs to other members of the Planning Board, including [Dr.] Almanaseer, who were loyal to Rezko. Beck testified that he understood that Rezko spoke for the Blagojevich administration when Rezko spoke to Beck about particular CONs. [Dr.] Almanaseer testified that Beck instructed him that Rezko wanted [Dr.] Almanaseer to vote a particular way and that [Dr.] Almanaseer should follow Levine’s lead in voting on CONs. [Dr.] Almanaseer testified that before certain Planning Board meetings, he received notecards from Beck indicating how to vote on certain CON applications. Beck testified he provided these notecards to [Dr.] Almanaseer and certain other members of the Planning Board to communicate Rezko’s directions about certain CON applications.

38. During his testimony, Levine described a plan to manipulate the Planning Board to enrich himself and Friends of Blagojevich. The plan centered on an entity commonly known as Mercy Hospital (“Mercy”) that was attempting to obtain a CON to build a new hospital in Illinois. Levine knew the contractor hired to help build the hospital. In approximately November 2003, on behalf of the contractor, Levine checked with Rezko to determine whether Rezko wanted Mercy to obtain its CON. Rezko informed Levine that Mercy was not going to receive its CON. According to Levine, he asked Rezko whether it would matter to Rezko if Mercy’s construction contractor paid a bribe to Rezko and Levine and, in addition, made a contribution to ROD BLAGOJEVICH. Levine testified that Rezko indicated that such an arrangement would change his view on the Mercy CON.

39. Levine’s testimony regarding Rezko’s actions to change the Planning Board decision concerning Mercy’s application for a CON based on contributions for ROD BLAGOJEVICH is confirmed by attorney Steven Loren. Loren testified at Rezko’s criminal trial and, before that, in the grand jury. According to Loren, in approximately December 2003, Levine informed Loren that Rezko was against the Mercy CON. According to Loren, Levine relayed to Loren a conversation between Rezko and Levine during which Levine asked Rezko whether a political contribution to ROD BLAGOJEVICH would make a difference for Mercy’s CON, and Rezko responded to Levine that such a contribution might make a difference.

40. Thereafter, and confirmed by the testimony of Levine, Beck, and [Dr.] Almanaseer, as well as recorded conversations, Rezko switched his directions to Beck and informed Beck that Mercy was to receive its CON. According to [Dr.] Almanaseer, although he previously had been told by Beck that Rezko did not want Mercy to receive its CON, he was later told that there had been a change and that Rezko now wanted Mercy to receive its CON.

41. Mercy received its CON as a result of a controversial and irregular vote at a public Planning Board meeting. [footnote: There was extensive testimony regarding the irregularity of the vote at the Planning Board meeting. In summary, during the vote, Levine got up from his seat and went to speak to Beck and to [Dr.] Almanaseer. After these discussions, [Dr.] Almanaseer then changed his vote to be in favor of Mercy receiving its CON. Beck then voted in favor as well and by a vote of 5 to 4, Mercy’s application for a CON passed.] The vote brought significant publicity to the Planning Board and ultimately led to the disbanding of the Planning Board. [Dr.] Almanaseer testified under oath in the grand jury that not long after the Planning Board vote on Mercy’s CON he saw Rezko at a fundraiser. According to [Dr.] Almanaseer, he was still embarrassed about what had occurred at the Planning Board vote on Mercy’s CON and Rezko’s role in the vote. [Dr.] Almanaseer testified that he asked Rezko why Rezko had switched the vote on the Mercy CON. According to Almanaseer, Rezko stated: “The Governor wanted it to pass.” [Dr.] Almanaseer understood the reference to “Governor” to be a reference to ROD BLAGOJEVICH.

[Before moving on, let's celebrate the internet's ability to provide some historical context, here from Crain's Chicago Business. Here's an excerpt from a 2004 article I found about the original decision:

Mr. Levine and Jacob Kiferbaum, president of Deerfield-based Kiferbaum Construction Corp., serve together as trustees of Rosalind Franklin University of Medicine and Science, formerly known as Chicago Medical School. Mr. Kiferbaum also contributed $45,000 to former state Attorney General Jim Ryan's 2002 campaign for governor, for which Mr. Levine served as finance director.

Mr. Levine, an attorney and investor from Highland Park, didn't return calls seeking comment for this story. A transcript of the April 21 meeting shows he led the board in discussing the Mercy application, encouraging members to vote in favor of the hospital and to disregard approval criteria he called "hopelessly outdated.''

During the roll call vote on the application, Mr. Levine voted for approval and walked across the room to talk with Imad Y. Almanaseer, a Glenview physician, who had abstained, according to two people who attended the meeting. After the conversation with Mr. Levine, Dr. Almanaseer changed his vote to "yes,'' giving the Mercy project the fifth vote needed for approval.

Dr. Almanaseer is resigning from the board July 1, when his term expires. He didn't return calls last week, but in an interview several weeks ago, he denied feeling pressured to vote in favor of Mercy.

"I honestly don't feel it,'' he said. "(Mercy) made a case for the need for more physicians in that area, and we agreed.'']


The second group of references comes in relationship to the desire of the governor to exchange an increase in reimbursements for pediatric care for a campaign contribution from a Children's Hospital CEO:

65. According to Individual A, on October 8, 2008, during a discussion of fundraising from various individuals and entities, the discussion turned to Children’s Memorial Hospital, and ROD BLAGOJEVICH told Individual A words to the effect of “I’m going to do $8 million for them. I want to get [Hospital Executive 1] for 50.” Individual A understood this to be a reference to a desire to obtain a $50,000 campaign contribution from Hospital Executive 1, the Chief Executive Officer of Children’s Memorial Hospital. Individual A said that he/she understood ROD BLAGOJEVICH’s reference to $8 million to relate to his recent commitment to obtain for Children’s Memorial Hospital $8 million in state funds through some type of pediatric care reimbursement. As described in further detail below, intercepted phone conversations between ROD BLAGOJEVICH and others indicate that ROD BLAGOJEVICH is contemplating rescinding his commitment of state funds to benefit Children’s Memorial Hospital because Hospital Executive 1 has not made a recent campaign contribution to ROD BLAGOJEVICH.

66. According to Individual A, during this same meeting, ROD BLAGOJEVICH began discussing recent media reports about the possibility that Antoin “Tony” Rezko was cooperating with the government. According to Individual A, at one point in the
conversation, ROD BLAGOJEVICH said words to the effect that he was not concerned about Rezko’s cooperation because he was not involved in illegal activity with Rezko. According to the Individual A, Fundraiser A then said words to the effect of, “unless
prospectively somebody gets you on a wire.”

a. On the morning of November 12, 2008, ROD BLAGOJEVICH talked to Fundraiser A. During the course of the conversation, which principally concerned the status of campaign fundraising efforts, Fundraiser A told ROD BLAGOJEVICH that Fundraiser A had never heard from Hospital Executive 1. Fundraiser A said, “I’ve left three messages there so I’m gonna quit calling. I feel stupid now.” ROD BLAGOJEVICH asked when the most recent call was, and Fundraiser A replied that it was two days ago. ROD BLAGOJEVICH said that if “they don’t get back to you, then, then, last resort is, I’ll call.”

b. Later on November 12, 2008, at approximately 2:14 p.m., ROD BLAGOJEVICH spoke with Deputy Governor A, a Deputy Governor of the State of Illinois. The following exchange began the conversation:
ROD BLAGOJEVICH: The pediatric doctors – the reimbursement. Has that gone out yet, or is that still on hold?”
DEPUTY GOVERNOR A: The rate increase?
DEPUTY GOVERNOR A: It’s January 1.
ROD BLAGOJEVICH: And we have total discretion over it?
ROD BLAGOJEVICH: We could pull it back if we needed to – budgetary
concerns – right?
DEPUTY GOVERNOR A: We sure could. Yep.
ROD BLAGOJEVICH: Ok. That’s good to know.

c. On November 12, 2008, at approximately 8:26 p.m., Fundraiser A called ROD BLAGOJEVICH and reported the status of fundraising efforts. During the conversation ROD BLAGOJEVICH instructed Fundraiser A to call Lobbyist 1 the following day and ask Lobbyist 1 what to do about the fact that Hospital Executive 1 is not calling Fundraiser A back and inquire whether it was possible that Individual A had instructed Hospital Executive 1 not to call back (see Paragraph 65). ROD BLAGOJEVICH asked, “what do we do with this guy, [Hospital Executive 1]?”

d. On November 13, 2008, at approximately 10:05 a.m., ROD BLAGOJEVICH talked with Fundraiser A. The discussion concerned the status of fundraising efforts. During this call, ROD BLAGOJEVICH asked about Highway Contractor 1. Fundraiser A stated that Lobbyist 1 is still working with Highway Contractor 1. Fundraiser A also advised ROD BLAGOJEVICH that he will be meeting Lobbyist 2 to meet with an individual at Weiss Memorial Hospital. ROD BLAGOJEVICH states: “Yeah, now be real careful there. I mean, the FBI went to see [Lobbyist 2]. You understand?” Fundraiser A also said that he had a call into Individual A and that Fundraiser A will talk to Individual A about Hospital Executive 1.

g. On November 14, 2008, ROD BLAGOJEVICH talked to Fundraiser A. During the conversation Fundraiser A told ROD BLAGOJEVICH that he had spoken with Individual A, and that ROD BLAGOJEVICH needed to call Hospital Executive 1. ROD BLAGOJEVICH said that he would call him.

Thursday, December 11, 2008

variation on a theme: romance of long hours

written post-call after a long ICU shift, which after I wrote it I realize is a reworking of some things I've written before

I used to work at a public health job, working for the city, with good benefits, and time to go to the gym before going home to make myself dinner. When I started talking about becoming a doctor, a lot of people said that was nuts, most of all some doctors who looked back on their experience bitterly. Others were more encouraging, and I chose medicine.

I have no idea what my life would have been like if I hadn't chosen medicine; but what I usually tell people is that although I've sometimes been exhausted or miserable or depressed or discouraged, I've almost never been bored. I hated being bored at work. Now I'm not bored.

But aside from medical training being totally absorbing, part of the dirty little secret of long work hours is that it is part of a romance that doctors and patients have with each other. Many of my patients look at me sympathetically and ask whether I ever go home, and even shake their heads over my working conditions. But many of them also seem to sort of appreciate the romantic idea that I'm some sort of insanely dedicated nut who cares only about helping people and has no life other than worrying about their telemetry alarms. I'm there all night, yes; but I'm there for them.

On the flip side, as I'm complaining to my friends with regular jobs, I'm also a little proud of myself for making a different choice. I joined the few and the proud; my life is full of drama and a sense of importance. In the dark early morning hours in my academic hospital, the halls begin sputtering with the energy of people working really hard to become who they are going to become. That's kind of beautiful, and I am proud to be a part of it. And, though usually I would only tell my mom this, I'm proud of myself. I'm proud of myself for choosing something tough. This is a common impulse: it is the basic idea of most military recruiting pitches, and it has worked to convince people to do difficult or even insane things for many generations before this one.

When I worked in a regular job, I felt that my life lacked significance or importance somehow, even though I was doing important work. That was because I lacked this sense of drama.

The sense of drama that draws doctors to our training--even as the conditions that make our training dramatic also sometimes make us bitter or depressed--is probably in the end a fiendish tool of The Man to make us work harder for cheaper, and like it.

It's also part of how doctors become self-justifying later; other people can just suck up whatever hardship they face, because we did. (As if a few years of earning an average American wage and working insane hours in preparation for joining the top tier of wage-earners and gaining inestimable social prestige is really a form of enduring suffering.)

Change won't occur until the rest of the society stops appreciating the beauty and the drama of the dedication that the medical training process represents, and starts viewing residents as participants in a high-stakes industrial process that must eliminate systemic sources of error. But the latter view is much less romantic, and much less beautiful.

For almost everyone involved, it is more emotionally satisfying and less safe to romanticize the difficulty of medical training. Perhaps this is not surprising: in many other parts of life, emotional appeal often wins out over sensible decisions. But that appeal is part of why doctors choose this life; and I think that the romance of the doctor as a special breed of person is part of what seduces patients of academic hospitals into accepting a system that is not always designed in their best interest.

Friday, December 5, 2008

Cat and mouse and us

The Hemodynamic Cat battling a swinging light switch, photos by Ms. Dr. Hemodynamics; the HC in a quiet time.

Recently, the Hemodynamic Cat did something surprising: she caught a mouse.

I would like to say that I have never doubted the Hemodynamic Cat's mouse-catching abilities, but this is not the case. She spends a lot of time pouncing on and batting around her toy mice, in a way that suggests some inner ferocity. But her record on watching cockroaches with interest rather than hitting them, and her failure to show any evidence of actual mouse-catching, left me a little skeptical. I've come to love the HC for other reasons.

Recently, I was coming to bed and saw that the HC had a mouse in front of her, and was looking up at me expectantly, as she sometimes does when she wants me to play with her and her toy mice. Then I looked more closely and saw that it was too thin and small to be one of her toys; and that in fact it was breathing.

My experiences in an immunology lab left me well-prepared for this moment; I picked up the mouse by its tail, and eventually delivered it to a warm spot outside our apartment where I hoped it might be able to recover and go on living outside our apartment. It wasn't moving much, and I thought about more definitively snapping its neck--to finish the job that the HC had clearly started and end its suffering--but I wasn't sure that it might not be able to rally once no longer stressed and stunned, so I left it. I later found it definitively dead, in the same spot. The HC had killed the mouse.

I know that some cat owners think that the cat's habit of bringing dispatched prey to display to their owner is some outgrowth of wild cat mothering habits. In terms of the original wiring for the behavior, that's probably true--there has to be some "little tasty things I don't eat right away" circuit available to build on. But the wild forebears of domestic dogs also feed their puppies, and domestic dogs don't make a point of sharing their catch with their people in the same way that cats do.

I've always thought that this behavior is actually part of the social contract that cats and people developed with the origins of agricultural society. Recent genetic work confirms what can be surmised from history, archaeology, and anthropology: cats go with agriculture, not with hunting and gathering. When people started having grain silos, field mice started becoming silo mice, moving to where the concentrated bounty of the fields were stored. Cats followed the mice.

This seems like the moment in which the "show the mice" strategy would have been most useful. The social bond would not have come first, and so the showing of the mice is not a process of mistaking people for kittens. It is an act of seeking patronage. A cat who just seemed to wander around the village but did not show the mice she caught to anyone might be tolerated or even enjoyed. But I'm not sure that early agrarian societies would have put much energy into caring for that cat.

On the other hand, the cat who comes to the peasant farmer, drops mice at the door, and meows loudly with enthusiasm, is saying, "I am worth keeping around." What the cat loses in protein from the mouse not eaten, she gains in protein from the people who want to encourage her mouse-killing. People, and especially grain-farming people, want cats to kill many more mice than they need to support themselves; they want cats to kill every mouse in sight. The cat that brings mice is showing her dedication to this shared mission. The cats that are also social and charming get to live inside and sleep next to the warm bodies of the giant primates, but the "show the mouse" strategy might well have been the first step in the evolution of cat domestication.

Cat experts sometimes say that cats, unlike other domestic animals, domesticated themselves. This explains their more ambivalent attitude about human attention; cats have eliminated only the wildness that kept them out of the house, and sometimes not even that. The Hemodynamic Cat, her ancestors having been bred for the company of princesses, is an extremely social creature with the people she knows, but she still has a wariness of new people that shows the not-so-ancient wild cat inside her.

As I held the mouse by its tail, its lungs expanded and contracted and its little legs kicked. In retrospect, given that the mouse could not get up and walk anywhere after I set it down, I think the legs kicking might have been a lower spinal cord reflex arc. Maybe if something grabs a mouse's tail there is no need to wait for the brain to tell the leg muscles to start making running motions; but the mouse needs the brain to communicate with the spinal cord in order to coordinate its movements. A mouse is a tiny thing, but with all the wonder of mammalian evolution, and of its own special qualities. From scores of dissections, I could imagine its heart; its thin, wide diaphragm; and, as I found again and again in the lab, its comparatively large spleen, full of blood and immune cells. I didn't want to touch its fur--I didn't want to give it a chance to turn and bite me--but I could remember what touching a mouse felt like, the warm softness of it, the vitality of the quick-moving lungs and heart. The mouse was beautiful, as all mice are, and I mourned its demise.

Still, I don't want mice eating our food and having the run of our house. And so when the Hemodynamic Cat looked up at me, with the little gray field mouse breathing but laying still in front of her, I saw our cat with a new respect, and felt something ancient: our cat was earning her keep.

Our social contract forged between two species, once seemingly consisting only of bonds of affection, had renewed its ancient preamble. I had thought that I loved the Hemodynamic Cat for her inherent value as a creature, and for her love of us, whether or not she caught mice. As I took the mouse out of the apartment, I realized that I now not only loved her, but respected her in a new way. Good job, I told the Hemodynamic Cat, and she said, "Mrowww!" back. I had killed mice for science. The Hemodynamic Cat had done something much more intimate and powerful: she killed a mouse for us.

Thursday, November 27, 2008

Thankfulness, after the fire

photo from Cambridge Chronicle

Of course I'm thankful for the usual things, which are no less important for being usual: the love of my honey, the excellence of our cat, the support and love of my family, privileges and gifts, education, job, paycheck, safety, health. Among other things.

Still, much of my life this fall has been shadowed by the effects of our apartment building's fire. I never noticed how many fires there are in a city, until we were displaced by the fire in our apartment. So, now I don't pass by articles about fires, but instead read them with a little knot of sadness and dread, vividly imagining what they describe: recently a large fire destroyed everything for many residents of a nearby neighborhood--a much worse outcome than we had, given that we only lost our home but not most of our belongings. (Water damage made us homeless, not the flames themselves.)

Earlier today, while I was still at work, a fellow resident was looking for her stethoscope and smelled one that looked like hers. "What are you doing?" another resident asked her. She said, "Mine looks just like this but it smells like barbeque because it was one of the only things that survived the fire." When we had our fire, she told me about hers; she had lost almost everything. I hope she finds her stethoscope soon.

Someone else I know had her house burned down by a lightning strike; she's still waiting for it to be rebuilt. Of course, each of our experiences was different; still, like any little club of survivors, we feel alone in what we've experienced, and relieved to find others who have some understanding of what we feel.

Today I'm thankful for what was not lost in the fire: our lives, our health, most of our things. Thankful that it was not worse. But this is a refugee's thankfulness, an it-could-have-been-worse relief tinged with the sometimes angry, sometimes bitter, sometimes just sad knowledge that it certainly could have been a lot better.

This week, we received an organic turkey we'd ordered a long time ago from the farmer's market. Getting the turkey was an adventure, including waiting all evening two nights in a row for the turkey farmer to bring the turkey to us, With some kind of non-functioning email confirmation system and orders written on the back of envelopes, he'd unsurprisingly run out by the time I got to the farmer's market to pick up the one we'd ordered, then was driving around the city with a broken GPS system and a borrowed cell phone, with his wife at the farm reassuring me he would surely be coming very soon. One more thing to be thankful for: I'm not a turkey farmer. Anyway, after we'd ordered the turkey but long before it was delivered, we'd decided that with our schedules and the limits of the apartment we're subletting now, it wouldn't work to cook Thanksgiving dinner. So we have a turkey but not a Thanksgiving turkey. (We're going out for dinner.)

That's OK. We're soon to sign a lease for a new apartment, starting in the first week of the new year if all goes well. I think once we have a real home again, we will feel more thankful. We'll be thankful for things that we are gaining, and not for things that we didn't lose. We're going to keep the turkey in the freezer; like other more important things, getting this turkey was harder than it probably should have been. We'll eat the turkey in our new home, when we're feeling thankful in a new way: in this way, among others, part of Thanksgiving will come late this year.

Wednesday, November 26, 2008

Mbeki as Macbeth

Someone has actually tried to do the math now that he's gone: how many people died as the direct result of Thabo Mbeki's AIDS policies? This particular estimate puts it at 365,000 lives and 3.8 million years of life.

Whatever the number, it was a lot:

As Zackie Achmat says in this NYT article:

“He is like Macbeth. It’s easier to walk through the blood than to turn back and admit you made a mistake.”

Wednesday, November 19, 2008

Hank Wilson, community organizer.

I wrote in my last post about Hank Wilson. Here's a much more lovely long remembrance of Hank Wilson, by his friend Bob Ostertag. Read it.

Here's the last paragraph:
What, exactly, is a "community?" At the university where I teach, there are "experts" in this matter who will give you definitions of community that use so many big words, you will need a PhD of your own just to figure out what they are talking about. Hank Wilson had a definition his kindergarten students could understand: a community was something that took care of its least privileged members. If this simple thing could not be done, then you didn't have much in the way of community. This was Hank's life project, his singular, profound contribution to the gay and lesbian community, and to the city of Saint Francis.

Also, some memories at the San Francisco Bay Guardian's web site (read the comments section);

the Chronicle's article;

for the historians in the crowd, here's the finding aid to the Hank Wilson Papers, which Hank donated when he thought he was about to die of AIDS in 1996, right before highly active antiretroviral therapy saved his life;

and finally, a Magnum Photos photo essay about the Ambassador Hotel.

Of course, you can always help out with the Wikipedia page, in progress.

Thursday, November 13, 2008

Hank Wilson, whistle-blower.

I wrote a while ago about the "No Obits" moment in the Bay Area Reporter.

Today I read a BAR obituary that made me pretty sad. Veteran activist Hank Wilson has died.

Here's Liz Highleyman's nicely-written obituary in the BAR; I'm pasting the text below my own.

Hank was a perennial presence in San Francisco political life and AIDS activism, before, during, and after the time I lived there. Many other people know Hank much better than I do. This is my testimony to Hank, and bear this in mind: I barely knew the guy. I never sat down individually with him and had any conversation with just him and me, never so much as had coffee with him. I saw him at meetings--a lot of meetings. And he was always kind to me.

Here are two things I remember about Hank.

I was working at the STOP AIDS Project and Hank called us. I didn't know Hank but I knew ACT UP, and Hank was calling from ACT UP. He told us that the CDC was having a meeting about HIV prevention for young people and that he thought they should have young people at the meeting. He knew we'd just started a young men's project, and he thought we were the sort of young people who should go to the meeting. He told us who to call.

We called. I told the person at the CDC that I was a young person, I was doing AIDS work, and I wanted to go to the meeting. She bought me an airplane ticket to Atlanta. I went to the meeting. I was in my early 20s, and it was the first time I went to a meeting like that--the first of what later became many. I don't know that we accomplished much. The CDC has its own momentum, and when we demanded youth representation in planning prevention campaigns they just hired some guy who was a CDC yes-man already. But I learned a lot about how the system worked. These were pieces of observation and understanding which I used later, things I still instinctively understand about government and public health now.

Hank was a true community organizer, and by this, I mean that Hank's whole life was spent making phone calls like the one he made to us. That was fifteen minutes he spent making a phone call, which still influences how I think about the world today. What a community organizer does is to organize the community, obviously. But what this actually means is finding the secret strength of the community. Especially, it means finding people scattered here and there, and bringing them together. Making them stronger. Teaching them new skills. Hank believed in this process in a deep way. It was not his job, though it later became his job; it was just who he was. The existence of Hank means that I know more about public health politics--just from that one phone call--than I would have if Hank had not existed.

Hank could drive you crazy by talking about poppers, but he never lost sight of bigger goals. Liz Highleyman's account in his obituary of the organizations he was involved in and helped start is likely hard to comprehend for those outside Hank's community. If that's you, you'll just have to trust me: a remarkable amount of cultural uplift, political power, and improvements in health came from these organizations.

I once saw Hank speak--characteristically, as part of a panel--at a community forum organized by the STOP AIDS Project. He talked about the Butterfly Brigade.

In the 1970s, the Butterfly Brigade was started because there had been gay-bashings in the Castro. And people started thinking, how the hell are there gay men getting beat up in the middle of a totally gay neighborhood? How is this hapenning? And the Butterfly Brigade was started as a self-defense organization. They started passing out whistles. And they set up the community expectation that when someone started blowing a whistle, that everyone else should come run to try to help. This included the Butterfly Brigade--which went on patrols, Guardian Angels-style--but everyone else too.

Hank said that this expectation of community mutual aid and self-defense helped stop gay-bashing in the Castro. Thugs stopped thinking they could get away with it. It sounds basic now--the idea that it would be a bad idea to try to gay-bash in a gay neighborhood--but it wasn't basic until people started sticking together.

But the whistles also did something even more important later, Hank said. When AIDS came a few years later, there was an idea already in place: we defend each other. We stick up for each other. This is not just some zone full of bars and cruising spots; it is a community. That was an idea that people were just starting to understand in the 1970s.

In other words, Hank believed that these whistles were a symbol of the underlying idea of how much of the community responded to AIDS--and in some way, a kind of disaster drill that prepared the community for what was to come. They already understood the principle. They just had to apply it to a new example.

The idea: community organizing builds strength that lasts beyond particular causes.

Hank Wilson, a kindergarten teacher who became a community organizer, has died. Keep him in your thoughts, not for his sake, but for the sake of your community. We all need to figure out what kind of whistles we can be passing out now, for the threats our communities will face in the future.


Veteran activist Hank Wilson dies

by Liz Highleyman

Longtime gay and AIDS activist Henry "Hank" Wilson died Sunday, November 9, at Davies Medical Center in San Francisco. A longtime HIV/AIDS survivor, Mr. Wilson succumbed to lung cancer at age 61.

Mr. Wilson was a veteran of countless struggles, from the fight against the Briggs initiative to AIDS and homeless activism. Over more than 30 years, he played a pivotal role in San Francisco's LGBT history.

"If ever there was a man whose vocation was helping others less fortunate and speaking truth to power, it was Hank," said friend and fellow activist Michael Petrelis.

Mr. Wilson was born and raised in Sacramento. He graduated with a bachelor's degree in education from the University of Wisconsin in 1971. Soon thereafter, he moved to San Francisco, where he taught kindergarten and grade school and was a swimming coach.

In the mid-1970s, Mr. Wilson, together with fellow teacher Tom Ammiano (now a city supervisor and assemblyman-elect), started the Gay Teachers Coalition. The group fought discrimination against gay teachers, culminating in the San Francisco school board's decision to add gays and lesbians to its non-discrimination policy in 1975.

"Hank was impressive even then," Ammiano recalled. "He was big, he was handsome, his energy was boundless, but his ego was very, very small. I just can't imagine the number of people he has touched and how much he's going to be missed."

In the late 1970s, Mr. Wilson participated in the fight against the nascent religious right and its efforts to roll back advances in gay equality. He was instrumental in the successful No on 6 campaign against the 1978 Briggs initiative to ban gay teachers in public schools – a battle many have likened to this year's Proposition 8 in its national significance.

The activism that emerged in that era spurred the creation of many long-standing LGBT organizations. Mr. Wilson served on the board of the Gay Youth Advocacy Council, which gave rise to the Lavender Youth Recreation and Information Center. He helped shape school district policies regarding anti-gay harassment and comprehensive health and sexuality education, and with Ammiano, he started a speakers bureau to inform students about gay and lesbian issues.

Mr. Wilson helped launch a small gay film festival, which later evolved into Frameline. An early advocate of gay self-defense, he started distributing whistles in the late 1970s and co-founded the Butterfly Brigade, which became the Castro Street Safety Patrol. Both the speakers bureau and the safety patrol later became part of Community United Against Violence.

"[Hank] was a sort of Johnny Appleseed of gay and lesbian organizing; wherever he went, organizations sprouted," said longtime friend and caretaker Bob Ostertag. "As soon as something was up and running, he would move on to start something else."

In 1976, Mr. Wilson co-founded the San Francisco Gay Democratic Club, which was renamed after Harvey Milk following his assassination in November 1978. Mr. Wilson took part in the May 1979 White Night riot to protest Dan White's lenient manslaughter conviction, and he later regaled younger activists with tales of throwing flaming newspapers into unoccupied police cruisers outside City Hall.

The poignancy of Mr. Wilson's death so soon after the premiere of the Milk biopic and the recent election was not lost on friends and fellow activists. Before he died, he had the opportunity to see the film and he celebrated Barack Obama's victory from his hospital bed.

"We watched Obama's acceptance speech, and he couldn't have been more delighted," said Stephen LeBlanc, who spent election night with Mr. Wilson. "He cheered out loud when Obama said 'gay and straight.'"

Direct services
While Ammiano and Milk directed their activism into political careers, Mr. Wilson devoted himself to providing direct services for people in need. In the late 1970s, he and a friend, Ron Lanza, took over management of a group of SRO hotels in the Tenderloin – as well as the Valencia Rose, an influential queer performance venue.

One hotel, the Ambassador, was frequented by many queer and transgender people and became an early epicenter of the AIDS epidemic. Mr. Wilson put together a team of care providers, and with a small group of activists including Dennis Conkin and the Reverend Glenda Hope of San Francisco Network Ministries, started the Tenderloin AIDS Network in 1986. After running on a shoestring budget, TAN obtained city funding to open a storefront in 1990, becoming the Tenderloin AIDS Resource Center.

During Mr. Wilson's tenure, the Ambassador was known as housing of last resort for people no one else would take. By the early 1990s, it was the largest supportive AIDS housing program in the country, and it came to be regarded as a model of community care and harm reduction.

"People took advantage of him, ripped him off, disrespected him, but he just kept taking them back," said Hope. "If there was one person who taught me the meaning of forgiveness and unconditional love, it was Hank Wilson."

"There was nothing quite like the experience of Hank Wilson reading some bureaucrat's beads or telling it like it was," Conkin added. "I learned a lot about speaking the truth from Hank. And how to maintain kindness and compassion, and not get stuck in rage or despair or hopelessness."

Mr. Wilson – who was himself diagnosed HIV positive in the early 1980s – was also instrumental in starting the city's earliest AIDS activist groups. He helped form the PWA Coalition and Mobilization Against AIDS, and organized the city's first AIDS memorial candlelight march in 1983.

Before the cause of AIDS was known, Mr. Wilson suspected poppers had a detrimental effect on the immune system, and he started the Committee to Monitor Poppers in 1981. He compiled volumes of research and opposed the sale and advertisement of poppers – a campaign he revived periodically as community awareness waned. With John Lauritsen, he co-authored the book Death Rush: Poppers and AIDS (1986).

In the late 1980s, Mr. Wilson joined ACT UP/San Francisco and participated in countless actions, including an early demonstration against Burroughs Wellcome demanding a lower price for AZT. Over the years, he advocated for alternative therapies, expanded access to experimental drugs, needle exchange, and medical marijuana.

"Hank was one hell of a committed AIDS activist who fought against all injustice," said fellow ACT UP member Matthew Sharp. "The only meetings or demonstrations he missed were because he was involved with another activist project or was in someone else's face."

Mr. Wilson was a founder and integral member of ACT UP/Golden Gate when it split off from ACT UP/San Francisco in 1990, and he remained active through the group's evolution to Survive AIDS in 2000 until it folded four years later.

"Hank insisted that we could still make a difference, even when we were just a handful of people," added longtime member Michael Lauro. "It didn't matter whether he had 20 people beside him or just himself, if he saw a wrong he'd try to right it."

Mr. Wilson's activism extended beyond HIV/AIDS to encompass a broader view of community health, and he attended several gay men's and LGBT health summits starting in the late 1990s.

"Hank was one of the pillars of the gay men's health movement in the U.S., and he fought for many other communities too," said Chris Bartlett of the LGBT Leadership Initiative. "He dedicated his life's work to the health and welfare of the underdog, and he based that work on the principles of gay liberation, human rights, and a powerful awareness of the structural forces that impact our day-to-day health."

Mr. Wilson managed the Ambassador until 1996, when he left due to his own worsening health and to care for his ailing parents (the Tenderloin Neighborhood Development Corporation now runs the hotel). Having fallen to just 20 T-cells and plagued with Kaposi's sarcoma and opportunistic infections, he was told his death was imminent, but he was among the first to gain access to effective new antiretroviral drugs and his health turned around.

Mr. Wilson soon got back to work, managing TARC's homeless drop-in resource center and volunteer program from 1998 through the mid-2000s (TARC and Continuum HIV Day Services merged to become Tenderloin Health in 2006). His final job was with the Shelter Monitoring Committee, verifying that city homeless shelters were providing mandated services.

Write-in campaign
Though he eschewed a political career, Mr. Wilson never strayed far from politics. In 1999, he spearheaded the effort to convince Ammiano to run for mayor against incumbent Willie Brown. Along with Robert Haaland and Tommi Avicolli Mecca, he managed a write-in campaign that forced Brown into a runoff and is credited with reviving the city's progressive movement. After district supervisor elections were reinstated in 2000, Mr. Wilson ran – unsuccessfully – for the District 6 seat.

Always unassuming, Mr. Wilson lived for more than 30 years in a small studio apartment near Civic Center, sleeping on a mat on the floor until he entered home hospice care and friends insisted he get a bed. He remained active until his final months and was hesitant to reveal the severity of his illness.

"Hank wasn't intimidated by anything. He could be outnumbered, outspent, and overpowered, but he was rarely outsmarted," said friend and fellow activist Gary Virginia. "I don't think he was 'fearless' in the sense that he wasn't afraid or scared. He just didn't let that stifle him. He empowered himself, and in doing so, empowered others."

Mr. Wilson is survived by a sister and a brother. A public memorial has been set up at the corner of Castro and 18th streets, and a memorial service is being planned (most likely for December). Donations in his memory may be made to one of the many causes he supported, including the Quan Yin Healing Arts Center and the GLBT Historical Society.


Sunday, November 9, 2008

The hybrid healthcare system

photo: from wikimedia commons, Barack Obama hearing from Ohio voter Marian Edwards about health insurance

At a small social gathering recently, a policy wonk doctor and I chatted about what the Obama era might bring to healthcare.

"I think he's going to try to do something quickly", the policy wonk said. "The difference between 1992 and now is that big business then was opposed to government involvement just on principle. But now they want it off their table. They can't keep bearing the cost of the whole system. They're ready."

I think the goal should not be a single-payer system. It should be a system that could eventually become a single-payer system in which the government runs an opt-in portion that gradually more and more people opt in to as business ditches health benefits. This is akin to building a hybrid car with the capacity, once a better battery is available on the market, to become a plug-in hybrid with a much greater share of electric power.

Sunday, October 26, 2008

Transparency of data

What's the difference between national polls and scientific data?

As this article at points out, the difference is transparency. The article takes the example of climate change modeling as one instance where a set of people with a big heap of quantitative data and statistical models share the data and the models' assumptions.

Interestingly, it's only since one month ago that clinical trials were required by the FDA to make some basic data accessible--September 27 of this year. But actually, it seems like this does not give the opportunity to re-examine the raw data--only a kind of summary of demographics and outcomes. The intent is to stop people from concealing negative trials.

But, to take the point in another direction, shouldn't drug trials be more transparent than political polls, which are run for profit by people who have a financial interest in concealing their raw data and their weighting methods (e.g., for "likely voter" screens)?

Oh, right. So are drug trials. Sorry.

But the ultimate transparency, and one that seems like it's long overdue, is for raw clinical trial data to be open-source, so that people with interests other than profit can examine that data and re-analyze it after the original academicians have published the initial report.

Thursday, October 23, 2008


This journal abstract caught my eye while searching for something else having to do with economics and HIV risk:

Women and Fish-for-Sex: Transactional Sex, HIV/AIDS and Gender in African Fisheries

Christophe Bénéa and Sonja Mertenb

WorldFish Center, Africa Regional Office, Cairo, Egypt; University of Basel, Switzerland
Accepted 22 May 2007. Available online 10 March 2008.


This paper analyzes the phenomenon of fish-for-sex in small-scale fisheries and discusses its apparent links to HIV/AIDS and transactional sex practices. The research reveals that fish-for-sex is not an anecdotal phenomenon but a practice increasingly reported in many different developing countries, with the largest number of cases observed in Sub-Saharan African inland fisheries. An overview of the main narratives that attempt to explain the occurrence of FFS practices is presented, along with other discourses and preconceptions, and their limits discussed. The analysis outlines the many different and complex dimensions of fish-for-sex transactions. The paper concludes with a set of recommendations.

Key words: artisanal fisheries; vulnerability; poverty; public health; Africa

It's actually a pretty thoughtful article and among other things makes sure we don't oversimplify the fish-for-sex phenomenon which I have to say I was immediately tempted to do. For instance, one thing that I didn't think about right off the bat was that "[W]omen fish traders—whatever way they ‘purchase’ the fish, i.e., with cash or through sexual arrangement—are economically productive agents within the fisheries sector... [and are] fully integrated in the fish value-chain" which despite the absurdity of that last phrase, appears to actually be a fair point (see below).

"Women engaging in FFS transactions are often depicted as sex-workers by their own community/society, conveying more or less explicitly a link between FFS and prostitution. While prostitution undeniably exists in the sector and fishers are certainly one of the socio-professional groups which have the most frequent contacts with sex-workers, assimilating FFS to sex-workers is socially and economically questionable. In particular, it does not acknowledge the fact that women fish traders—whatever way they ‘purchase’ the fish, i.e., with cash or through sexual arrangement—are economically productive agents within the fisheries sector: like any other fish traders, they process, transport, and retail fish. They are thus fully integrated in the fish value-chain, in contrast to sex-workers who do not create direct value-added in the sector.

"The association FFS-prostitution is also recurrently brought forward as part of the narrative of the poor, destitute woman who is forced to prostitute herself to buy fish—cf. Table 4. Although it can hardly be denied that female fish traders can be remarkably vulnerable to poverty—in particular the widows, single mothers, or divorced women—assuming a systematic link between extreme poverty and transactional sex may be too simplistic to capture the complexity of the factors leading women to engage in FFS. In particular it does not reflect the fact that women are socially active agents who may rationally choose their behaviors and negotiate the nature and continuance of their relationships with their partners. What, instead, the quotations listed in Table 4 may illustrate is that a large part of the literature essentially from NGOs and advocacy groups that focus on addressing extreme destitution and poverty among vulnerable groups (and in particular women) tend to use extensively or to instrumentalize the narrative of 'the poor woman who is forced to prostitute herself to survive' in order to draw public attention to their own cause."

"The existing documents reporting FFS indicate that a large proportion of the women who engage in FFS are widows, divorced or single women, re-emphasizing the relatively high vulnerability of this group to poverty and thereby reflecting the safety-net role that fish trading activities traditionally play for a large number of poor women, especially in Africa. This link between FFS and female fish traders’ vulnerability has been captured and reflected in a certain number of narratives and discourses which attempt to explain the occurrence of these practices. The most frequent one is probably the miserabilism narrative where FFS is viewed as a 'strategy for survival' and women engaging in FFS as victims. Linked to this perception and reinforcing it is the very frequent confusion made between FFS and prostitution. While this article demonstrates why this confusion is disputable, it also recognizes that the increasing vulnerability of female traders is a reality which certainly reduces the negotiation/transaction power of these women, and also encourages fishers to impose these FFS transactions through 'no-deal no-fish' coercive arrangements. At the same time, the new institutional economic approach proposes an alternative to the miserabilism narrative and highlights the transactional dimension of FFS practices, suggesting that the lack of cash may not systematically be the only determinant that leads women to engage in FFS. Surely, there is no contradiction between these two interpretations. Social structures or institutions, class, gender inequality, kinship, and marriage do have a bearing on women’s decisions, but those must still be seen as social actors with some power to negotiate."

Follow-up to McCain and melanoma

Kyle makes a couple of arguments below in the comments of my last post, and my reply is long enough and separate enough from my original post that I'm posting it separately:

I don't disagree with your political conclusion of what to do at the end of the day. The point is that any president might die. The fallacies of the Altman argument are that:

1) the medical chart does not contain information on what is most likely to kill a president; and
2) John McCain has some unknown risk of recurrent melanoma, which further information might allow us to calculate slightly differently than what we know to be his generic risk without further information. But John McCain either will or will not die in office if elected. And, with or without melanoma, he has a reasonable probability of dying in office because US presidents generically do have a much higher probability of dying in a given four year span than many other people, entirely because of the risks associated with the office rather than the officeholder.

So whether the possibility is x% chance of melanoma combined with y% chance of cardiac disease combined with z% chance of lung cancer, the generic risk to the officeholder already meets a test of likelihood. That is, statistically, taking any president at any age, a generic voter should assume--regardless of what is in the medical chart--that the president is at least as likely to die before the end of the term as the voter herself, or at least, the voter's children.

So, the reason this is relevant to a medical blog and a medical argument is that melanoma in particular should not change the intervention--i.e., your vote. Whether or not he has a given chance of recurrent melanoma, Sarah Palin is not a qualified vice president, and she has a high generic chance of becoming president if elected as vice president.

Incidentally, though the two candidates' generic risks of mortality can be influenced by their age, this is an easily discernible and intuitively obvious risk which does not require Lawrence Altman digging through colonoscopy reports.

Because the baseline presidential risk of death is high, the issue of Sarah Palin's competence is more or less exactly the same as the issue of Joe Biden's competence. If Obama had picked Palin, it would be just as bad a pick, for the exact same reason.

Now, take the low-probability but possible chance of Lawrence Altman finding something in the chart that a group of Mayo Clinic doctors deliberately concealed or misrepresented when they vouched for McCain's health. When going through McCain's chart, the greatest likelihood is that whatever Altman would find would be a "false-positive"--that is, it would raise concerns for voters but would not actually change the outcome of the next four years.

That would be unfair to McCain, and more importantly to democracy in general. It would represent a medicalization of democracy--a completely out-of-proportion ability of a few doctors and medical screening tests to influence democratic elections.

Also, at least as importantly, it would be unfair to anyone with "concerning" things in their medical charts who wanted to be in a powerful position. There is no magic about a president; to the workers of a company, the CEO and CFO might well have greater power to determine their quality of life in the next four years. So, should boards of directors have the right to examine every bit of the medical record of any executive? And how far down the management trail are you willing to go with that logic? And what does that mean for people with family history of genetic diseases, for people with past medical issues, for people with high epidemiological risk?

Aside from this, I want to make sure I am clear about the statistical and medical argument I'm making, so let me take a less-loaded and very common medical parallel. Let's say someone comes into the emergency department with shortness of breath and a fast heart rate. There are various possibilities. One is a blood clot in the lung, known as a pulmonary embolism (PE).

To diagnose PE, I can get a CT scan with contrast, which can damage the kidneys. I can also do a blood test, the result of which will increase or decrease my estimate of the chance that the person has a PE. If the blood test increases my estimate, I'll get a CT scan. If it decreases my estimate, I won't get a CT scan.

So, if I think there is a clear alternative explanation and no reason to suspect PE, should I get the blood test? No, because it will not change my decisionmaking. I am more likely to get a false positive than a true positive, and therefore, the CT scan is more likely to be dangerous than helpful.

What if it's someone has a very high risk of pulmonary embolism--a known clot in the veins of the leg, and cancer which predisposes to PE? Will I do the blood test? No, because I don't care if the test is negative. I will still not be satisfied until I do the CT scan.

So it turns out that the only time to do the blood test is if you're not sure whether or not a PE is likely--the risk is indeterminate, or "medium-risk." The argument Altman is making relies on the idea that a medical chart is the equivalent of this blood test. That is, you will cast your vote--the potentially wise or unwise and highly consequential decision, the equivalent of CT scan with contrast--based on the information in the medical chart. This is a common issue in medicine: will a given test change your medical choices? If not, why are you doing the test?

Given that the Altman chart review is the equivalent of the "medium-risk" blood test, where we are trying to convince ourselves that a candidate will very likely die in office or will very likely not die in office. But this is not the right choice from the point of view of the "change your choice" test. That's because a president is not medium risk for death in the next four years. At least historically, a president is high risk. So, I certainly will not fail to care about the qualifications of a vice president. But I will not use the medical chart to decide how much I care. I already care a lot, because I know no matter what the chart says, I care. Any reasonable person should vote with the assumption that a president has a high chance of dying in office.

If examining the chart had no impact, then it wouldn't matter. And I'm the last person to defend McCain.

But I'm not defending McCain or a decision to vote for him. I'm defending people with a history of melanoma, and a lot of other people too. For anyone with higher probabilities of disease (whether through genetics, behavior, or past medical history), the risk of making the argument Altman is making is actually quite high. So, thinking through the issue of whether you do a test, and whether the Altman chart review is a test we should be doing:

the test does not change my ultimate decision
the test has a high chance of falsely influencing my thinking
the test has a high chance of other bad effects.

And therefore, the test should not be conducted. And Lawrence Altman doesn't need to look through every page of John McCain's medical chart.

[edited for clarity later in the day]

I vote against John McCain because he is a risk to people with melanoma, not because of his risk of melanoma.

Before I go any farther, let me just say that this post is the one time I'll say anything sympathetic about John McCain who I desperately hope loses this election and loses big. But this isn't about him, really.

It seems like during most election seasons, the New York Times' Lawrence Altman MD seems to get worked up about whether he has had enough access to political candidates' health records. Altman was a medical resident about 40 years ago and has never been much of a clinician as far as I can tell besides that--he did preventive health, public health work, and journalism. But, he seems to feel that reporters--and especially, he, being a doctor/reporter--have a right to go over presidential candidates' health records.

This is an appalling idea if we take away John McCain and our hope to see him lose, and think about this in the abstract. And I'm frustrated that a bunch of doctors who support Obama have apparently signed some kind of letter asking that McCain release all his medical records, and that some of them are saying a bunch of stuff in public about his melanoma risk. First of all, I don't know anything more about John McCain's melanoma risk than Bill Frist knew about Terri Schiavo's neurological function, which is to say, I know better than to pronounce my opinion about it.

Second of all, if I was able to look at all of John McCain's medical records, do a physical exam and history, and then quickly become a melanoma expert, does risk for a serious health condition mean that you're supposed to bow out of public life? If you think so, how far down does this argument apply? Governor? Mayor? City Council? Why would it stop at any particular level of office? If the argument is reasonable at the top, why shouldn't the voters of any given town know whether their mayor had guaiac-positive stool? Is it relevant to know whether your congressional candidate might have a brain aneurysm? Is it your right--no, your duty as a citizen--to demand full body CT scans and head MRIs for every person entering any political race at all? As a doctor, shouldn't I reserve my vote only for the candidate who puts his colonoscopy report up on the web so I can look inside his ass and judge for myself whether his polyps are sufficiently presidential?

John McCain's health plans mean his risk to people with melanoma is much more significant than his own risk of melanoma.

Finally, epidemiologically, the melanoma argument opens the door to a truly terrible line of logic, because underneath the medical argument must always be an epidemiological argument. By far the most common cause of death among US presidents in office is assassination. And deaths from cholera or bacterial pneumonia are unlikely for current US presidents. For all of Lawrence Altman's piety about presidents concealing their medical conditions, JFK hiding his Addison's disease was obviously irrelevant in the larger scheme of things. If we're so concerned about a president's chances of death, should we ask Lawrence Altman to be joined by security experts who can analyze the candidates' risk for being assassinated before we vote, which in presidential epidemiology is more likely than death from cancer? Does the public have a right to read all the death threats sent to presidential candidates so we can judge for ourselves whether they are serious? Shouldn't the Secret Service be granting the public complete access to suspected or potential assassins-in-the-making to assess whether they are serious threats or just rifle-toting equivalents of negative lymph nodes? In this election, I don't even want to think about such a thing.

So presidential epidemiology be damned; I am casting my vote for a black man with a significant smoking history and a bunch of racists who want him dead. I'm voting for him because of who he is while he is alive, not because of my morbid guesses about when he might die.

(If you want to be a doctor for Obama, here's a more reasonable way to do it.)

Monday, October 20, 2008

Rachel Getting Married

This weekend, we saw a great movie.

It's been a while since Ms Dr Hemodynamics and I have had an actual date, what with lots of night float shifts, lots of moving and fire logistics, and lots of just plain being overwhelmed by events. But Friday night we had a great date. When we met in medical school one of the first conversations we had was after I said I'd just seen The Station Agent and how I thought it felt--in its smallness, its authenticity, and most of all its particularness, the way it was a story just about these people and no one else--like You Can Count On Me. She said, "I loved that movie!" and that started one of those early conversations where we realized we had some tastes and ways of looking at the world that might match up. Another one of those conversations took place at the B-Side Lounge, a restaurant not far from a movie theater we like, where we went for our first date.

So last night, as if to restart our dating life after all the chaos in our lives, we went to the movies and then the B-Side. The movie was Rachel Getting Married, written by Jenny Lumet (Sidney Lumet's daughter) and directed by Jonathan Demme. The writing is smart, with natural-sounding dialogue supporting a tightly-structured story. The casting is so rich and the acting so good that even minor characters seem like interesting people, believable people. And like The Station Agent and You Can Count On Me, these characters don't belong anywhere else except in this story, this movie, and for that reason, they fill the movie and seem to live beyond it. Demme keeps the hand-held cameras moving, but close-in; we are guests at this wedding, not omniscient viewers.

Anne Hathaway is the center of the movie as Kym, Rachel's addict sister, back from rehab on furlough to see her sister get married. She starts the movie as a completely irritating and totally self-centered person who seems mostly frustrated that her sister's wedding is not really about her. Kym never turns into an angel, but the depth of her character and the complexity of her relationship to her family slowly evolves beyond addiction's irritating interpersonal effects and into its more profound pain and tragedies. I ended up feeling strongly connected to her even as her tally of bad deeds and pain caused becomes larger and more awful as the movie goes on. The movie seems as if it is about her, and thus about a family's relationship to an addict--and it is. But we come to realize the movie is also about something and someone else: a family's relationship to a person who isn't present at all, except in all the main characters' thoughts.

The movie revolves around Kym, and that means it's not a big sprawling multi-character document of a family; it's a much smaller movie than that. Nonetheless, it becomes an ensemble movie because the actors playing the other characters are compelling and interesting enough that you begin to get a sense of them as people just by watching them watch Kym. Bill Irwin, Anna Deavere Smith, and Tunde Adebimpe are all people with their own creative agendas, and their intelligence and watchfulness is part of what makes each of them so compelling as actors.

I'd love to know Kym and Rachel's dad, played by Irwin--he's a sweet, generous-spirited guy--but he'd clearly do well to get himself to a Nar-Anon meeting before he offers someone another sandwich. Irwin, a guy who has taken clowning to a new level of art, and plays Elmo's friend Mr. Noodle on Sesame Street, uses his big mobile face to underline the desperation of his hope that happiness can reign. His expressiveness and hope is contrasted with the cool distance of Debra Winger as Kym and Rachel's mother, who makes a late appearance in the wedding proceedings and in the movie, but makes every second count.

Tunde Adebimpe, of the band TV On The Radio, plays the groom, Sidney. He is a large almost awkward-seeming man, but his gentle kindness amidst the emotional chaos make it clear why Rachel needs him, and why she is so delighted to be marrying him. Sidney and his friends and family stand in contrast to Rachel and Kym's tense prickly family web. They are constantly in the background of the movie as a vision of ease and happiness that Rachel is trying to grab for, and Kym thinks she'll never have.

Go see it.

Saturday, October 18, 2008

No on 8--and yes for marriage equality

Gay marriage: it's not just for anonymous trailblazing ordinary people anymore--but even celebrities can get their rights taken away in November

If you make one political donation this season, the way to have the biggest long-term impact for your dollar is right here:

No On 8 Website

Yes, you should pony up for Obama--but lots of people are already doing that. Fewer people are donating to another important campaign, which means your donation can make an even bigger difference for the dollar. The campaign to save same sex marriage in California is an urgent moment for equality in the United States, and it will be a turning point for the struggle for equal rights for gays and lesbians. Recent polls show that the latest misleading ads for the proposition are working, and many Californians are prepared to vote for Proposition 8. If the election was held today, Prop 8 would win. That would be terrible news for my friends and family in California who need same-sex marriage for all kinds of practical reasons, and also some basic reasons of justice and equality.

I hope you'll join me in opposing Proposition 8. We in Massachusetts can breathe easy knowing that same sex marriage is safe here for now--but if it's defeated in California, the forces of intolerance will be coming back here to try to roll back the clock. I don't make a lot of money as a medical resident, but I just gave $200.00 to this campaign. I hope Hemodynamics readers will consider joining me--and if you do, let me know in the comments section of this post.

(PS: A challenge grant means that if you donate before Sunday October 19, your donation will be matched dollar for dollar--so you can double your already significant impact.)

Saturday, October 11, 2008

where there was smoke, there was fire

It's too long a story to tell here for now, and with too many complicated feelings to tell easily. But, we had a fire in our apartment building, and we were temporarily homeless (though in an upper-middle-class stay-at-your-friends' houses kind of way), and now temporarily housed. I feared for my life only in retrospect, and all of the Hemodynamics family got out safely.

We're actually back in our old building but in another part of it, subletting the apartment of someone who didn't want to come back while the building was being rebuilt. In our old apartment most of the walls and ceilings are now demolished: our apartment itself didn't burn, but the water of the hoses came down through the walls to our apartment from where the fire was being fought above.

The halls are full of the white plaster dust, and the floors in the halls are stripped down to the wood underneath them. Everything is dusty and each time I turn the corner I smell the smell of smoke, which just reminds me of that night. Coming back to our building means smelling smoke, both literally and figuratively. It means being reminded of a traumatic event. But it also means reclaiming that event not simply as a disruptive moment, but as something that is part of our history, and shapes our future. It smooths out the trauma, into the clay of the larger lives we build. I think it's a good thing.

In the hospital, I realized recently that I was in a "don't f- with me" mood. Without my clippers and feeling grumpy about buying new razors and other such things that the movers were supposed to return to us, but didn't, I let my beard grow into a unruly patchy mess. Facial-hair-wise it was if I was some kind of Che Guevara wannabe slouching through a Harvard hospital, just biding my time until I could really make some trouble. I was using swear words more than usual. I was making dark jokes more than usual.

Today, maybe it's a sign of starting to recover that I went to the barbershop, and got my beard trimmed, and my hair cut, and even got shaved above and below my beard line with a straight razor, an unprecedented event. Slowly, I think my unconscious mind is joining my conscious mind in rejoining the normal world.

Still, out in the hallway it smells like smoke. It's going to take a long time for that smell to go away.

Saturday, August 30, 2008

Manhunt, McCain, and the Boyfriend Problem

photo from

I've been thinking a lot about gay male culture while I've been out in Provincetown. Gay male culture here is concentrated, combined, and distilled: here are the Bears, the dads with a kid and a Labrador, the club boys, and the drag queens. In the clinic, gay life becomes both more ordinary and more quietly charming when an old drag queen, i.e., an old queen who is actually old, comes in wearing flip flops and an old t-shirt to discuss diabetes management.

It's been bringing back some memories, but also some new ways of looking. Back in Boston, my life outside of work revolves around Ms. Dr. Hemodynamics and the Hemodynamic Cat. But when I was younger, my personal life and affections were more complicated. And I was doing HIV prevention work in San Francisco. In that time, I was a much closer observer of gay life, and sometimes an observer with more personal stakes in the questions of the day.

Back then, I was also living with a woman for much of the time I was doing that work; I've long been the male equivalent of that time-honored tradition among women's college alumni, the has-bians. But finding love with women has always caused me to reflect on the obstacles my gay male friends have in finding love with men, and to think about how they might solve the perennial Boyfriend Problem which seems to afflict so many. That road not taken looks pretty bumpy from over here on the paved expressway.


I used to see gay life through some notion of gay culture, the community, something greater than the sum of the parts: that was how I saw gay life when I was an idealistic young person, and when I worked as a community organizer and public health worker. That makes sense. That's how idealists and public health workers (and especially, idealistic public health workers) are supposed to think.

Now I see gay culture one gay man by one gay man, each individual coming into my social circles or my clinic in the midst of all of the other people I encounter. I don't see a united culture or community in the way that I used to. Part of that is the product of seeing people through the lens of medicine instead of community organizing; medicine is individualizing.

At this remove, I now think that a lot of what I used to think of as "gay culture" is really mainly about of the lives of single gay men. Once gay men couple up, they remain part of the community, but they are often less visible, live elsewhere, and almost by definition spend more time with each other than they do with other men. They still come to the doctor's office, though, and so I'm reminded of them more than I used to be when I was a community organizer.

It's also true that Boston is different than San Francisco. Gay life is both less visible and less separate from the rest of the city. That doesn't mean that all of Boston's gay men are living in a closet, it just means that they don't all live in the South End, or any other neighborhood. And there is no designated space of outrageousness in the city itself, like San Francisco's Castro District, where any given night might mean an encounter with some crazy drag queen doing some nutty schtick. That space exists for Boston men, but it is 90 minutes away by fast ferry. It is tucked away down here in Provincetown, isolated from everything else, and seasonal. Its location is based, no doubt, on those two cherished New England values: freedom and discretion.

So I've changed my relationship to the gay world, my role in it, and my geographic position. And each of those changes means that I've personally moved much of my day-to-day view of gay life from neighborhood to individuals, from community problems to individual needs.


But the change from community to individual seems to be happening in some other ways, too, which have nothing to do with my shifts in jobs or geography. Around the country, whether your local gay mecca is a distant refuge, or a right-in-the-middle-of-town liberated zone, geography has become less important to gay men. In part this is because the geography of cruising and hooking up with other men has become decentered and electronic, conducted through Internet hook-up sites like Manhunt.

And the rest of the geography of gay life may also be dispersing and diffusing, as younger men stop having to leave behind their straight friends from high school, college, or work behind when they come out. Straight culture's transformation towards increasing acceptance of gay lives in the last thirty years has meant that more and more queer people can lead social lives that have continuity with childhood and young adulthood, instead of requiring either a closet (as in the older days), or a complete break and reinvention (as in the slightly more recent days).

This all may mean that, as a Boston Globe think piece argued, gay bars will go the way of Jewish delis. Only a few iconic delis now survive as "Jewish Delis", living on as places of history built for occasional pilgrimages in from other neighborhoods or suburbs, rather than existing as true centers of community life. I think there could be worse fates for gay bars than for most to close and a few to become "Gay Bars" where men go on third dates for a fun experience of gay culture nostalgia, but not to meet their first date. Of course, the "Gay Bar" will be something less than the original, likely full of straight tourists buying kitschy "Gay Bar" t-shirts and getting their pictures taken with the drag queen at the door. But if you had to choose whether gay bars should be more or less prominent features of our cities and of gay men's lives, I think it's not unreasonable to choose "less." There are others who can sponsor gay softball teams.


But the internet's role is potentially more troubling than whether it may be biting into gay bar profit margins. A recent essay in, entitled "Has Manhunt Destroyed Gay Culture?" by Michael Joseph Gross, is partly an essay that could have been (and has been) written any time in the last thirty years of gay culture. It laments gay men's focus on sex which it argues precludes a focus on longer and more meaningful relationships. I found this article because of my political junkie Internet addiction which led me to the controversy about one of Manhunt's founders donating as much money as the law allowed to John McCain.

The part that could have been written any time since the 1970s and perhaps earlier is as follows:

But the most powerful secrets that live on Manhunt aren’t the ones we keep from the outside world. The most powerful secrets on Manhunt are the ones we keep from ourselves. Practically every gay man has his own version of this secret, which we learned to keep while growing up in the closet: the secret fear that, if we were truly known, we would never be loved.

This is probably as true (but over-simplified) today as it was in 1978 when Larry Kramer was working this angle, though probably not more true. However, because there is so much more capacity to create visual images quickly, including movies and digital self-portraits that require no photo lab technician to see the photo, people are becoming pornified, and pornifying themselves, in a way that they weren't before. The fact that more of the sex is virtual is only good from a strict-constructionist public health point of view. From a broad wellness point of view, I'm not so sure that it's an improvement.

Along those lines, we find the special Hemodynamics angle in another paragraph:

Employers now routinely reject job applicants after checking MySpace and Facebook profiles for suggestions of irresponsible or reckless behavior. Yet the explosion of amateur online porn has given many gay men, particularly younger men, a remarkable sense of security about their choice to perform. Last year a medical student in Manhattan told me he decided to have sex on-camera because “I’m not going to run for the Senate. I’m going to be a doctor in New York City. If anything, being a gay porn star is something to talk about at a cocktail party. That sort of thing here is like, ‘Oh you were in porn? Me too!’”

Personally, I would give this young doctor-to-be the advice that if he's going to sell his body, it should be at a high enough price to pay off his student loans. There must be some rich medical fetishist in New York who wants a highly-trained rent boy. But that's just me: always with the helpful suggestions that no one wants to hear.

The putatively more Internet-specific part of the essay's argument is here:

The seemingly endless stream of available men on Manhunt is, according to marketing director Henricks, “addictive, like a slot machine. You keep hitting next, to see another screen of profiles, thinking you’re gonna get lucky sevens.” This drive, according to Alan Downs, a psychologist and author of The Velvet Rage: Overcoming the Pain of Growing Up Gay in a Straight Man’s World, lies at the core of the appeal of online cruising: “Variable payout schedule, which is used in slot machine designs, is the most addictive form of psychological conditioning, because you never know when you’ll get paid. It could be every 10 times you play, or every hundred.” In the same way, Downs adds, “every time you log on, you never know what you’ll find. That’s why it expands to fill a person’s time. Last night was a bust, but who knows who will be online this morning or tonight.”

How vulnerable are Manhunt users to its addictive quality? “We’re the second-stickiest website in America,” Henricks boasts. “Stickiness,” he explains, is slang for attention ranking, the measure of the amount of time a user spends on a website each time he visits. According to, the Web’s Nielsen equivalent of attention rankings, the average Manhunt user spends 40 minutes on the site per visit. That’s about twice the amount of time the average Facebook or MySpace user spends on those sites. And, back to the slot machines, the only website in this country that is stickier than Manhunt is the wildly popular gambling website

I don't know that this is different than cruising, which itself has always led to variable payouts, and has long consumed a significant amount of some gay men's time. Still, like pornification replacing simple objectification, the internet intensifies this effect and makes it more efficient. The difference is not in what is going on--there were variable payouts in the process of looking around a bar, too--but the effect of its new form in making this process more targeted and efficient, and also more geographically diffuse.


The not-Internet-specific part of this Manhunt essay gets written every few years in new form by an educated gay man who realizes with a start that the way that he and his urban friends conduct their lives does not lead to having long-term stable relationships. He then works out his frustration about this by writing an essay or a novel on the topic, which I hope helps him meet a nice man who agrees with him:

"Looking for Mr. Right,” countless Manhunt profiles claim, but until he comes along, they’re open to playing with Mr. Right Now. Online cruising has its place in gay society: Access to a satisfying number of Mr. Right Nows is part of the pleasure and the privilege of moving to the big city to be gay.

Beyond a certain point, though, perpetually settling for Mr. Right Now becomes a failure of hope. When you came out, you did it because you wanted something. Part of what you wanted was sex, but part of what you hoped for was the possibility of being loved as your true self. And when, as often happens while cruising online, we diminish the hopes that drew us out of the closet, we reduce sexy to a purely physical act.

There is nothing in this that mothers don't tell teenage girls every day of the week, and maybe mothers need to tell their gay sons too, so this idea doesn't come as such a surprise. Still, the combination of emotional vulnerability and sexual availability is especially intense for some gay men.

Barack Obama was a community organizer for people whose lives had been damaged by closing steel plants and plagued by racism. I was a community organizer among people whose lives were threatened by the AIDS epidemic, and injured by homophobia. And, I would argue, chick flicks. I remember with a sense of vivid tragedy a safe sex workshop that I was facilitating, in which a young man said, "Even if I'm in some car giving head to some guy who I just met, there is always some voice in my head that asks, 'Could he be The One?'"

In my work in the South Side of Chicago--I mean, the Castro--I found that there are more gay men than there should be who think this way. Gay men who find themselves in this way of thinking have stumbled into a dumping ground of the worst ways that straight women and men think about love and sex, respectively. It's as important for gay men to realize that chick-flick ideas of romance are nonsense as it is for gay men to realize that true love only rarely begins with a hookup based on a picture of your butt. (Acknowledging, of course, that love can be powerful enough to create exceptions everywhere.)

No one should be surprised that the Manhunt guy gave money to McCain. Figuring out how to turn basic human yearnings into payola is the genius of American capitalism, and McCain is nothing if not pro-capitalism. Manhunt is just another version of that amoral form of genius. And that built-in structural feature of capitalism is so powerful that it's probably folly to think that somehow gay men will break free of each decade's version of the gay bar or Manhunt.

Maybe the only way to solve this problem is for love to reign, for the power of Community, capital "C", to awaken the love in all gay men's hearts. But let's not be sentimental about this. Love is too profound for sentimentality.

And if American capitalism has taught the world anything, it's that nothing is too profound to generate cash. So I hope that some capitalist will figure out how to get gay men to realize they could stop looking for the Magic Boyfriend, but start actually being each other's boyfriends. I'd like to think that the person who solved the gay boyfriend problem would bring in some real money. But capitalism may have already given us the answer: if gay men could bring in a bunch of money by truly looking for love, someone would already be making a lot of money off of it.

One problem is that gay male profits are made off of single gay men. Once gay men couple up and move to the suburbs there is less that is gay about them, and therefore less distinct marketing that can be done to them, and less money that can be made from them as a distinct group. They fade into the Ikea-furnished masses, no longer a distinct target market, no longer a definable profit opportunity. If you make your money from helping gay men fall in love, you have to make up in volume what you lose in repeat business.

It would be nice if the gay wedding industry were to become so lucrative that it could start investing in up-front love generation in order to keep the back end profitable. But it's unlikely. Which leaves us with this unsatisfyingly sentimental and apparently unrealistic and idealistic answer: the only way for gay life to become more filled with long-term loving partnerships is for love to prevail over profits, and for genuine attempts to build human connection to win over the seduction of variable payouts. I don't think that this means that gay men need to rise up and smash capitalism, and thank goodness: that's even harder than finding true love.

But anyone who is paying a business for the chance to meet another person is potentially susceptible to the interests of that business. If the interests of that business are psychological conditioning via variable payouts, then the customers will pay for their own conditioning. Even as gay business hosts each new form of gay male community--first physical space, and now virtual space--it also usually promotes individualism. By designing an environment in which jackpots can be won at any moment, customers will constantly return for more opportunities to hit the jackpot. And since part of the reward of the jackpot is the electric charge of novelty, they will usually return as individuals, as single people.

Any gay business which relies on repeat business by individuals acting in their individual interests has a profit interest in foiling true love. Gay restaurants don't need to pornify their customers; they just need to serve brunch. That's why love-wise, I think you can trust a gay restaurant, more or less: they get paid whether you come there again with your same boyfriend, or a different one. But gay bars and internet sites create a pornographized and individualized world within them, because this yields variable payouts and repeat business. Their profits depend on it.

Much of gay male culture has been produced by this profit interest, and at the same time has often been at war with it. That's because the Manhunt/gay bar business strategy depends on supporting gay community but preventing gay love. For the gay man seeking love, then, we can only say, caveat emptor.

image: The Stonewall Rebellion as immortalized by gay capitalism: the Advocate with a headline reading "First Gay Riots", a naked picture of present-day John McCain supporter Jon Voight, and a teaser for pictures of 18 other groovy guys.