Sunday, April 25, 2010

1996: protease inhibitors were confusing

For my zine, I wrote this; although my life changed in other ways shortly afterwards, and somehow that also meant that I stopped publishing my zine. Those were in the days before blogs, children; in the days of photocopiers when self-published writers had to go to the Leather Tongue video store and drop off five copies of the zine for the magazine rack, in hopes that there might be only two when they returned a month later.

Not long after this I ended up going to work for an HIV vaccine research group, which restored my sense of urgency. It also stalled the question of doctor or account planner (see previous 1996 post); then I learned immunology, did some needle exchange, and with much more excitement and no inertia, I decided to become a doctor.

October 14, 1996

At my job [at an HIV prevention agency in San Francisco] another person has quit; everyone seems disspirited and low. To some extent, that’s because of the particular politics of the agency: personnel absences, departures, events, personality changes, etc. But I’ve been wondering, on my return, whether there’s something deeper. The advent of the new drug treatments, and the incredible promise of the protease inhibitors, may have subliminally actually depressed people.

The idea that we are an important lifesaving effort is slowly losing focus; if people are staying alive with HIV, then we are disease prevention specialists, not the first line of defense in a community under siege. In itself, that would be great news, but unfortunately, no one knows for sure what the truth is.

How many people will really benefit from the protease inhibitors? The most optimistic school of thought has it that the protease inhibitors, if used for somewhere around the range of three years, might be able to help some people’s immune systems to entirely eliminate HIV from the body--in other words, that in a couple of years, we might have a partial cure blossoming in front of our eyes! Others are more skeptical and uncertain about the longterm prospects of the new drugs; if this group of people is more correct, we will only see people with AIDS die a couple of years later than they would have before.

So we can’t yet cheer the end of an era. On the other hand, the urgent language of our previous era is fading and cracking under the dim light of future prospects. We are left with no sure knowledge of our role, no clear sense of how important our work will be, and no overtly stated acknowledgement that things have changed. I am beginning to suspect that inertia is the result.

Saturday, April 24, 2010

1996: what color was my parachute?

I was looking through old files for something else, and found this. Since you're reading this blog, you know what finally happened. Math was hard, but I stopped letting that stop me. I bought an algebra book, re-learned algebra and trigonometry, took science classes, went to medical school. Apparently What Color Is Your Parachute? knew what it was talking about. Maybe.

Also I had kind of forgotten how into REM I was back then.

Whenever someone asks me what I’m up to these days, I say, “Oh, trying to figure out what I’m doing with my life.” Then they chuckle. Heh heh. They’ve been there.

But were they ever really as desperate as I am now? Because I’ve turned not once, but twice to What Color Is Your Parachute? It’s maybe the most famous self-help book ever--so I must be in bad shape, right? The concept of the book is that if you follow its instructions, you’ll not only find just some job, but you’ll figure out exactly what your ideal job is and then get it. I’m a product of the culture that this book helped to create--it was first published a year after I was born. Maybe that’s why I hold on to the belief that it is actually possible to find an ideal job, a true calling, even outside of “Lottery Winner.”

A while ago, I was housesitting in a house so beautiful that I went out and bought twenty lottery tickets so maybe I could buy a house just like it. At least one of the beautiful house’s owners had read an early edition of What Color Is Your Parachute? which they still had laying around, marked up with notes. So, after my lottery tickets yielded no results, I sluffed my way through a few of the book’s career exercises. I came up with a plan, which was a pretty good plan except that it depended on some people who didn’t agree with it. After that, I managed to ignore my career woes for a while. Actually, I was sort of ignoring my career, period. My new boss, the smarty-pants bastard, eventually sat me down and told me that I’d better start shaping up. Which reminded me--oh yeah!--I still hadn’t figured out what I was doing with my life.

So--back to Parachute. This time I started in on informational interviews. A series of what-do-you-dos and how-do-you-like-its yielded a great deal of interesting information, not least of which was that if you sit people down and ask them about themselves, some of them don’t really want you to leave. Maybe ever. A couple of people told me I should be a doctor. Sounded cool, but difficult. I’m like that talking Barbie--math is hard. Plan B was a little more accessible: account planner at an ad firm. Until I realized that having Plan A as “Be a doctor” and Plan B as “Be an account planner” was a little too much like talking Barbie. I still really hadn’t figured it out.

So, back to the book. I started doing all the exercises, not just the few I didn’t find depressing. While I was writing a list of everything that I had ever learned, I was listening to an REM song and it occured to me that part of what bothers me most about submitting to the indignity of this kind of exercise is the overwhelming sense that most of my heroes never really did this. When REM were a bunch of students in Athens, GA, they just started playing music because they loved playing music, and then they started putting out singles and albums and videos, until they became the huge phenomenon they are today. I just can’t see that there would have been any career self-help books in the process.

From when I was fifteen to when I was twenty-four or so, I had a calling. I wanted to be a movie director and I wanted to make frequent interview appearances in oversized magazines and late night talk shows. But let’s not speak of those mistaken notions now. Let’s focus on the future: I need a new plan. I know that What Color Is Your Parachute? should help me find some reasonably satisfying direction, but I yearn for something more: a new calling, a new certainty that what I want is what I will be best at and enjoy the most and give the most to the world by doing. And also that it will be infinitely glamourous and make me famous and loved.

The problem is that this book, this Parachute is designed to move you away from obvious answers and convince you that, for instance, everything you like about being a movie director is actually fulfilled by being a freeway engineer. The idea is, obvious answers aren’t always the best answers. Sometimes you’d actually be happier designing freeways or selling plastics. But in the direction of obvious answers also lies the allure of glamour--of what everyone wants, or thinks they want. Diving with sincerity into a career self-help book is a sure sign that you’re giving up glamour. An important step, no doubt, but also, inevitably, a sort of depressing one. This isn’t going to be about your calling, the moment in Athens, Georgia where everyone realized you really had something. This is about settling down and going to work.

When you're done getting dressed, take the rooster to the front desk

Sue Lowden is a Republican running to capture Sen. Harry Reid's seat in Nevada. Recently she suggested that we should go back to the days when people paid their doctors directly, whether in money, or you know, if they didn't have the money right then, then maybe, barter, with, you know, like, chickens and stuff. That back-to-the-old-days nonsense is so phenomenally stupid, it nearly begged for someone to set up this site:

Prices of medical procedures in number of chickens.

Make sure to read the fine print to properly adhere to the plan's rules.

For big procedures, the site suggests possibly converting to cows.

On the other hand, teaching hospitals might consider accepting chicks in order to subsidize medical education--and to pay residents with. Residents, being mere doctors-in-training, should be paid in chicks rather than in chickens. This will also allow them to invest in their future. Once the chicks grow up, they can be used to pay off student loans.

The Democratic Senatorial Campaign Committee has a different plan available.

Unbelievably, after taking a week of jokes (Jay Leno: "But what if your doctor isn't Amish?"), she continued to promote this idea, in the tone of making a helpful suggestion for the folks at home.

Wednesday, April 21, 2010

Jamie Oliver, ABC's pop Alinsky

Photo: Jamie Oliver in Britain, where he transformed national school lunch policy.

Ms. Dr. Hemodynamics and I were having a little bit of TV time the other night, and Jamie Oliver was trying to convince the lunch ladies of West Virginia that cooking from scratch was a good idea, and railing against some state bureaucrat's affection for chocolate- and strawberry-flavored milk.

Surprisingly, we kept watching.

OK, so, admittedly, I've only seen one episode thus far--but still, I found myself surprisingly compelled by the episode I saw, as a template for health-oriented community organizing.

I have mixed feelings about the moral panic in progress about obesity. The term "obesity" has become so loaded with moral judgment that I've taken to showing people in my clinic the NHLBI BMI calculator while holding my hand over the category labels. I always explain that this is a continuum, and that it's my view that the terms "overweight" and "obese" are better understood as "higher risk" (for 25 to 29.9) and "even higher risk" (for over 30). I don't think that calling someone "obese" is that useful. And absolute weight numbers, especially around the high 20s/low 30s fairly "overweight"/slightly "obese" range that so many of my patients and I occupy, may be at least as important as proxies for other things--like cardiovascular fitness and nutrition--as problems in and of themselves.

But my own struggles with weight and fitness, and those of my patients, are for a different day. The genius of Jamie Oliver's show, at least the episode I saw, is that he doesn't waste a lot of time trying to persuade individuals to change their individual diets. He knows that they'll drink the chocolate milk if it's in front of them and they have a choice between that and regular milk. Who wouldn't? And if the chocolate milk isn't there, they won't drink it, because how would they?

Here are some other aspects of why Jamie Oliver showed himself to be a smart community organizer in the 45 minutes I watched him:

1. Big change comes from changing big systems. He knows that the leverage is in the structural intervention. Children in this town all eat lunch at school, so don't try to get them to bring their lunches. Change the school lunches. People at a work place eat food that's close to work, so don't ask them to drive to some place that has a salad bar two miles away: drive a food truck that serves salads and bison burgers up to the work place. Like smoking, a lot of food choices are made because of availability, proximity, habit--all things that can be affected by altering the physical and economic environment at least as easily as changing individual minds.

2. Individual beliefs matter. Conversely, he knows that structural interventions can only work if a large enough number of individuals support them. People who think eating better food and avoiding obesity is a good idea will appreciate the support that a structural intervention gives their personal goals. But if people don't understand the rationale behind the changes, they'll just be mad that there's no chocolate milk or french fries--they'll register a change, understand it as out of their control and leading to a result they don't like, and demand a change back to the old system.

3. Every individual matters. Anyone at any point in the process, from state bureaucrat to food supplier to principal to cook to teacher, can either advance or sabotage a project for change. Because of this, he also lets everyone know that when they are supporting change, they are instrumental in doing so. He lavishes praise on the smallest change. "Fantastic!" he raves, as if the low-level administrator who removes the chocolate milk for a day should win a MacArthur "genius" award. Even non-committal shine-on answers get a "great, great" from Jamie, as long as they're not frankly obstructive--though he doesn't take "maybe" for an answer, and goes back to trying to close the deal.

4. Follow the money. He understands that the approach he's recommending will cost more. He targets the town's biggest employer, which nicely is a hospital. He shows that they should have an interest in supporting his changes and relentlessly hits them up for money. (That in fact they may not have any particular economic interest in the changes he proposes is a sign of the utter perversity of the healthcare system, but that's another reality TV show.)

These four ideas are the basis for a lot of successful community organizing.

I'm not sure Jamie Oliver has got it all figured it out--most importantly, I'm not seeing him build a corps of organizers who will stick around to keep the pressure on. But maybe at the end of the show, the real point is not the people in that particular town--but the corps of organizers he might build from the millions of people who are watching him on Friday nights.

Wednesday, April 7, 2010

Miners die, again

The newspaper from Harlan, KY sends a reporter to the Montcoal mine disaster.

And though statistically, mining has become safer overall in recent years, that's in the context of technology that could make mining disasters entirely a thing of the past. Why aren't they a thing of the past? Here's a glimpse from In These Times, which makes me feel like

the more things change, the more they stay the same.

Stay the same

Stay the same

Stay the same, the same

Stay the same

Stay the same.