Wednesday, May 30, 2007

Prevention Works still fighting in DC

When I lived in DC, I worked at an immunology lab, and I volunteered for Prevention Works, Washington, DC's beleaguered needle exchange program. Ron Daniels was one of the staff members who was often on the van supervising sessions where I was a volunteer. I did simple work like counting out new needles and giving them out to people, or explaining the basics of the program to new participants, while Ron and others would be talking to people about tougher stuff, like drug treatment options and doing HIV testing.

Ron and people like Ron are incredibly inspiring to me. For anyone who becomes a part of Prevention Works or supports it, needle exchange is a great way to make a difference. But for people like Ron Daniels, needle exchange is not just that; it's also a way of reclaiming the meaning and value of their own lives, and the lives of many other people as well. It's a beautiful thing.

Ron Daniels was recently in the New York Times in an article that gives a little bit of hope that maybe the Democratic Congress will finally take off the obscene funding restrictions that prevent the DC city government from spending its own local tax money on needle exchange. This restriction is not only a terrible piece of public health policy, it's an insult to the people of Washington, DC, who should have a right to make their own political choices. (For more about the wisdom of this choice, check this recent quick .pdf summary of the benefits of needle exchange programs.)

Lots of Washingtonians need what Ron Daniels and the other staff and volunteers of Prevention Point have to give. Please tell your congressional representative to lift the ban on funding. But until the Congress finally gets out of DC's way, I can't think of a better or more effective place to spend your philanthropic dollar. Here's a link to give the money that Republicans from Missouri and Oklahoma won't.

(And thanks to John S. for sending the NYT article around to an email list to which I subscribe.)

video: uploaded on Current TV, a video about Prevention Point's work.

Tuesday, May 29, 2007

How I changed, part 2: love and faith

Image: from Harvard Medical School's Countway library: a fifteenth century view of the Antichrist being born by C-section.

* * *

More in how my view of the world has changed since I started medical school, now that I’m graduating:

Before medical school, I used to believe that people were inherently good and that their bad qualities were the product of bad events that happened later. Now I don’t believe that people are inherently anything. Now what I wonder about is whether it is still important to love them.

I understand now that the willingness to try to love everyone in some way is not based on some factual insight about character, but on a large and partly irrational secular leap of faith. For example, when I am feeling nervous about a public speech, one of the things I try in order to summon the best part of myself is to actively think about loving the members of the audience, each one of them. This allows me to try to be my most generous, my most honest, my most enthusiastic. They may not like what I say or how I say it, but if I am in this mood, at least I can be sure that I have given them the gifts I have to offer, as best I can. Loving them is not the same as thinking that they are inherently good (whatever good is), but maybe it involves some faith in their potential for goodness.

At least sometimes, this is how I think I want to be a doctor. And talking about this to Ms Hemodynamics, I said, “I think I need that faith to be a good primary care doctor.”

Ms. Hemodynamics disagrees with this idea. She says that being a good physician means meeting people where they are, whether they’re good or bad; whether they’re good or bad isn’t even part of the question. And she says that she believes that who ever you are, you don’t deserve to suffer, or to be afraid, and that a doctor should believe that; but that a doctor does not need to believe that people are good, and does not need to love them.

I know that she and I both reserve some of our most pointed skepticism about a set of doctors who would at first seem to have much in common with us in their politics and their relationship to the medical-industrial complex. These doctors claim to love people, but actually when you get to know them as clinicians or teachers, you realize that sometimes they love The People more than they love actual people. And one can’t help but think that some portion of them love the idea of being loved by The People more than the idea of actually loving them. The line between The People and actual people is a fine one, but I want to stay on the right side of it: I’m no Ché Guevara, and I’m in no way convinced that The People even exist.

So maybe her approach is the best one: don’t worry about who the people are, or who The People are, and don’t worry about loving them, and definitely don’t worry about being loved by them. Just meet them where they are; figure out what they need; help them get it. When I think about it, this is how I often operate in a day-to-day way.

And yet I think that when I do the best job it is at least sometimes because I have found some kind of love for my patients. This is not always with my most lovable patients. In fact, to persist in trying to do a good job for some of my least loveable patients, I sometimes need to remind myself to try to love them—and that when I do, I often do a better job. This is an active process of trying to summon up some version of Buddhist loving-kindness—again without believing in the larger Buddhist scheme of things. The challenge, I think now, is to love people without becoming attached to the outcome of that love—to not be too upset, for example, when you know a patient is saying one thing to you and actually doing the exact opposite.

“But I love you,” some internal voice of mine has said at a couple of times in medical school with patients I’ve hoped might behave differently, mostly without clear words but just the feeling: “Why are you lying to me and letting me down?”

Given the inevitability of the range of human behavior, including some not entirely palatable kinds of behavior, and the inevitability that some of that behavior will take place in a clinic or in a hospital, it may be too much to ask of myself to love my patients. Or it may not. I’m not sure.

What I think now that is different from before I started medical school is that I don't think that people are inherently good, or inherently anything; I've stopped expecting to be able to find that in everyone. To walk into the clinic expecting something from one’s patients is a sucker’s game, and a sure path to bitterness.

Is unconditional love for my patients the cure for the cynicism that comes from disappointed expectations? Or is it a risk factor for disappointment, and thus, cynicism?

Or, probably most likely, both? brief

1. The blog From Med Skool is hosting the blog carnival Medical Grand Rounds and was very kind in listing my last post as his first featured choice. My very grateful thanks--and for a roundup of health-related blog posts, take a look at the rest.

2. For some reason this morning I woke up with the song from Rent that goes, "There's only us, there's only this" in my head. It was on cable the other night, but I've listened to lots of music since then. Why couldn't I have woken up with Cat Power's latest in my head? (It came out a while ago, but I've just started listening to it.)

3. Actually, despite the fact that by day I am totally relaxed and on a totally relaxing vacation, I keep waking up anxious and agitated, with thoughts of the hospital (and apparently, sentimental songs) in my head. And this is how I know I'm starting to get pretty nervous (appropriately so, I think) about the start of internship. Which is very very soon.

Thursday, May 24, 2007

How I changed, part 1: life and death

"Any animal’s minute-by-minute life is a constant process—or actually, a system of many interlocked processes. All of us animals are constantly kept alive by our systems of life." Video: the Hemodynamic Cat takes a nap.

“This process must have changed you,” my friend R said, as we were talking about my upcoming graduation from medical school. “But how did it change you?”

I’ve been thinking about that ever since, and I’ll be thinking about it more—this surely won’t be the last that I write about it.

* * *

Life and death changed around me even in pre-medical biology classes, but much more acutely as a medical student. Walking along a crowded beach, or out in nature, or even sometimes in the city, I much more frequently and knowledgeably remind myself of the physiology of the life around me. There are the big bipedal apes (you know, us); the birds; the dogs; the fish in the sea. When I see a dog running down the beach, or children splashing in the waves, or a row of birds flying in formation, I am much more likely now to remember how they are able to do these things. Their hearts are beating, their lungs are taking in oxygen, the mitochondria of their cells are using the oxygen for biochemical reactions which allow them to store energy, and the cells of the brain are using that energy to direct the activity of the rest of the body.

Any animal’s minute-by-minute life is a constant process—or actually, a system of many interlocked processes. All of us animals are constantly kept alive by our systems of life. Those systems are so complex that even after a lifetime of me learning about the biology of people alone (never mind birds, or dogs, or fish), I will die having learned only about a fraction of the cells and molecules and organs that will have kept me alive until that moment.

And if any of it stopped for any of the animals around me, the whole scene would change. A bird would fall into the water. A man would fall down on the beach. A dog would stop moving. The change from my previous life is that I more frequently remember that these underlying processes must constantly be working to allow the life around me to keep living. I more reliably remember some basic information about how these processes work. And so I more often appreciate that their workings all around me—the panting of the dog, the shouting of the children, the bird using its muscles to flap its wings—are each made possible by still more mechanisms. I more frequently notice and love the baroque and beautiful details of life.

* * *

I came to understand emotionally—and not just intellectually—that life is not the default. In fact, life is an improbable and incredible struggle made possible only by a constant cooperative struggle of cells working against the processes of entropy. Death no longer surprises me, though it still can upset me.

I first began to understand my own mortality at around the time a lot of people do, in my early twenties. But my understanding began in the midst of the HIV epidemic. Before medical school, I devoted a great deal of my work life and much of my volunteer civic energy to the cause of preventing new HIV infections. And partly because my consciousness of death came from HIV in the early 1990s, I was always conscious of the possibility of death, but I was always engaged in the effort to prevent it.

A few years after I started doing HIV prevention work, a high school friend of mine was diagnosed with metastatic cancer. I was not much involved in her care, and although we stayed friendly throughout, her social world contracted to a small circle in which I was not usually included. The one thing that my partner of the time and I were able to do to help was to find her and her boyfriend an apartment in San Francisco, which at the time was no small feat. The apartment was immediately below us, so although I did not see her socially very often, I saw her through windows or during comings and goings, and saw her getting more and more skinny and weak. I saw her boyfriend going through many stages of worry and grief. I knew when she died.

Though I knew intellectually that it shouldn’t, emotionally her diagnosis and death surprised me. My friend seemed like a buckle-the-seatbelts, wear-your-condoms sort of person; she won lots of the good student awards in high school. My surprise and shock about her death helped me see that my public health work had an irrational emotional abscess festering within it: the hope that somehow everyone could be saved from death if we all just behaved ourselves. Looking back, I think that her death was one part of my trajectory towards medicine. It helped me towards the very beginning of realizing emotionally and viscerally that death and suffering is a part of life--and not just the product of a particular epidemic that had to be stopped.

When I got to medical school, death gradually became much more a part of my regular experience. Two different anatomy classes (the required one and an optional one) meant that I dissected two different bodies. This required a very lengthy and detailed involvement with the bodies. And that meant a close-up constant literal immersion in the fact of death.

Then there were my patients, many of whom were dying, facing life-threatening diagnoses, or fearing the possibility of death; and some of whom died. I actually gravitated towards some of this in medical school. I took more oncology-related rotations than most people do, and I did an ICU rotation. Before death, there were worries; struggles with families and within families; various forms of physical suffering, and even more forms of emotional suffering. Death started to seem like the simple part. Living near death is much more difficult and complicated.

From being immersed in the bodies of my two anatomical donors, and then also from physical exams, Pap smears, stitching up wounds and draining abscesses, and standing next to surgeons in the OR trying to make myself useful, I got the immediate and now deeply-remembered sense of the physicality of our bodies. Before medical school, I was moved and fascinated by the fact that we were only frail physical bodies. I once wrote a kind of prose poem about it, which I must have in an old notebook somewhere. But I did not regularly make the emotional leap from my intellectual or poetic understanding of this frailty. That emotional leap required learning biology. It required knowing in detail the ways in which we are physical beings. Knowing these details convinced not only my intellect but my emotions that our physical selves must eventually cease to exist.

I am not a religious person: I believe that who we are is contained by our physical selves. Biology is the beginning and end of life, and it is life itself. We live because our cells work. We die because of the built-in limits of our cells and the systems they make. Even those limits are part of our biology.

It shouldn’t be a surprise to me that going to medical school helped me understand life and death in a different way. But I think I hoped when I started that the understanding would come as a mystical or philosophical insight, or some spiritual catharsis on a call night. That’s not what happened. Instead, I learned biology, and learned more biology, and then I started seeing life as biology, and biology as life.

How we feel about all of this, and what we say to each other about it, is important; but how we feel and what we say is also part of the beautiful biology of long-lived social animals. We are bipedal apes; we use tools and language; our hearts beat. Like pelicans and elephants, we are born, we live together, and then we die.

Photo: based on their behaviors, it seems reasonable to believe that elephants mourn the dead.

Wednesday, May 23, 2007

Vacation - Ferry (video)

I'm on vacation... which means I have to think up little projects to keep myself busy. (I'm still learning how to be on vacation.) I used Ms Hemodynamics' little snapshot camera to make this movie of part of our trip. Admittedly, this has nothing to do with "the pressures and flows of medicine" except maybe that it is of a time when there isn't much pressure.

Friday, May 18, 2007

"Far horizons": no AIDS vaccine today

Top: Bill Clinton and Bill Gates, both of whom head foundations which make AIDS a high priority, and also tend to favor technological solutions; since leaving office, Clinton's own choices have suggested more strongly than ever that political expediency drove his AIDS decisions in office. Bottom: George Bush plugs a cord into a prototype hybrid electric-hydrogen car.

Ten years ago today, on May 18th, 1997, President Clinton called on scientists to develop a vaccine to prevent HIV infection, and to do it within ten years:

“My fellow Americans, if the 21st century is to be the century of biology, let us make an AIDS vaccine its first great triumph.”

Clinton compared this presidential goal to President Kennedy’s “moon shot.” But this year, we mark the date knowing that Clinton’s goal was not reached, and won’t be any time soon.

When Clinton made his speech I’d just started working as a community educator for an HIV vaccine research group. The next year, some of my fellow community educators and I started marking the date with media briefings, community forums, and other outreach events. When we started the idea of marking the date each year, public relations people from the National Institute of Allergy and Infectious Diseases resisted it. “We don’t like timelines,” I remember one saying.* No wonder. Vaccine scientists have been saying that an HIV vaccine might be about ten years away for about twenty years now.

I was deeply committed to the cause of HIV vaccine research. (I still am.) At the time, I thought holding the government to a timeline was just fine. What I also knew then, and understand even more clearly now, is that although Clinton’s pledge was inspiring and important, it was also a political dodge.

During the same time that President Clinton was calling for an AIDS vaccine, he was refusing to take leadership to support needle exchange, which he and his scientific advisors knew would prevent HIV infections immediately, and not just ten years from then. And until the end of his administration, he supported international trade rules that made it impossible for poor people living with HIV and AIDS to get generic versions of life-saving medicines.

We can keep supporting the HIV vaccine effort even as we understand that there are more immediate things we can do about AIDS today. But today, let’s mark the anniversary of Clinton’s speech by looking back to another recent presidential call for a new technology:

“I ask you to take a crucial step and protect our environment in ways that generations before us could not have imagined. In this century, the greatest environmental progress will come about not through endless lawsuits or command-and-control regulations, but through technology and innovation. Tonight I'm proposing $1.2 billion in research funding so that America can lead the world in developing clean, hydrogen-powered automobiles.”

That’s George Bush, in his 2003 State of the Union address. He’s making the same gesture that Clinton made in 1997, although with a much less eloquent speech and an even more egregious policy context. In both cases, these presidents made bold calls for new technology that didn’t (and doesn’t) yet exist, as a way of avoiding political choices they didn’t want to make. AIDS means talking about sex and drugs; AIDS means realizing that “free trade” isn’t free. And global warming means making tough changes today, rather than waiting for a hydrogen car to let us keep living the exact same lives we have today but with water vapor coming out the exhaust pipe.

This similarity between the two presidential speeches suggests that this is not a problem of Democrat or Republican tactics: it’s a common mistake in American politics generally.

Bill Clinton’s AIDS vaccine speech was really a more broad-ranging speech about science and technology, made at a black university in the same week that he apologized on behalf of the US government for the Tuskegee Experiment. In his broader discussion of science, two of Clinton's sentences that sound like political throw-away lines turn out to be the key to understanding the whole speech. These two sentences illustrate how Americans get ourselves in trouble when we look to technology to save us from politics:

“We have always believed, with President Thomas Jefferson, that freedom is the first-born daughter of science. With that belief and with willpower, resources, and great national effort, we have always reached our far horizons and set out for new ones.”

Thomas Jefferson or not, nothing about this is true. Freedom is not the daughter of science: science is the daughter of freedom. And as this anniversary reminds us, we actually quite often fail to reach “our far horizons”; and having failed, we sometimes never get around to setting out for new ones. Asking engineers and scientists to solve a political problem with new technology does not require willpower, significant resources, or great national effort; it is an act of avoiding all of the above.

Most of all, when we look to science to bring us freedom from responsibility to make difficult social and political changes, we tarnish the value of science, and the importance of freedom.


* NIAID now coordinates observances for the day and puts on its own PR effort. The anniversary created its own momentum that was hard for any PR person to resist. And in the absence of startling scientific progress, there was no other regularly predictable news angle for the vaccine development effort.

Thursday, May 17, 2007

Testimony: Alberto Gonzales should be kicked out... of the ICU

Apropos of I'm not sure what, except to illustrate the general theme that Alberto Gonzales is an ethics-less toady, Senator Chuck Shumer (D-NY) drew the following story out of former deputy Attorney General James Comey, told below in an excerpt of the transcript from Wednesday May 16 2007.

Let the other blogs chatter about how this hurts or doesn't hurt Gonzales' chance at keeping his job. Here are the questions from the Hemodynamics.blogspot point of view:

Where was hospital security?

And where were the doctors? and John Ashcroft's nurse?

And if you were a resident that month in the ICU, and John Ashcroft were your guy, and you'd been having family meetings with Mrs. Ashcroft, and you knew that Mr. Ashcroft was not the acting attorney general at that moment, what would you do?

Finally, if the president calls the hospital and tells the nurse that Alberto Gonzales is coming and needs to talk to John Ashcroft, but Mrs. Ashcroft is forbidding all calls and does not want Alberto Gonzales to come, what is the legal right and what is the legal obligation of medical staff to stop Gonzales and Card?

Read, and discuss amongst yourselves.


SCHUMER: Before we get to the other issues, I want to go back to an incident from the time that Mr. Gonzales served as White House counsel. There have been media reports describing a dramatic visit by Alberto Gonzales and Chief of Staff Andrew Card to the hospital bed of John Ashcroft in March 2004, after you, as acting attorney general, decided not to authorize a classified program. First, can you confirm that a night-time hospital visit took place?

COMEY: Yes, I can.

SCHUMER: OK. Can you remember the date and the day?

COMEY: Yes, sir, very well. It was Wednesday, March the 10th, 2004.

SCHUMER: And how do you remember that date so well?

COMEY: This was a very memorable period in my life; probably the most difficult time in my entire professional life. And that night was probably the most difficult night of my professional life. So it's not something I'd forget.

SCHUMER: Were you present when Alberto Gonzales visited Attorney General Ashcroft's bedside?


SCHUMER: And am I correct that the conduct of Mr. Gonzales and Mr. Card on that evening troubled you greatly?


SCHUMER: OK. Let me go back and take it from the top. You rushed to the hospital that evening. Why?

COMEY: I'm only hesitating because I need to explain why.

SCHUMER: Please. I'll give you all the time you need, sir.

COMEY: I've actually thought quite a bit over the last three years about how I would answer that question if it was ever asked, because I assumed that at some point I would have to testify about it. The one thing I'm not going to do and be very, very careful about is, because this involved a classified program, I'm not going to get anywhere near classified information. I also am very leery of, and will not, reveal the content of advice I gave as a lawyer, the deliberations I engaged in. I think it's very important for the Department of Justice that someone who held my position not do that.

SCHUMER: In terms of privilege.

COMEY: Yes, sir.

SCHUMER: Understood.

COMEY: Subject to that, I -- and I'm uncomfortable talking about this...

SCHUMER: I understand.

COMEY: ... but I'll answer the question. I -- to understand what happened that night, I, kind of, got to back up about a week.

SCHUMER: Please.

COMEY: In the early part of 2004, the Department of Justice was engaged -- the Office of Legal Counsel, under my supervision -- in a reevaluation both factually and legally of a particular classified program. And it was a program that was renewed on a regular basis, and required signature by the attorney general certifying to its legality. [An NSA surveillance program.] And the -- and I remember the precise date. The program had to be renewed by March the 11th, which was a Thursday, of 2004. And we were engaged in a very intensive reevaluation of the matter. And a week before that March 11th deadline, I had a private meeting with the attorney general for an hour, just the two of us, and I laid out for him what we had learned and what our analysis was in this particular matter. And at the end of that hour-long private session, he and I agreed on a course of action. And within hours he was stricken and taken very, very ill...

SCHUMER: (inaudible) You thought something was wrong with how it was being operated or administered or overseen.

COMEY: We had -- yes. We had concerns as to our ability to certify its legality, which was our obligation for the program to be renewed. The attorney general was taken that very afternoon to George Washington Hospital, where he went into intensive care and remained there for over a week. And I became the acting attorney general. And over the next week -- particularly the following week, on Tuesday -- we communicated to the relevant parties at the White House and elsewhere our decision that as acting attorney general I would not certify the program as to its legality and explained our reasoning in detail, which I will not go into here. Nor am I confirming it's any particular program. That was Tuesday that we communicated that.

COMEY: The next day was Wednesday, March the 10th, the night of the hospital incident. And I was headed home at about 8 o'clock that evening, my security detail was driving me. And I remember exactly where I was -- on Constitution Avenue -- and got a call from Attorney General Ashcroft's chief of staff telling me that he had gotten a call...

SCHUMER: What's his name?

COMEY: David Ayers. That he had gotten a call from Mrs. Ashcroft from the hospital. She had banned all visitors and all phone calls. So I hadn't seen him or talked to him because he was very ill. And Mrs. Ashcroft reported that a call had come through, and that as a result of that call Mr. Card and Mr. Gonzales were on their way to the hospital to see Mr. Ashcroft.

SCHUMER: Do you have any idea who that call was from?

COMEY: I have some recollection that the call was from the president himself, but I don't know that for sure. It came from the White House. And it came through and the call was taken in the hospital. So I hung up the phone, immediately called my chief of staff, told him to get as many of my people as possible to the hospital immediately. I hung up, called Director Mueller and -- with whom I'd been discussing this particular matter and had been a great help to me over that week -- and told him what was happening. He said, "I'll meet you at the hospital right now." Told my security detail that I needed to get to George Washington Hospital immediately. They turned on the emergency equipment and drove very quickly to the hospital. I got out of the car and ran up -- literally ran up the stairs with my security detail.

SCHUMER: What was your concern? You were in obviously a huge hurry.

COMEY: I was concerned that, given how ill I knew the attorney general was, that there might be an effort to ask him to overrule me when he was in no condition to do that.


COMEY: I was worried about him, frankly. And so I raced to the hospital room, entered. And Mrs. Ashcroft was standing by the hospital bed, Mr. Ashcroft was lying down in the bed, the room was darkened. And I immediately began speaking to him, trying to orient him as to time and place, and try to see if he could focus on what was happening, and it wasn't clear to me that he could. He seemed pretty bad off.

SCHUMER: At that point it was you, Mrs. Ashcroft and the attorney general and maybe medical personnel in the room. No other Justice Department or government officials.

COMEY: Just the three of us at that point. I tried to see if I could help him get oriented. As I said, it wasn't clear that I had succeeded. I went out in the hallway. Spoke to Director Mueller by phone. He was on his way. I handed the phone to the head of the security detail and Director Mueller instructed the FBI agents present not to allow me to be removed from the room under any circumstances. And I went back in the room. I was shortly joined by the head of the Office of Legal Counsel assistant attorney general, Jack Goldsmith, and a senior staffer of mine who had worked on this matter, an associate deputy attorney general. So the three of us Justice Department people went in the room. I sat down...

SCHUMER: Just give us the names of the two other people.

COMEY: Jack Goldsmith, who was the assistant attorney general, and Patrick Philbin, who was associate deputy attorney general. I sat down in an armchair by the head of the attorney general's bed. The two other Justice Department people stood behind me. And Mrs. Ashcroft stood by the bed holding her husband's arm. And we waited. And it was only a matter of minutes that the door opened and in walked Mr. Gonzales, carrying an envelope, and Mr. Card. They came over and stood by the bed. They greeted the attorney general very briefly. And then Mr. Gonzales began to discuss why they were there -- to seek his approval for a matter, and explained what the matter was -- which I will not do. And Attorney General Ashcroft then stunned me. He lifted his head off the pillow and in very strong terms expressed his view of the matter, rich in both substance and fact, which stunned me -- drawn from the hour-long meeting we'd had a week earlier -- and in very strong terms expressed himself, and then laid his head back down on the pillow, seemed spent, and said to them, "But that doesn't matter, because I'm not the attorney general."

SCHUMER: But he expressed his reluctance or he would not sign the statement that they -- give the authorization that they had asked, is that right?


And as he laid back down, he said, "But that doesn't matter, because I'm not the attorney general. There is the attorney general," and he pointed to me, and I was just to his left. The two men did not acknowledge me. They turned and walked from the room. And within just a few moments after that, Director Mueller arrived. I told him quickly what had happened. He had a brief -- a memorable brief exchange with the attorney general and then we went outside in the hallway.

SCHUMER: OK. Now, just a few more points on that meeting. First, am I correct that it was Mr. Gonzales who did just about all of the talking, Mr. Card said very little?

COMEY: Yes, sir.

SCHUMER: OK. And they made it clear that there was in this envelope an authorization that they hoped Mr. Ashcroft -- Attorney General Ashcroft would sign.

COMEY: In substance. I don't know exactly the words, but it was clear that's what the envelope was.

SCHUMER: And the attorney general was -- what was his condition? I mean, he had -- as I understand it, he had pancreatitis. He was very, very ill; in critical condition, in fact.

COMEY: He was very ill. I don't know how the doctors graded his condition. This was -- this would have been his sixth day in intensive care. And as I said, I was shocked when I walked in the room and very concerned as I tried to get him to focus.

SCHUMER: Right. OK. Let's continue. What happened after Mr. Gonzales and Card left? Did you have any contact with them in the next little while?

COMEY: While I was talking to Director Mueller, an agent came up to us and said that I had an urgent call in the command center, which was right next door. They had Attorney General Ashcroft in a hallway by himself and there was an empty room next door that was the command center. And he said it was Mr. Card wanting to speak to me.

COMEY: I took the call. And Mr. Card was very upset and demanded that I come to the White House immediately. I responded that, after the conduct I had just witnessed, I would not meet with him without a witness present. He replied, "What conduct? We were just there to wish him well." And I said again, "After what I just witnessed, I will not meet with you without a witness. And I intend that witness to be the solicitor general of the United States."

SCHUMER: That would be Mr. Olson.

COMEY: Yes, sir. Ted Olson. "Until I can connect with Mr. Olson, I'm not going to meet with you." He asked whether I was refusing to come to the White House. I said, "No, sir, I'm not. I'll be there. I need to go back to the Department of Justice first." And then I reached out through the command center for Mr. Olson, who was at a dinner party. And Mr. Olson and the other leadership of the Department of Justice immediately went to the department, where we sat down together in a conference room and talked about what we were going to do. And about 11 o'clock that night -- this evening had started at about 8 o'clock, when I was on my way home. At 11 o'clock that night, Mr. Olson and I went to the White House together.

SCHUMER: Just before you get there, you told Mr. Card that you were very troubled by the conduct from the White House room (ph), and that's why you wanted Mr. Olson to accompany you. Without giving any of the details -- which we totally respect in terms of substance -- just tell me why. What did you tell him that so upset you? Or if you didn't tell him just tell us.

COMEY: I was very upset. I was angry. I thought I just witnessed an effort to take advantage of a very sick man, who did not have the powers of the attorney general because they had been transferred to me. I thought he had conducted himself, and I said to the attorney general, in a way that demonstrated a strength I had never seen before. But still I thought it was improper. And it was for that reason that I thought there ought to be somebody with me if I'm going to meet with Mr. Card.

SCHUMER: Can you tell us a little bit about the discussion at the Justice Department when all of you convened? I guess it was that night.

COMEY: I don't think it's appropriate for me to go into the substance of it. We discussed what to do. I recall the associate attorney general being there, the solicitor general, the assistant attorney general in charge of the Office of Legal Counsel, senior staff from the attorney general, senior staff of mine. And we just -- I don't want to reveal the substances of those...

SCHUMER: I don't want you to reveal the substance. They all thought what you did -- what you were doing was the right thing, I presume.

COMEY: I presume. I didn't ask people. But I felt like we were a team, we all understood what was going on, and we were trying to do what was best for the country and the Department of Justice. But it was a very hard night.

SCHUMER: OK. And then did you meet with Mr. Card?

COMEY: I did. I went with Mr. Olson driving -- my security detail drove us to the White House. We went into the West Wing. Mr. Card would not allow Mr. Olson to enter his office. He asked Mr. Olson to please sit outside in his sitting area. I relented and went in to meet with Mr. Card alone. We met, had a discussion, which was much more -- much calmer than the discussion on the telephone. After -- I don't remember how long, 10 or 15 minutes -- Mr. Gonzales arrived and brought Mr. Olson into the room. And the four of us had a discussion.


SCHUMER: Let me ask you this: So in sum, it was your belief that Mr. Gonzales and Mr. Card were trying to take advantage of an ill and maybe disoriented man to try and get him to do something that many, at least in the Justice Department, thought was against the law? Was that a correct summation?

COMEY: I was concerned that this was an effort to do an end-run around the acting attorney general and to get a very sick man to approve something that the Department of Justice had already concluded -- the department as a whole -- was unable to be certified as to its legality. And that was my concern.

SCHUMER: OK. And you also believe -- and you had later conversations with Attorney General Ashcroft when he recuperated, and he backed your view?

COMEY: Yes, sir.

SCHUMER: Did you ever ask him explicitly if he would have resigned had it come to that?


SCHUMER: OK. But he backed your view over that what was being done, or what was attempting to being done, going around what you had recommended, was wrong, against the law?

COMEY: Yes. And I already knew his view from the hour we had spent together going over it in great detail a week before the hospital incident.


SCHUMER: OK. Well, let me just say this, and then I'll call on Senator Specter who can have as much time as he thinks is appropriate. The story is a shocking one. It makes you almost gulp. And I just want to say, speaking for myself, I appreciate your integrity and fidelity to rule of law. And I also appreciate Attorney General Ashcroft's fidelity to the rule of law as well, as well as the men and women who worked with you and stuck by you in this. When we have a situation where the laws of this country -- the rules of law of this country are not respected because somebody thinks there's a higher goal, we run askew of the very purpose of what democracy and rule of law are about. And this -- again, this story makes me gulp.

Friday, May 11, 2007

Neurodiversity: a video that beautifully illustrates the concept

There is a really interesting symposium now available by webcast from MIT's Media Lab. Though the name, "Human 2.0" is sort of irritating to me, some of the content is fascinating, including a talk by Oliver Sacks, some introductory remarks by John Hockenberry, and presentations of interesting work by Media Lab researchers.

I am still making my way through the day-long proceedings, but as I watched some of the morning session today, one speaker mentioned a video by Amanda Baggs--who was in the audience--that I went and watched on YouTube. I found it to be both a lovely work of art and a striking political statement. I hope you'll watch it. The videomaker (whose blog is here) introduces her work on YouTube this way:

The first part is in my "native language," and then the second part provides a translation, or at least an explanation. This is not a look-at-the-autie gawking freakshow as much as it is a statement about what gets considered thought, intelligence, personhood, language, and communication, and what does not.

Cat whisperer

YouTube, aka,, has this video which more or less illustrates the content of my conversations with the Hemodynamic Cat, except this guy has two.

Ms Hemodynamics is off on vacation with her mom, so I am staying in the Hemodynamics HQ with the Hemodynamic Cat. The Hemodynamic Cat is a Siamese cat, and like many others who share her ancestry, she has a strong personality. She also seems to have strong opinions which she expresses quite forcefully with sometimes unstoppable loud meowing.

The meow-screeds are sometimes especially unrelenting when Ms Hemodynamics is away. She was Ms Hemodynamics' cat before I came into the picture, and initially waged an incredibly stealthy and devastating terrorist campaign against me to try to stop me from dislodging her from her place as Ms Hemodynamics' BFF. We get along very nicely now that she realizes that even if I dislodged her from her pillow, I would never dislodge her from Ms Hemodynamics' heart. Still, I think she is just slightly more uncomfortable with me, so that she can not decide whether she wants me to reassure her in Ms Hemodynamics' absence, or whether she just wants Ms Hemodynamics to return now and wants to express her opinion about this, or whether she would prefer that I leave her alone to think about Ms Hemodynamics on her own.

This can sometimes become upsetting. When I can not seem to satisfy the gnawing discontent in the Hemodynamic Cat's soul, and she keeps yelling despite my best efforts, I sometimes wonder about the wisdom of becoming a father. (Her meowing can become intensely distressing, and seems to have evolved to resemble the cry of a human baby. It takes real determination to ignore it.)

There are a few tactics which work, but I've recently discovered one that works the best, but is kind of distressing. And it reminds me of a nasty doctor trick.

When cats are content, they make a big long blink of the eyes. And for cats, this signal is contagious, like a yawn, and it seems to be strongly communicative. At some point in the last two days I started doing this to the HC when she was on a tear of yelling. And most of the time she has this reaction:
1. Looks at me insistently, and meows one or two more times loudly.
2. As I continue slowly blinking, she sits and looks down at the floor in a kind of gesture of disappointment, like when we leave the apartment and she realizes that we are leaving.
3. Meows a few more times, but with a quieter, sadder, hoarser tone.
4. Gives up and walks away.

In other words, I think I've figured out how to communicate in cat terms: "I'm content. What's your problem?"

Which, really, is not very nice. It's like when people come in to a doctor's office all freaked out and worried and the doctor says, "I'm not worried at all. You are 100% healthy." And then won't elaborate.

I started feeling a little bad, and now I resolved that there have to be many repetitions of "pick cat up, cat purrs, cat wriggles out of my arms, cat walks around the house, cat comes back and starts yelling again" before I try this tactic. After all, since she's yelling, I'm not at all content. And it's not nice to lie--especially to cats.

Thursday, May 10, 2007

A glass ceiling in academic medicine?

Rosie the Riveters of academic medicine: the first women admitted to Harvard Medical School, in 1944. Women limited to 5-10% of the class for decades thereafter. From the Countway Library, HMS.

Medical academic extraordinaire Orah Platt putting a white coat on med student Tara Benjamin in 2001. Women are becoming a majority of entering medical students, but it's not yet clear how quickly the highest ranks of academic medicine will catch up with the lowest. From HMS's Focus newsletter.'s "White Coat Notes" has a brief article about recent adding-up-the-basic-numbers findings, showing a lack of women in leadership positions in medical schools in Boston. A man who has been one of those looking into the problem says, "People might reflexively think that it's discrimination or a glass ceiling, and there may well be an element of that."

Right. There may well be.

Then he says, "It may be in some cases that women choose not even to apply for these positions or don't aspire to them because they are not appealing to women at that stage in life."

So, let's take the second proposition as true, for the sake of argument. Let's say that the medical schools have designed a set of powerful positions that they realize may not be appealing to women. That IS discrimination and a glass ceiling. It's discrimination against women the same way a set of stairs without a ramp is discrimination against wheelchair users. It's a way of saying we don't want you here, we don't want to find a way of getting you to come here, and in fact, we can't even imagine you being here--without actually having to say it to anyone's face.

For my part, I don't think there's really much functional difference between that kind of discrimination and the kind of discrimination that happens when some department chair just plain hates women in some kind of more personal and visceral way.

Wednesday, May 9, 2007

Abbott protest follow-up: "In a word, yes."

photo of Chicago protest with Thai activist Mai Rewthong speaking, from

Bill Clinton recently endorsed the decision of the Thai government to issue compulsory licenses for pharmaceuticals to be used in the Thai public sector medical system. It was really during Clinton's presidency that a global shift took place about intellectual property rules. As I wrote in my thesis/book-in-progress,

A debate about [global trade rules] came into the open in 1999, while pharmaceutical companies were suing the South African government. They objected to a 1997 law that permitted compulsory licensing for generic versions of patented medicines. In the United States, the Clinton Administration backed the pharmaceutical companies’ position, threatening trade sanctions. And the companies threatened to stop selling drugs in South Africa. When a New York Times reporter asked an industry spokeswoman if that meant they were “literally threatening to let people die if the law stands”, she “hemmed a bit and then answered: ‘In a word, yes.’”

Activist groups started strategizing. In the United States, a coalition of AIDS activists–who later formed the core of a group called Health GAP–began discussing how they could influence American trade policy. In South Africa, a small group of activists, led by the HIV-positive activist Zackie Achmat, had formed the Treatment Action Campaign (TAC) in late 1998.

TAC targeted the pharmaceutical companies and the US government with protests in South Africa, raising the visibility and political risk of the companies’ lawsuit and of US trade policy. In the United States, activists targeted then-vice president Al Gore as he began a run for president. At campaign appearance after campaign appearance, ACT UP activists shouted the slogan “Gore’s Greed Kills!” linking pharmaceutical companies’ contributions to Gore’s campaign with the government’s trade policy.

Gore and the Clinton administration faced a no-win political situation in the making. They started backing away from the fight. The companies kept up their lawsuit, but the activists had isolated them.

It's important to remember this history in the current controversy over Abbott: this fight has been fought (and won) before. Abbott is trying to roll back global trade rules to 1997, at a time when it thinks no one will notice. It's really important that we keep noticing.

I promised an update from the protest. (Links to media coverage are in a post below.) Three Thai AIDS activists accompanied a group of 60-70 student protesters (along with Brook Baker, from Health GAP) to Abbott Labs' facility in Worcester, MA. As a group, we staged a die-in, some activists delivered speeches, and won only slight coverage from the media. (The Worcester media covered it, though, which is more important than it sounds: for local Abbott employees, it's important to know why people are protesting in front of their building.) More coverage came from the Chicago Tribune and others covering the shareholders' meeting the next day; for this more important coverage, the Worcester protest and its many counterparts served mainly as a backdrop to emphasize the theme of a globally-coordinated activist movement opposing this global company.

A small group of UMass medical students, whose school and hospital is right across the street, were the only other med students there. I didn't get a chance to talk to them. They had an array of style choices--scrubs, white coat over jeans, white coat+tie, and so on--reflecting that some had just come over from the hospital while others had come from classes or a day off. "I've got to get back soon," one said to another, "My guy is going to have a thoracentesis to get two liters off." "Two liters?!" After a little bit of "Drugs Cost Pennies! Greed Costs Lives!" he was off.

I got to hang out a little bit with two activists from the Thai Network of People Living with HIV and AIDS, TNP+, including its head, and a woman translating for him (pictured above, ID'ed as Mai Rewthong by; I didn't write down either of their names, to my shame now). They were there with Jon Ungphakorn, a former Thai senator and long-time AIDS activist; the group of three were touring as many of these protest actions as they could. They were in Chicago at the shareholders' meeting the next day.

For my current work as a historian of AIDS activism, the most interesting moment was when someone shouted, "People with AIDS, under attack! What do we do?" and everyone immediately and vigorously responded, "ACT UP! Fight back!" This chant--and ACT UP itself--was invented twenty years ago, before many of the protesters were born. Everyone--Thai activists, college students, med students--felt that it somehow represented them. There are some amazing continuities in the AIDS activist movement, from gay men with AIDS in 1983 to the coalition of people with AIDS and queer activists in ACT UP in 1987 to today's student groups and global groups of people with AIDS.

On the bus back, I found out that many of the Harvard Student Global AIDS Campaign members who were coming to the protest were pre-med students, and I found myself giving pre-med advice to a small group of them during the bus ride. It is more than a little bit startling and disconcerting--but, I think, ultimately inspiring--to find that a number of Harvard pre-meds make it part of their pre-med process to get on a bus and shout "ACT UP! Fight back!" at a pharmaceutical company. Let's hope for more of that in the future. Perhaps one day, the pre-med mantra for getting ready to apply for medical school will be, "grades, MCATs, research, volunteering, going to die-ins."

Tuesday, May 8, 2007

This I believe... (a few short posts in one)

I believe that:

* Scrubs is the most realistic medical television show of our era, and an informal but long-lasting and multi-city poll I've been taking of other medical students and residents suggests that many agree.

* Scrubs are the clothing of the hospital as factory floor--the hospital as a production process with teams of workers working together--and their persistence and popularity suggest that more and more healthcare workers see their work in roughly those terms.

* Ties should be eliminated from the work clothing of male doctors, and I used to think they would disappear because we would follow the "creative" sides of the business, research and technology worlds. But I have come to think that I will wear a tie for a long time to come, and so will most of my colleagues. But perhaps not mostly for the reasons of "respecting patients" that most of us will use to explain the choice. We will wear ties because part of what the doctor is offering is the power he will wield on your behalf. We will not admit the extent to which this power is an illusion, perhaps even a dangerous one.

* Women in medicine will continue to struggle to find the right outfit that expresses what it means to be a doctor, without clear rules and with much criticism for breaking unclear rules. Men in medicine should continue to struggle to find the right outfit that expresses what it means to be a doctor, but they will stick to clear rules and not give it enough thought. Transgendered people in medicine will be too cautious to innovate in the workplace.

* The trashy semiotics of medicine--the television shows, the clothes--are more important than they first seem. They are the visible signs of unspoken ideas of our culture.