Eric Balderas is free, for a little while

Eric Balderas, a Harvard College sophomore studying molecular and cell biology, was recently granted a stay of deportation. Eric was picked up by immigration authorities after trying to use a Harvard ID card to get on a plane. His story is one of many arguments for the DREAM Act, which would enable undocumented young people, brought to the United States as children, to earn citizenship if they met a specific set of conditions (earning a high school diploma, college degree, or serving in the military). This would transform the lives of many members of our society, including some who matter very much to my family and me.

Around these parts, Harvard actually has a significant number of students in this situation, in part because it can offer full financial aid to young people who are not citizens or legal residents. But it is only a temporary refuge, as an article from the Crimson explains. The article puts particular focus on one Harvard student who is applying to medical school this year; I don't know when and whether she'll go, but I can only hope that she joins us in the hospitals and clinics, as a colleague who never has to doubt that she has a place here.

Here's a Crimson news video from earlier on in the saga, interviewing Eric Balderas.

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:

Kyle,
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]

HIV meets diabetes meets HIV

In the early 1990s, I never believed it would happen. But in mid-February 2007, I heard a cardiologist talking about the cardiovascular effects of HIV, who then put his talk in context by casually saying, “Even so, I’d choose to have HIV over having diabetes.” The doctors-in-training listening nodded in agreement. They probably didn’t remember that people used to talk about comparing HIV to diabetes like it was an impossible dream.

In 1992, Bob Rafsky, a person with AIDS and a member of the activist group ACT UP, wrote in the New York Times, “It's always possible we'll win. The drug, or drugs, that will turn AIDS into a chronic illness like diabetes will finally be discovered.” But, he wrote, “it's not likely, at least not in time for me.” Rafsky died the next year, in 1993.

Just three years later, starting in 1996, the kinds of drugs Rafsky had hoped for arrived in wealthy countries like the United States, used in combinations of medicines that together became more than the sum of their parts. Along with other improvements in HIV care, that allowed people to live with HIV for much longer periods of time than before.

Even back in 1996 and 1997, people were starting to say that living with HIV could finally be like living with diabetes, a difficult but manageable chronic disease. This didn't mean that it would be easy.

With modern medical strategies, the most common and serious effects of diabetes aren’t short term crises of sugar levels, but the effects of long-term damage to blood vessels: problems like stroke, heart attacks, kidney failure, blindness, nerve problems, and foot and leg infections that can sometimes require amputation.

Avoiding these problems over the long-term requires constant vigilance. In fact, as HIV medications become easier and simpler to take, sticking to them is often less complicated than sticking to diabetes regimens.

Especially early on, most Americans with HIV got the virus either from unprotected gay sex or sharing needles, which is part of how HIV got the stigma that it still has today. By contrast, Type I diabetes often comes in childhood, as a result of an autoimmune problem; no one blames people with Type I diabetes for their disease.

But stigma does influence how society responds to the much more common kind of diabetes, called Type II diabetes. Whether people get Type II diabetes has a lot to do with genetics. But higher amounts of body fat are associated with higher risk for Type II diabetes. That’s political poison for mobilizing a response to Type II diabetes, because Americans tend to misunderstand why people gain weight, think of fat as a kind of moral shame, and vastly underestimate the difficulty of losing weight and keeping it off. And so society can distance itself from Type II diabetes, by blaming the disease on the people who have it.

When AIDS was a more lethal disease in the US than it is now, it inspired intense fear and stigma and discrimination. In the late 1980s and early 1990s, people with AIDS and their allies, including activists like Bob Rafsky, began speaking against that fear and demanding the solidarity of others. They won the support of many; red ribbons became de rigeur for celebrities for a while. That kind of activism (both the angry kind and the syrupy Oscar ceremony kind) helped bring the day that HIV infection became more like diabetes.

Now, as Type II diabetes becomes more common, and also stigmatized for its increasingly well-publicized association with fat, the new challenge might be for Type II diabetes to become more like HIV—in which people with the disease and their allies stand up to demand that the society get over its prejudices, and start paying more attention.

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.

Boston.com'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.