Pediatric Admissions

Moral Dissolution through Moral Indignation

2017-01-21T12:31:00.002-08:00

The cycle of violence in American politics

Let me take you on a journey – a journey that most people are already on. In this post we will descend into the depths of American political discourse. Without realizing it, most people are somewhere on this road, even the disinterested who’s political engagement is purely incidental through their Facebook newsfeed. We all have feelings about what is right and what is wrong with this country. Unfortunately, those feelings are only the beginning of this journey, which may not end well.

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Have you ever been had a conversation with someone who seemed like a compassionate and intelligent person one minute and a crazy political extremist the next? Perhaps he favors taking health care away from people for the sake of smaller government, or redistributing wealth from hardworking Americans so that poor people are given more material resources, or loosening climate regulations to boost fossil fuel production – Earth be damned, or making abortion services available to mothers in the 3^rd trimester. How could a person who seems so nice and reasonable think that way?

It’s possible after reading that list that you had an immediate emotional reaction to the statements – I’ll admit I could feel emotional content stirring in me as I typed it. Perhaps, if you’ve spent enough time thinking about the topics, a list of talking points spewed into your consciousness like a geyser exploding from its pressurized reservoir. The reason these topics are so emotionally volatile is because at their core, they are moral issues. These are fundamentally questions about right and wrong, about how humans should act toward each other and toward the world they inhabit.

Your emotional and moral reactions to the topics are the reasons why your hypothetical conversation partner looks ghastly to you as they fall on the wrong side of the moral divide (and the wrong side of history, as we’re quick to point out). It seems our culture (and the internet) believes that people who hold morally wrong beliefs are by extension immoral people who must be corrected, coerced, or contained – a process that daily plays on repeat in our news cycle (source: CNN.com). This moral condemnation cycle drives the tribalism into which our country has descended. The two sides can’t talk because the other side is so abhorrent. The natural outcome of this process is emotional and physical violence as interpersonal relations break down. 2016 was filled with such examples, from violence at political rallies, to protests dissolving into riots, to ambush-style cop killings, to the spike in hate crimes after the election.

Another casualty of this moral condemnation cycle is truth. Much of what we know as “truth” is based on trusting authorities that report events to us. Moral revulsion and tribalism erode trust in those outside the group. As trust shrivels, unbelief blossoms. You won’t believe the New York Times to tell you about shadowy Russian hackers - a topic you have no empirical access to - if you believe there is moral rot in the hearts of the writers. Although skepticism can be a virtue when coupled with impartial intellectual analysis, moral tribalism tends to drive motivated reasoning where our “truth barometer” is not what accords with the fundamental principals of logic and reason, but rather what resonates with our pre-existing beliefs about the world. As a result, fake news goes viral and truth recedes into relativistic obscurity.

Though interpersonal violence and motivated reasoning are natural outcomes of moral tribalism, we have not yet spiraled to the bottom of this destructive cycle. The current situation in the country, two sides that find the other morally abhorrent, is an inherently unstable arrangement. Moral revulsion repels and with each instance of violence or faulty reasoning, the two sides are pushed further apart. As the distance grows, our ability to understand the other side dissolves and productive conversations fizzle. Unfortunately, since we share a country together, each side still needs to influence the other to obtain their own political goals; however, since the ability to influence through reason and compromise has collapsed, the only available route is through force. So each side finds forceful displays of power to be the most expedient political activity. We can see this process play out, for example, through the Left’s use of identity politics or the Right’s obstructionist behavior in congress over the last 8 years.

While these types of power plays have existed in American politics since the birth of the nation, as the country’s shared values erode, the range of acceptable political behavior widens to include previously unthinkable acts. Donald Trump not only normalized but also benefited from violating political norms, such as insulting the spouses of his political opponents, lying about releasing his taxes, and breezily threatening war on Twitter. Trump is neither special nor clever; he is merely filling the space opened by our country’s moral dissolution.

He is also not the worst that could come.

If Trump continues to wield his newfound political power like a bludgeon, the rift will widen and moral norms will continue to erode. As each side suffers violence, frustration will turn into hatred. This hatred will be disguised as moral indignation, a self-righteous deception that justifies the violence it produces. Moral indignation will act as an engine for this cycle of violence as we roll into the abyss of hyperpolarized tribalism. Downward we will spiral until the situation is right for the next Trump-like figure to appear, the Trump of nightmares, the Trump empowered by an electorate who is ready to send the opposition to Hell.

This devil-Trump may not arrive in the near future. Such an evil may yet be decades in the making, but if our country continues on its current course, we will run directly into his seductive embrace. One may think I’m being dramatic, prophesying doom based on fantastic guesswork. To this I would reply that 2016 happened…and they said, “it can’t happen here”.

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It is highly likely that you do not identify with the moral tribalism identified here. You probably have some political thoughts and you likely identified with a candidate in the election, or were just frustrated by all the candidates. But I would invite you to remember the feeling of powerlessness you felt from this election. You may have felt powerless when Trump, who you thought had no chance in the world of winning, dominated the Electoral College vote. Or you may have felt powerless when neither candidate even approached representing your unique views, and the political discussion moved on without so much as noticing you were there. This is the danger of a binary choice in a world of infinite possibilities: the choices do not reflect the choosers, and yet the choosers choose nonetheless. This same binary choice of Left and Right continues today, and the locus of power is migrating towards the extreme ends of the spectrum. Although you may not be far along with the process I just described, it is undeniable there are many people (who you probably do not interact with and who are not in your social media networks) who are quite far along this path. If you do not counteract the process now, you’ll be powerless to do it later. You’ll be trapped in a more extreme version of the same false dichotomy in which you were just crushed.

Sunday Prayer, after the election

2016-11-13T05:58:00.000-08:00

“Forgiveness flounders because I exclude the enemy from the community of
humans even as I exclude myself from the community of sinners. But no one
can be in the presence of the God of the crucified Messiah for long without
overcoming this double exclusion — without transposing the enemy from the
sphere of the monstrous… into the sphere of shared humanity and herself from
the sphere of proud innocence into the sphere of common sinfulness. When
one knows [as the cross demonstrates] that the torturer will not eternally
triumph over the victim, one is free to rediscover that person’s humanity and
imitate God’s love for him. And when one knows [as the cross demonstrates]
that God’s love is greater than all sin, one is free to see oneself in the light of
God’s justice and so rediscover one’s own sinfulness.”

- Miroslav Volf

Both sides of American politics will have much to forgive of the other in the coming years. Grievance can lead either to hatred and then bitterness or to forgiveness and then peace. No matter how wide the political divide, we all live in the community of sinners, each of us usurping God as king of our lives, called to kneel before the throne to find true redemption and peace.

Lord, may my soul lay prostrate before Your divine love.

Amen

A Prayer on the Eve of the Election

2016-11-07T19:33:00.004-08:00

The Perspective of Infinity

Peace,

Wholeness,

Ultimate good

Perfect fulfillment,

The way things were supposed to be.

In Hebrew You called it shalom. It was Your original plan for Your creation, a beatific vision for Your beloved creatures. Man was designed for a sublime equilibrium of harmonious relationships between himself, other men, the creation, and You. Peace was to resonate throughout these connections, proceeding to the rhythm of Your own heartbeat. Psychological wholeness, sociological perfection, ecological equipoise, theological consummation – these were the seeds of the Garden of Eden and their symphonic interactions, the branches of the Tree of Life.

Yet the brilliant light of perfection cast a shadow. Man made a choice to remove You from Your throne of Glory and exalt himself as god. As he ascended the steps of the throne, shalom crumbled around him and dissolved into obscurity. As he sat and placed the crown on his head,

The music stopped,

The garden died,

Corruption

Reigned.

When the divine reality is juxtaposed against the worldly, I feel as though I’m overlooking the edge of a chasm, transfixed by what I do not see, crushed by the weight of the void. We’ve fallen so far from Your Beatific Vision for us. Since the time we usurped Your throne, history has unfolded as a perversion of Your original story, a debased specter of what could have been.

And here we are now in 2016, our country on the eve of a presidential election that has reminded us how profoundly wide is the gap between the good life that You want for us and the corrupt reality that we inevitably produce. I cannot help but feel a profound sense of loss of Your shalom.

Lord of Peace, Jehovah Shalom, my prayer is that we see the world, and this election, from your infinite perspective.

I pray for the United States.

From the time our country was founded we have claimed to be exceptional, a city on a hill, a light that cannot be hidden. Yet we continue to fall short of that ideal. We claim to be pro-life, pro-choice, pro-marriage, pro-equality, pro-American, pro-immigrant, pro-business, pro-worker. Yet all these things we are for set us against our fellow countryman. Racial tension, religious animosity, tribal culturalism, corporate greed, and public corruption dominate our news cycle. Our societal dialectic has thrust us into discord, and from the very existence of the “other” we’ve fled toward “us” to rid ourselves of “them”. The gap between our reality and Your shalom is widening. Lord let us feel the weight of its absence.

I pray for the candidates, Donald Trump and Hilary Clinton.

Through the rancor of election rhetoric, it easy to forget that behind the political façade are real people created in your image in the same existential state as the rest of us. I do not know either of them personally, nor can I speak to their motivations or the state of their hearts. All I can do is humbly compare their public image to the harmonious state which you have intended for man, and, acknowledging my own epistemic limitations, evaluate their policy proposals against the resonant perfection of the created order which You intended. By this comparison, their political personas measure so small against your Beatific Vision, it is as if they disappear. All that remains of them is the enduring part common to all of us, the divine image-bearers which you created and humanity itself corrupted. So we are left with Donald Trump, the man, and Hilary Clinton, the woman, desperately clambering for something that does not seem to be Your shalom, and therefore tragically missing the only thing of true value in this life. Lord let them see Your glory.

I pray for the state of my own soul as I relate to my fellow man

Am I in so different a state than the candidates? How often do I aim at futility or run after destruction? Looking the candidates in the face shows me that I’m not so different from them. There are no stones to throw here. I too have ascended the throne and displaced You as king of my life. I have participated in the disunity of national tribalism. I measure to the same infinitesimal height as Trump or Clinton when compared to Your shalom. Lord let me not look past my own illness, as I too readily diagnose it in others.

Hope

So it is that the nation, the candidates, and I are all in the same situation. Side by side, we occupy the same strident reality, perched on the edge of the chasm, peering into the darkness for something more.

Yet, thankfully, incredibly, You offer us hope for redemption. Your Son has provided the possibility of restoration. An infinite God paid an infinite sacrifice displaying infinite love toward us, the idolatrous usurpers. And so You have closed the infinite gap between our corruption and Your perfection.

Election 2016 will come and go. People will yell, emotions will flair, politicians will scream. The discordant parade of history will march onward.

Yet from the perspective of infinity,

the noise will echo

into the void

until shalom

returns.

Taming your inner troll: The 4 rules of sharing political opinions responsibly on social media

2016-10-09T12:04:00.003-07:00

This is the second in a 2-part series. Read the first part here.

Source: https://xkcd.com/386/

Remember that time the Internet lost its mind? It might have been about holiday cups at Starbucks, a satirical racial joke by Stephen Colbert, a lion or monkey being killed, some actor saying something offensive or a journalist asking a politically incorrect question. While each issue has its own degree of legitimacy (large or small), the tidal wave of outrage it triggers represents the destructive potential of social media. The smallest perceived offense can ignite the Internet’s fury.

On the flipside, remember when we had a presidential race that featured candidates with such loose relationships to reality that people simply stopped being outraged. Like the proverbial frog that let the water heat to boiling around him, so too have many people come to expect, or worst accept, this toxic political environment. The deluge of unreality has blunted our ability to react appropriately.

Both of these examples of outrage and apathy demonstrate the importance of social media as a tool for social conversation. In my last post, I discussed how social media can help us as a society decide what is right and what is true. Knowing this will help us deal with outrage and apathy appropriately. Yet these examples also demonstrate that social media can be destructive and actually push us further apart.

To turn social media into a constructive force, we need guidelines to harness its power. Here I will discuss the 4 rules of using #SocialMediaForSocialGood.

The 4 Rules

These rules are taken from Daniel Dennett’s book Intuition Pumps and Other Tools for Thinking in which he relays debate rules that he received in conversation with the accomplished mathematician and game theorist, Anatol Rapoport.

1. You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.”

2. You should list any points of agreement (especially if they are not matters of general or widespread agreement).

3. You should mention anything you have learned from your target.

4. Only then are you permitted to say so much as a word of rebuttal or criticism.

Let me take each of these one at a time.

You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.

This one is key on social media. The vast majority of Facebook arguments I have either seen or participated in became contentious because people were arguing against things their opponent was not saying. The format of social media lends itself to miscommunication because it is so constrained. You have 144 characters on Twitter or clunky comment boxes on Facebook to express yourself. You need to focus on the specific point the person is making and not argue against a conclusion you think they will make three logical steps down the line.

Suppose I post something negative about Trump like “whenever Trump talks, he lies a lot”. My conservative friends will immediately respond with how terrible Hilary is. The conversation is already off to a bad start because I didn’t say anything about Hilary, they just assumed a conclusion that wasn’t made. Re-expressing the argument helps to narrow the scope of the conversation to a manageable topic over social media: “I think your point is that Trump says things that are untrue, for example during his political speeches, well if you look at the context…” and so on. Now we are on the same page and won’t be talking past each other.

One last note, this rule also implies that the original poster is the person setting the scope of the debate. If Trump’s lying makes you want to say something about Hilary’s emails, then either take the time to logically connect the original point to the emails, which will probably take multiple back-and-forth posts, or post a new topic yourself. The conversation will be pointless if we continually talk past each other or bury each other in an avalanche of disconnected opinions.

You should list any points of agreement (especially if they are not matters of general or widespread agreement).

This is an important point for both participants in the conversation. It serves to close the ideological gap by allowing all parties to realize what they have in common. This also helps to further narrow the scope of the debate so you both know what is already considered true in this particular conversation. It also has a nice psychological benefit of lowering the oppositional barriers the participants might be feeling that are inherent in disagreements. Keeping with our Trump lying example, you as a Trump supporter may say something like “I agree that many of his comments are untrue at face value, for instance there is no way Mexico will pay for the wall. But he says these things to make a larger point about immigration policy….” and so on. Now we both know our common ground and where the disagreement begins.

You should mention anything you have learned from your target.

The point of the discussion is to get closer to what is right or what is true, so hopefully you are learning something along the way. You have not somehow “lost” the discussion by learning from your opponent. This is actually evidence of the back-and-forth process at work and should be encouragement for further discussion! Like the second point, this also has psychological benefit because it breaks down the divide between participants and reframes the experience more as two humans trying to decide what is right or what is true together rather than as a competition between two opponents.

Only then are you permitted to say so much as a word of rebuttal or criticism.

Now we both understand what the argument is about, where we are beginning from, and what the benefit of the conversation has been. So now, its time to tussle!

Let me make a few concluding observations:

· These steps do not necessarily have to happen in order or with every reply or post that is made. Some of them can happen a few times throughout a conversation or sometimes you can just check them yourself mentally. The point is that these guidelines should provide structure for how you approach discussing sensitive topics with another human; how you actually employ them is up to you.

· During political discussions, we are ultimately arguing about what is right and what is true (see the last post). We shouldn’t be trying to “win” or “defeat” an opponent. It also helps to assume good motives in others, for instance that they too want to better understand what is right and what is true

· However at times it becomes clear that some people have bad motivations, such as trying to belittle your point. I would argue that it’s not worth engaging these people because it will quickly degenerate into a rhetorical competition. The only level in which you could engage them is to argue that what is right and what is true should be the purposes of their arguments.

· Emotions play a big role and need to be observed mindfully throughout a discussion. Sometimes its just better to sit on that message overnight before pressing send.

· Be responsible, don’t drink and tweet.

So there you have it, my (actually Daniel Dennett’s) proposed rules for debating politics and other sensitive topics on social media. With these rules, we can overcome the cycles of clickbait outrage and sensational apathy and instead learn to thoughtfully use #SocialMediaForSocialGood.

On Botswana

2016-05-12T14:25:00.002-07:00

My first day in the pediatric cancer ward in Botswana was striking. We have two rooms with multiple oncology patients in each room. One room is designed for 6, the other is designed for 4; however, if there are not enough beds, then mattresses are flung on the floor wherever there’s a spot. (So I suppose the true capacity of the rooms is the surface area of the floor divided by the surface area of a mattress…). There are no labels to the beds, nor bracelets for patient ID, there are only names and landmarks (e.g. “Namueli under the Garfield poster”). The most striking aspect, I think, are the flies. There are flies everywhere. They crawl on the floors, they chill on the beds, and they land on the kids, even the cancer kids who are immunosuppressed!

As this description of the unit illustrates, medicine is very, very different here in Botswana. Resource availability, workflow, cultural practices, social interactions are all radically divergent from where and how I was trained. I find that these differences make the workday quite difficult. Cancer care is extremely complex. Adequate resources are essential and the system needs to operate smoothly in order for treatment to proceed. The deficiencies in the system tend to inhibit the progress of care.

……

I feel that many times when I hear or talk about international medical missions, this is the kind of description I end up with - a laundry list of all the ways the system is not what we think it should be. Yet while the difficulties here are many, our group is nevertheless providing ever-improving, high-quality care to the kids in our program. We can do such good work because Botswana is an incredible country to work in. It is true there are many difficulties to working here, but by developing a deep understanding of these difficulties, they can be overcome. More importantly, we need to acknowledge that Botswana has many unique assets, which can be leveraged to unlock its potential. To better understand healthcare delivery in Botswana, I want to go beyond the laundry list of complaints and explore its difficulties and its assets with the nuance and dignity that the country deserves.

The Difficulties

To discuss the difficulties of care let's use the example of the flies. At first it seems ridiculous that there are flies in the hospital! They pour in through the open windows in the unit. They are diarrhea vectors from hell and they all need to die a horrible death. It is frustrating to see them swarming the kids who have already been through so much. Yet they persist in the unit because getting rid of them defies easy answers.

Easy answer 1: Close the !@#$ windows!

Nope: You’ll give the kids tuberculosis and you definitely don’t want to do that. Botswana has one of the highest rates of TB per capita in the world at about 5 per 1000 people (http://www.aho.afro.who.int/profiles_information/index.php/Botswana:Analytical_summary_-_Tuberculosis) and all of those people love coming into the hospital to share the joy. The hospital does not have any sort of central air conditioning and people are much more likely to contract it in enclosed environments with stagnant air. So opening the windows and doors is the WHO-sanctioned poor-man’s version of environmental control (http://www.who.int/tb/publications/2006/tbhiv_infectioncontrol_addendum.pdf). So easy answer 1 ended up with a bunch of tuberculosis infected cancer kids. Go us.

Easy Answer 2: Buy air conditioning! Then close the !@#$ windows!

Nope: Are you kidding? The climate in Botswana is quite temperate most of the year, except for the very hot (but not humid!) summers, which can be relieved with fans. So most of the time central heating and air conditioning is a waste of money. The hospital can do far more good for the patients by taking the money they would spend on air condition and instead buying vital supplies like antibiotics and chemotherapy. AC is an incredible expense that outweighs the value of banishing the flies. (At least we didn’t give the kids TB with this answer)

Easy Answer 3: Buy screens for the windows!

Nope: Well actually, that’s not a terrible idea. Except its already been tried and failed. There are screens scattered on a few random windows throughout the unit, which is evidence of a past attempt at fly control. I think the problem was that the windows were designed really terribly and it is very hard to open them with the screens on them, not impossible mind you, just more difficult. The difficulty made people haphazard with how they handled the screens so they fell off over time. It seems no one really cared to maintain them and put them back up. This issue spirals into a really interesting discussion of organizational practices that perpetuate inefficient processes, for example facilities upkeep. I will not indulge in the discussion here, but suffice it to say we’ve identified a larger organizational deficiency of maintenance that neither I nor you are in a position to address at this particular moment. So not a bad thought (by that I mean I don’t really have anything sarcastic to say it), but been there, done that.

Easy Answer 4: Put up flytraps!

No…Actually maybe: As it happens, I’ve made my own and am trying that as we speak. I made homemade traps using coke bottles and sugar dissolved in water as an attractant (Youtube says it should work). I have my reservations as to the efficacy of these contraptions, mainly because I’m not sure my sugar water is going to be attractive enough. Flies seem to really like moldy fruit, rotting meat, or poop – none of which the hospital administration felt comfortable allowing me to hang in the rooms. They also aren’t keen on using other types of chemicals or pesticides for understandable reasons. So sugar water it is! (If anyone has any other suggestions, I'd love to hear them...)

This analysis illustrates that many seemingly simple problems defy easy answers. Granted, I’m experimenting with an easy answer right now, but I don’t have much confidence I will be successful. The larger point is that the roots of many of the problems extend far into the larger structures of the organization where no one person can reach them. These structures include the actual infrastructure of the facilities, the resources available to us, the organizational practices of communication, the workflow of laboratory tests and other processes, and longstanding cultural practices. This list is certainly not unique to this hospital, I could tell exactly the same story (and probably worse ones) at any hospital in the United States. The point is that this list helps to identify the relevant domains that need to be engaged if we are to improve the quality of care we provide. Building health systems defies easy answers. Our analyses of systemic deficiencies have to be as complex and nuanced as the system that created them.

The Assets

Botswana is a magnificent country with incredible prospects for continued development. To truly provide high quality care in international settings, we have to understand and leverage the strengths of the system. To identity its specific assets, a nuanced and complex understanding of the historical, social and environmental milieu is essential.

Botswana was a British colony until independence of 1966. It is completely landlocked and has very few natural resources except for diamonds discovered shortly after independence. At independence it was extremely poor with a gross domestic product (GDP) per capita of about $70 per year. Over the next 35 years, Botswana would clock one of the fastest economic growth rates in the world at 7.7% peryear from 1966-99, which is phenomenal when compared to other “economic success stories” over the same period such as Hong Kong at 4.6% and Singapore at 6.2%. As a result of this growth, Botswana is considered an upper-middle income country by the World Bank and boasts a GDP per capita of $7315. Researchers attribute this economic success to lack of interference from post-colonial powers such as Britain, strong democratic government institutions, the consistent enforcement of property rights, and political leaders that made reasonable economic decisions. A striking result of this success has been the country’s stability. It has never had a major war even though almost every other country in southern Africa has experience exceedingly violent conflicts – Angola, Zimbabwe, South Africa, Namibia, Mozambique, DRC, Tanzania… the list goes on.

This historical backdrop reveals many advantages that Botswana has when considering how to provide complex healthcare in this setting. Its British roots made English one of the official languages of the country. Its economic growth means that resources are more available than in many poorer countries. Its strong government has provided a strong social safety net. All people have access to health care either through paying for private-insurance or free government insurance. Its lack of conflict means the population has avoided the catastrophic physical and mental consequences of war, allowing it to focus its priorities on expanding rather than rebuilding the health system.

Each of these assets can be leveraged to continue improving the healthcare system. For example suppose we want to better educate nurses about caring for oncology patients. The task will be much easier, and therefore more feasible and impactful, because English is the common language in the hospital. If we wanted to establish an outreach oncology clinic in a village 10 hours from the main hospital, that might be a feasible undertaking given the strength of the national health infrastructure and the presence of other outreach clinics already in the region. Suppose want to work with the government to increase funding for cancer patients. If there were warring factions vying for power or if corruption was too high, such discussions would be all but impossible. These are just a few examples of Botswana’s assets at work.

Botswana’s most important asset of all is its people. The people I have encountered here are beautiful. There is a strong sense of community that is very evident in the hospital. Mother’s are almost uniformly at the bedside 24/7. When the odd kid comes in who’s parents are unable to accompany him, the rest of the mothers in the unit care for him as their own, even making sure baths are taken and clean pairs of clothes are available. Cancer care is a very long and grueling process, especially when you have to travel for 2 days every month to make it to the hospital, but families consistently make the journey and complete therapy (it is not unusual for many families to abandon therapy in the middle of it in many developing countries). My Botswana co-workers are intelligent and hard working and represent a very promising future for the healthcare system. The people I encounter in the town are uniformly friendly and willing to help out when I look hopelessly lost. I’ve never once felt unsafe or any hint of aggression while walking through the city streets. I’ve even noticed the men do not ogle at women nor make catcalls, but are rather respectful around them, which is a big deal if I ever returned with a family. I don’t think I could honestly boast of this collection of social capital about any other developing (nor most developed) countries I have visited.

Basically, Botswana is amazing. Its healthcare system certainly has its deficiencies, but all healthcare systems do, rich or poor. To address these deficiencies we need to honestly assess the system and avoid easy answers. More importantly, Botswana’s assets are exceptional. With a rich history, impressive economic growth, sturdy social institutions, and lovely people that form the foundation of a strong society, Botswana is a success story that many people have never head of. These attributes allow us from America to partner together with the people of Botswana to deliver high-quality cancer care to kids across the country.

Movement 1: Medical Missions as an Act of Selfishness

2016-04-30T13:31:00.000-07:00

[Note: I was "lovingly" told that some of my posts were too long and I need to include a summary at the top. So here you go. Tldr: I'm serving sick children in Africa! I'm also a prideful jerk! Who can save me from my pride? Jesus! What does my tendency to pride mean for medical missions?!?....O_o]

I’m currently in Botswana, Africa. I will be working in a children’s cancer ward that my hospital in the United States has an international partnership with. I’m incredibly excited because international Pediatric Hematology/Oncology is the trajectory of my professional career and I feel that this is the first step. I am struck by the fact that 80% of children in rich countries are cured of their cancers; however, 80% of the pediatric cancers occur in low- and middle-income countries, where survival rates are often less than 25%. Children die every day of preventable reasons and I would like to be part of fixing that disparity.

As excited as I am, I have a thought that has been weighing heavily on me lately. I’m bothered by the reason why I want to do this. Saving a child’s life from cancer is clearly good work to do, but what is my motivation for doing it? Now I think motivations can be mixed and there can be many contributing reasons for a given action, but as I navigate the answer to this particular question, one motive stands out above the rest: I am selfish. If I’m being honest I have to say that it is really important to me that it makes me feel good and, more importantly, look good to go serve cancer kids in Africa. “Look at what I’ve given up! See how altruistic I am!” are unfortunately common thoughts that energize my actions.

Before we proceed I should offer a disclaimer. Self-glorification is not the only reason that I want to help people. I am genuinely animated by a desire to serve the Lord with my life, by an altruistic impulse to help people, and by a deep longing for justice. I would even venture to say that these motivations are much stronger than my selfishness. However, I’m wondering if this selfish motivation is like the proverbial poop in the brownie mix, a little bit ruins the whole batch. It is this tendency to corruption of something good that I will explore.

So now that I’ve established I am, among other things, kind of a self-interested tool, I need to answer a few more questions for myself: Is this selfishness a problem? What does it say about me? What does it mean for my work in medical missions?

Is my selfishness a problem?

As I’ve already pointed out, saving kids from cancer is inherently a good thing. I think very few people would argue against that. So if the outcome is good, does the motivation matter? Since I’m betting there are other selfish people like me in the world, maybe doing good deeds should be made as self-glorifying as possible so as to maximize good deed doing. One can argue the point, to which I would reply that it is an undeniable fact that our society values right motives. If Batman fights crime because he enjoys violence, we wouldn’t find him much of a superhero. If a politician expands access to healthcare because he is invested in the insurance company, we would cry fraud. If an activist raises funds by lying about the impact of his charity, even if much of the money returns to the charity, we call him a disgrace. These examples show that society values motivations in judging the goodness of an action even when the outcomes are good.

Beyond a societal definition of what is good, I value motivations because I am a Christian. As a Christian, what I find to be good and right is defined by the very nature of God himself and his subsequent description of how we should follow his example. In one of the most famous verses in the Bible, we have a strong description of God’s motivation in acting in the world in John 3:16, “For God so loved the world that he gave his one and only son.” Love motivated God to give his son, Jesus. If God’s reason for giving his son was for 10% of our income or to create an army of evangelical Republicans, we would feel very differently about this God. In God’s love, however, I have an example of right motivation. Philippians 2:5-6 goes on to say, “…have the mindset of Christ Jesus, who being in very nature God, did not consider equality with God something to be used to his own advantage; rather he made himself nothing by taking the very nature of a servant, being made in human likeness.” Christians are called to have the mindset of Christ, who was motivated to serve through love. So motivations matter to God and, therefore, ought to matter to me.

What does my selfishness say about me?

Now that we’ve established a reason to value right motives, let’s explore what my selfishness says about me. To do this, I’ll walk through what happens when I perform a “selfless” act of service. To illustrate selfless service in the Bible, Jesus washed his disciples feet after his last Passover meal and right before his arrest and subsequent execution. Christians find this imagery, that the God of the universe would bend a knee to wash the dirtiest part of his peoples’ bodies, to be a beautiful expression of what it means to follow Christ. Some groups of Christians will do this ritual as an act of worship to God from time to time. While it makes for a pretty description, let’s see what it actually looks like when its my turn to wash someone’s feet:

Alright, its time to whack these guys upside the head with Love. We’ll see what God wants to do through me being a stud.

'Hey everyone, God says we are supposed to love and serve one another as Jesus loved and served us. To illustrate that point I’m going to wash all of your…’ (sick-nasty) ‘…feet.’

Good speech, that really set a pensive tone. I wish there was some epic music playing in the background, like I’m the main character of a movie – mental note for next time. Who first? Jeff just said something dumb and Nate is still snickering at him. I’ll wash Jeff first to both give him a little love fist-bump and to heap some proverbial burning coals Nate’s way. Bwaha. Ok, somberly grab the water and then take off his sho- Oh shi….rrrroudofTURIN! That smell! Don’t react, don’t react, don’t react. Hey I kind of hope the others smell that. Ok slowly wash. Bleghh, is that a bunion? Hmm maybe nonchalantly angle the foot out so the others can see it better. Perfect. Look how much I am suffering! I wish I could capture this moment in Sepia tone. Embed a photographer - another mental note for next time. What a good illustration of God’s love – high five, me!

Although there is a heavy dose of facetiousness in the story, note the obsession with image and appearance. Even while doing something selfless, there is a meta-narrative unfolding in my mind that is reframing the experience to be about me. This reframing will direct my subsequent actions. It is this corrupting feedback loop that turns an action into an exercise in pride. The action may start well-intentioned and emanate from a genuine desire to benefit others, but as the corrupting thoughts occur, it slowly pulls the direction of my focus from others to myself.

The corrupting thought doesn’t necessarily have to be appearance. It could be a motivation for a good feeling. A common response to the question, “Why do you do the work you do?” is the answer, “It’s just so rewarding.” A variety of interpretations are possible in that statement, but if I said it, I would probably mean that it makes me feel good to help people. A degree of nuance is needed here to admit that the good feeling from helping others is itself not a bad thing (the same can be said for looking awesome while serving). But it becomes a bad thing (i.e. a selfish thing) if that is my main motive for serving. These corrupting thoughts can take many forms, from desire for material gain, to sex, to power, but they all have the final common pathway of self-serving motives. In other words, pride.

So here is what I’ve noticed about myself. When I try to do something good, no matter how genuine, how well intentioned, there is a significant temptation to make it about myself instead of the object of my service. I have a continual tendency to pride and self-exaltation, which are both grave sins in the Christian vernacular. Am I alone in this struggle? Thankfully no. The Apostle Paul had something to say about the continual struggle with sin in Romans 7:21-25:

So I find this law at work: Although I want to do good, evil is right there with me. For in my inner being I delight in God’s law; but I see another law at work in me, waging war against the law of my mind and making me a prisoner of the law of sin at with work in me. What a wretched man I am! Who will rescue me from this body that is subject to death? Thanks be to God, who delivers me through Jesus Christ our Lord!

That’s me, a wretched man. I want to do good but I know that sinful pride is right beside me, or more accurately inside me. It’s comforting to know that Paul struggled with similar feelings. And truly, I think he’s describing a more universal struggle. It is a basic fact of the human condition that no matter what we do, no matter how impressive our accomplishments, no matter how dirty we get serving the poor, no matter how much personal sacrifice, the corrupting influence of sin remains. For me, as I’ve already confessed, that corrupting influence is pride. I am the most important thing in my life. How do I escape a situation where the very problem is that I exist?

Thankfully, God has provided an answer through Jesus. I’ve found I cannot change how important I find myself to be. But Christ provides a definitive, external answer to my internal cycle of corrupting self-love. As the omnipotent, transcendental Creator, he posses an existence much greater than my own and, therefore, is a much greater object of worship than I am. Through his sacrificial death on the cross, he provides a way to change my basic motivations by connecting me to God and teaching me what selfless love truly is. Christ can redeem both the object of my desire and my motivations for obtaining it, from self-focused to Christ-centered.

Though Christ offers such a beautiful redemption, I still struggle with sin. I’m not perfect, nor will I ever be while I’m here on earth. The Christian life is a process of learning to reflect Christ’s love more clearly. Like a mirror, I cannot project my own light but rather I’m learning to more clearly project Christ’s. So I will continue to serve. Sometimes I will make it about myself. Other times, and hopefully more and more frequently, I will genuinely say that I am serving with the mindset of Christ.

What does this mean for International Medical Missions?

This framework is my foundation for a Christ-exalting, thoughtful and (hopefully) intelligent approach to international medical missions. I must start with understanding my own state in the world, both wretched and hopeful, before I can focus outwardly on serving others. In future posts, I hope to more explicitly connect these dots. Stay tuned.

Eulogy: Land that Drinks the Rain

2016-02-28T13:09:00.001-08:00

[Author's Note: The subject of this meditation is a family friend and not a patient of mine. I have received permission from his legal guardians to publish this post.]

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He saw too much hardship. He died too young. He was 7 years old, far too young for a funeral. How can those he left behind process such a tragedy?

It is customary at funerals to give a eulogy, a recounting of the life of the dearly departed. The design of such a speech is to celebrate the deceased by memorializing the events if his time on earth. Through this narrative, we hope to illuminate the meaning of the loved one’s life. But what if the deceased has felt so much pain and experienced so much evil, that it is hard to see the meaning through the suffering? How do we see the good when it is wrapped in darkness? Perhaps this is the true purpose of a eulogy. By recounting the good despite the bad, perhaps we will find meaning of the young boy’s life:

“You were born into poverty and grew up in a broken home. You spent your early years lonely and afraid. While you could not care for yourself, you had no one else to care for you. You were separated from your family and sent to a children’s home to find a better life. As stability was within your grasp, cancer ripped it away. You fought hard, enduring years of treatment, and you won many battles. You even thought you had it beat, you thought it was gone, the doctors told you so, and yet the cancer returned, more vicious and deadly than before. As the hopelessness grew, you soon found an army of friends, family, doctors, and nurses beside you. The struggle was fierce; you fought to the point of breaking. You endured many things that kids your age should never have to endure. Good news and the promise of victory again gave way to defeat. The cancer again returned, and this time there was nothing we could do. The cancer slowly took you from us, and now you are gone.

Despite these trials, the good that we can recount about your life is plentiful. I knew you briefly, but I quickly learned your smile could light up a room and your joy, when it shined through the pain, was as infectious as it was evident. You were resilient, able to endure treatments designed to push your body to the brink of collapse. You were obedient to your foster parents, always trusting in their guidance and ever respectful of their wishes. You loved well and loved much, always thinking of the wellbeing of your friends and family. You were imaginative, playful, and free spirited; it was very clear the cage your body had become could not adequately contain your lively soul. Moreover, you had a community around you that loved you dearly. You meant the world to your brothers and sisters, caretakers, and foster parents at the Home. You were also always faithful to your God, believing in him to the very end for hope, strength, and salvation. All of these examples illustrate the undeniable fact that while your body slowly deteriorated, your soul and your spirit were beautifully alive. Those of us you left behind will forever cherish these memories of how you have impacted our lives…”

…Is this where the eulogy ends? I have recounted the good of his life and assured him I will forever hold fond memories. Is the meaning of his life the memories we shared? Yet I cannot keep the immense pain he have experienced from seeping into the spaces between the memories, dampening their color and obscuring their light. I find myself, despite these good things, pressing my questions: Why so much suffering? What is the meaning of it all?

There are those who see only the material world and declare there is no ultimate meaning. Richard Dawkins expresses this sentiment when he says, “the universe that we observe has precisely the properties we should expect if there is, at bottom, no design, no purpose, no evil, no good, nothing but pitiless indifference” (River Out of Eden, 1996). He believed that the material world is all there is to existence, so there was no more meaning than that which we can create within ourselves. Such a view can offer someone nothing more than a recounting of a life’s events yielding a subjective assessment of its significance. The value of a life is in the eye of the observer as he decides what the historical data of a life means. As the French existentialist philosopher Jean-Paul Sartre declares, “One always dies too soon — or too late. And yet, life is there, finished: the line is drawn, and it must all be added up. You are nothing other than your life” (No Exit, 1944).

So is my dear friend truly nothing other than the sum of the events of his life? What if it’s characterized by so much suffering as his was? Was it still worth living? There exist no scales on which I could begin to weigh such values, yet confined to the pitiless, indifferent world, this is exactly what we must do. So bounded by naturalism, significance cannot extend beyond an observer’s ability to evaluate a life. As the remembrance of his existence passes, then so does his significance. We can exalt our finite importance as high as humanly possible, and yet in the end it cannot escape the gravitational pull of meaningless oblivion. Surely there is more to life than this.

For those of us who claim a relationship with a transcendental God, there is more. For if God exists beyond the natural world, and if he is a personal being with values and preferences, then anything that God values is imbued with a transcendental significance. Because of the nature of God, this significance is eternal, immutable, and infinite. It is incomparable to any that we know in the natural world. While there is certainly some significance in human accomplishments and relationships, it is a finite, fluctuant, and temporally limited sort. If you look for this type of human significance juxtaposed against God’s infinity, it will be hard to see.

From this it follows that if God values us, then we have such a transcendental significance. But how are we to know if God values us? Earlier, I said that a eulogy is a speech of praise meant to articulate a person’s value. The word “eulogy” comes from the Greek “eulogia”, which can mean either “praise; good or fine language” or “blessing”. Note that our modern word for eulogy comes from the Greek word for blessing. So a euology can be thought of as a final blessing for the dead. In the New Testament we find that God’s blessing, his eulogia, is directed towards us.

Land that drinks in the rain often falling on it and that produces a crop useful to those for whom it is farmed receives the blessing of God. Hebrews 6:7

Much can be said of this verse about the nature of suffering and its relationship to a benevolent, omnipotent God, but I haven’t the space for adequate treatment in this meditation. For our purposes, let us note that our lives are described as “land that drinks the rain”. Now rain can either be good or evil, nourishing or destructive, depending on the context. These rains are the events of our life. As land cannot control the location or amount of rain that falls on it, so we too cannot control most of what comes to pass for us. Thus exposed to the tumult of nature, we must endure the experience of reality as it comes, with the hope that something redemptive exists beyond the horizon of this land with its erosive forces.

Beyond the horizon, we find God. He promises to bless us, to articulate our significance through his own eulogia of us. What he asks of us is to produce a crop, in this context meaning knowledge, faith, and joy in Christ Jesus. Here we see our lives can have a transcendental significance to him. The rain that falls may be an overwhelming flood. Someone may experience only suffering in his life, and yet through God, he has eternal significance. Regardless of our subjective evaluation of our lives, we are significant because God has declared it to be so through his eternal, unchanging, and ultimate evaluation of us.

There is one final component of how God values us that must be mentioned. He does not see us as though he were watching a comedic movie or a tragic play. God is not a mere spectator of our lives. He intimately understands us through Jesus Christ, who has experienced the full breadth of evil, pain, and suffering. Christ himself drank the rain through his life, death and resurrection. So we can be confident that whatever our suffering, be it from pain, loneliness, cancer, rape, or torture, He who declares us eternally significant understands its cost because he paid it himself.

So for my young friend who suffered so much, who died, and who was faithful to his God to the end, let us see the significance of his life through God’s eulogia for him:

“He knows the overwhelming pain of your life because He was there. Through the sleepless nights, the loneliness, the abandonment, He was there. Through the diagnosis, the breaking of your body, the poisonous treatments, He was there. Through the love of your family, the support of your friends, the joys of your life, He was there. Through all of it, He was there because you are infinitely valuable to Him. You are so much more than the sum of the events of your life. Your significance to Him extends beyond life, death or time and into eternity. You have drunk the rain and now you may forever rest in His eternal delight.”

On a Christian Solution to the Syrian Refugee Crisis: Who is my neighbor?

2015-11-17T12:30:00.001-08:00

“But the religious expert, seeking to justify himself, said to Jesus, “And who is my neighbor?”

This question, uttered 2000 years ago by a man wishing to know the limits of personal compassion, echoes throughout history as mankind tries to define who is worth loving and resounds loudly today in the public debate of the refugee crisis. To this question, Christ has a ready reply in the parable of the Good Samaritan.

As the story goes, a man was assaulted on a lonely road from Jerusalem to Jericho. Two Jewish religious leaders give a wide berth of the man as they pass him by. A Samaritan then sees the man bruised and bloodied and stops his journey. Surely the questions of his own safety occur to the Samaritan, as there is no guarantee the person or people that assaulted the man are not still lurking in the shadows. To help a stranger is to leave himself all the more vulnerable to attack. And yet he picks the man up, takes him to an inn, and pays for the man's needs himself. In the parable, Christ illustrates the neighbor as the man who crosses cultural boundaries, who sees his fellow man in need and, despite personal risk and financial loss, comes to his aid. To his questioner Christ poses the question, “who was a neighbor to the man who was assaulted?” to which the religious expert rightfully answers, “the man who showed mercy to him.”

The answer to this question of who is our neighbor is important for us today. Prior to asking it, the religious expert had correctly answered Jesus that the second most important commanded is to “Love your neighbor as yourself”. So for those of us who follow Christ, contained in this interchange is both the command to love, the definition of who to love, and a demonstration of what it is to love.

UNHCR 2015. International refugees and internally displaced

people by year.

To what degree can we apply these principals to the Syrian refugee crisis? The United Nations High Commissioner for Refugees estimates there are over 60 million refugees in the world today, either seeking refuge internationally or as internally displaced people. Not since WWII, and arguably in the history of the world, has the number been higher. Half of these people are children. Taken together, these people would be the 24^th largest country on the planet. Their original countries are broken, so they are wanderers on the road, existing in a space between national borders and legal status. Their needs are the fundamental needs for all humans: shelter, nourishment, medical care and a place to call home. They are an entire nation of the man found assaulted on the road.

Yet there is potential peril to ourselves if we help. If we take in Syrian refugees, the argument goes, then who knows if we are letting in ISIS. Are we leaving ourselves vulnerable to attack? Will we be the next Paris? Is there the potential for something worse than Paris? There are many questions and few answer to such objections. Yes the potential for harm exists, no we cannot guarantee against unintended consequences if we allow these people in. History and human psychology would suggest xenophobia far outpaces actual risks of xenophilia, but nonetheless risk remains. Like the Samaritan, as we stop and gaze at the assaulted millions, the risk of personal involvement weighs heavily on us.

Furthermore there are financial considerations. What does an influx of thousands or millions of displaced people do to an economy? What about jobs? I find it hard to believe that our economy is at the point of a zero sum game, where one more person in means one other person out, and yet it seems incredible that there is room for everyone. As more people come in, the economic stretch will be gradual, and those first affected will be the poor on the fringe. If 10,000 refugees mean 1,000 American families are displaced from jobs, what is our moral responsibility to those families? What about the already burgeoning costs of medical care, education, and social welfare? I can conceive there is a balance where at some critical number of new people, the scales will tip toward economic disaster, where more people will end up hurting than if we had never allowed anyone entrance in the first place. Like the Samaritan, we will certainly feel our wallets lighten and our resources stretched by the moral obligation to provide for those we have taken responsibility for.

What conclusions can we draw from the above discussion? Is this a Good Samaritan moment where we help every person we encounter on the road? Or are the complexities such that we are justified denying refuge to those seeking it? The answer, as almost all answers in the real world, lies in a balance somewhere between the extremes. For Christians, the command to love is overwhelming. “Loving our neighbor as ourselves” is the second greatest commandment, subordinate to and proceeding from the greatest command to “love the Lord your God with all your heart, soul, mind and strength.” Christ’s answer to who is our neighbor is the man on the road in need of help. Personal and financial perils are inherent in this command and acceptable risks to take, as Christ himself demonstrated on the cross. We are no greater than our master. Yet we are also not called to be destructive with our love. After this experience, I doubt the Samaritan did then give up everything and committed his life to roaming the roads, looking for hurting people to help. There was also a limit to Christ’s healing ministry, he did not heal every person in every place he went. He also spent time alone, praying and resting, valuable time than could have been spent helping the poor. As Christians, we are called to selfless love, but we are not called to self-destruction.

How do we strike such a balance with Syrian refugees? This balance does not give us an exact answer, but it certainly gives us the criteria by which we should approach an answer. The correct answer is a selfless but not self-destructive one. The answer that shows we love our neighbor as ourselves, and that accepts a certain amount of risk. An answer that shows we are not first preoccupied with our own wellbeing, but rather the wellbeing of our fellow man. However, It is also is an answer that accepts the complexities of the potential for harm in well-intentioned actions.

With this discussion in mind, I will attempt a concrete solution to the problem. I think the Christian response is to let Syrians in. We need to be thoughtful about the amount we take and perhaps take some steps to verify the identity of the individuals, but we should open our doors to a decent number of them. We should encourage both our European partners and American continental neighbors to do the same, so no one is burdened with too many. Then we should stay vigilant, having a good way of accounting for these individuals through appropriate identification mechanisms, perhaps tracking bank accounts and financial transactions, living situations, etc. We should be strict in the law, with felony offenses resulting in removal from the country. We should also commit to social services commiserate with their humanity, such as basic housing, food assistance, education and job training and medical care all delivered with the goal of self-sufficiency within a few years time.

We also need to address the supply of refugees from Syria, which means increase the military response to ISIS in an intelligent manner as well as a work with our multinational coalition to end the war in Syria. Of course, this recommendation makes the situation sound simple when it is actually ludicrously complex and such an answer may be year away or may end in the dissolution of the state or worse, who knows. But it needs to be higher on our priority list as a nation or else the humanitarian catastrophe will continue to degenerate and the Middle East itself will be at risk of explosion.

Moreover, we need to pray. Pray for the refugees, for a just solution to this madness. Pray for the disaster that is Syria, for peace and an end to the war. But also we need to pray for ISIS, for both the individuals’ salvation and the organization’s destruction. An enemy is still an image-bearer of God, made in his likeness even if the eternal light in him seems long snuffed out.

Lastly, this needs to elevate other matters of compassion in our minds. Syria is all the rage right now, but what about the Latin American refugee children or refugees from other nations? What about the homeless American veterans? What about our actual neighbors next door with cancer, with broken homes, with selfish pride, with mental illness? Ultimately, this is a question of a Christian’s response to the evil and suffering of this world. Christ’s answer to the problem of evil is a call to selfless, risky, sacrificial, but-not-self-destructive Love.

“And we, seeking to justify ourselves, say to Jesus, ‘And who is my neighbor?’”

To which Christ responds, “Everyone.”

On Combination Chemotherapy: Hope through Death

2015-09-13T19:03:00.000-07:00

The following is an essay limited to 500 words and answering the prompt, "What new medical intervention in the last 50 years had the greatest impact on pediatric medicine?":

Leukemia is form of liquid death. First described in 1845 after a patient died from a “suppuration of blood”, any such ghostly white appearance of the humors portended certain death. Slowly, doctors learned the true depravity of the disease: it was the blood, the ‘life of the flesh’, which attacked the body.

In the early 1960s, leukemia remained uniformly fatal. Surgery had made progress against solid tumors and radiation oncologists had treated lymphomas, but both were impotent against the amorphous liquid cancer. In humanity’s great battle against cancer, leukemia was the victor. However, the first glimmer of hope arose from the ashes of one of humanity’s greatest battles, World War I. As nitrogen mustard gas crept across the killing fields of Europe, researchers noticed it depleted the leukocytes of its victims. Thus began intensive research into chemotherapeutic agents, poisons that could kill cancer faster than they could kill the body. Researchers discovered many types of chemotherapy, but none with enough killing power to completely eradicate leukemic cells. After decades of research and war, doctors won several fights, but leukemia consistently won the battle and claimed its victim.

Doctors Emil Frei and Emil Freireich of the National Cancer Institute realized no single chemotherapeutic agent possessed enough power to eradicate the leukemic cells from the body. So the duo proposed a clinical trial of a four drug combined regimen: vincristine, amethopterin, mercaptopurine, and prednisone. VAMP, as it would come to be called, was a wildly controversial idea. No one had administered so many poisons to a person before. Even worse, the trial was for children, leukemia’s favorite target. Despite the opposition, Drs. Frei and Freireich maintained that the body had to be pushed to its limit, to the door of death itself, to push leukemia into the abyss.

In 1962 the trial commenced and the infusions started. As the drugs dripped slowly into the children’s veins, their little bodies began to shrivel. Leukocyte counts plummeted, as did the body’s ability to fight infections. Some children experienced days of fever-induced delirium, others spent nights retching in the bathroom. Drs. Frei and Freireich could only sit at the bedside, hold a hand, and wait. Slowly, the miraculous began to happen. The shriveled bodies plumped up, their energy returned, their infections subsided. Laughter soon bounced off the walls of the oncology unit as the trial participants became children again. Even more awe-inspiring, the cancer cells were gone from the blood and the first true remissions had been achieved!

The VAMP trials proved that cure was possible, and the work of Drs. Frei and Freireich inspired generations of doctors to continue research on combination chemotherapy. The results of this effort are stunning: from 100% mortality 50 years ago, a child’s chance of surviving leukemia in certain circumstances is now greater than 95%. From its dark beginnings as a weapon of war to its ascendant triumph as a lifesaving cure, the story of combination chemotherapy is a beautiful reminder that even in the darkest times, hope lives.

On Vaccines 3: Fear as Fission

2015-07-23T18:12:00.001-07:00

Author's Note: I request you remember the ground rules for this post: I am taking it as a given that vaccines are effective and safe. If you would like to dispute this fact, then please review this obnoxiously hyperlinked sentence.

Part 1: Hear no Measles, See no Measles, Think no Measles
Part 2: Risky Feelings

In this series, I am attempting to answer the question, “What keeps people from vaccinating their children?” We are discussing vaccination behavior as a balance between the perceived risks and benefits of the choice. In the first post of the series we discussed how we perceive benefits. In the previous post we discussed the cognitive mechanisms of risk assessment as related to the affect heuristic. Here we shall continue the discussion of risk and finish by exploring its relationship to our humanity.

Loss Aversion

People dislike losses more than they like gains⁴. Psychologists call this loss aversion. Many studies have demonstrated this tendency. When participants were asked how much they would have to win to participate in a coin toss where they would lose $50 if they called it wrongly, people set the average price around $100³. That is, a participant had to win twice as much as she could lose to make it “worth her while.” Loss of what you already own is much more painful than a gain is pleasurable.

Loss aversion affects more than financial gambles. When a dad weighs the risks of vaccines, a prominent fact in his mind is that his child is healthy now. Suppose he consents to give his son the MMR vaccine at 1 year of age, and then at 3 years he’s diagnosed with autism. If dad convinces himself of a causal relationship between the two events, then the sense of loss he would feel from his complicity seems unbearable. If he compares that potential loss of his child’s good health against the potential benefits of preventing vaccine-preventable diseases (VPDs), uncertain and far in the future as they are, then loss aversion can be the key factor in his decision.

Regret

Related to loss aversion, people prefer sins of omission (bad outcomes from inaction) compared to sins of commission (bad outcomes from action)⁴. Consider two investors. The first owns stock in company A but considers selling it to buying company B. He decides not to buy, and later learns he would have gained $2,000 if he had purchased B. The second owns stock in B and then sells it for stock in A. He also learns he would have $2,000 had he not sold B. Which investor regrets his decision more? When asked this questions, 92% of respondents say the second³. Regret is a powerful emotional manifestation of loss, and our minds feel more regret when our actions are the cause of a bad outcome.

Now consider again the dad who is already uncertain about vaccines and is weighing the risks. He is the one who has to consent to the shot. His action of consenting directly results in the vaccination of his child. If his child develops autism and he believes vaccines were the cause, then he will profoundly regret giving his consent, as he believes he is part of the cause. However, suppose he decides not to vaccinate. This is the inactive option since his child is naturally unvaccinated. If his child catches severe pneumococcal pneumonia, it is easy to imagine that he will more readily forgive himself for his inaction and experience less regret. In the calculus of choice, regret is an important variable.

Reference Frames

Both loss aversion and regret depend on your frame of reference. What is the default position against which losses and gains are compared? If asked who is happier, someone with $2000 who wins $500 or someone with $3000 who loses $500, the obvious answer is the first person, by a lot³. If satisfaction only depended on money, then they should be equally satisfied as they have the same amount at the end of the transaction. However, we see that the starting point matters; it determines whether a final state is a loss or a gain. If a third person initially had $2000, was given $1000 briefly and then had $500 taken away, we intuitively see this person is less unhappy (and probably quite happy) compared to the second person above. This third person, although briefly owning $3000, feels little ownership of it – her frame of reference is starting with $2000 and thus her final state is a net gain of $500.

Applying this logic to vaccines, we can see that the above examples of loss aversion and regret depend on the reference frame of the unvaccinated child with his current state of health. From here, perceived injury by a vaccine is viewed as a loss of health and prevention of a VPD is a gain. Now imagine a society with a robust public health program that has swayed public opinion heavily in favor of vaccines. Society as a whole views the state of being vaccinated as the default state, where a child’s health should be. Now when a parent considers not vaccinating, that is an act of commission, as it is their choice (choosing not to) which caused the deviation from the reference state⁴. Similarly, he will feel less regret if he believes his child suffers an injury from the vaccine. He was merely doing his fatherly duty of maintaining the reference health state. Unfortunately for many people, the vaccinated child is not their reference state and loss aversion and regret come to bear negatively on their decisions.

Overestimating Small Probabilities

In general, humans are terrible with statistics, especially with small probabilities. Research consistently demonstrates that we overestimate the frequency of rare events. One group of researchers showed that people consistently overestimate the percentage of death from rare causes⁷. This is particularly true when the events are vivid, as other researchers have shown that people judge death by tornado to be much more frequent than death due to boring, everyday asthma, even though asthma kills 20 times as many people³. Consider the fear the 9/11 terrorist attacks caused compared to the fear people felt on that same day towards a common, yet much more dangerous, activity such as driving. Granted, many factors contribute to the fear caused by terrorism, but among them is the fear that you will be the victim of an attack. This fear is irrational compared to the risk we face everyday by getting into a car.

Similar to overestimation, we overweight the importance of small probabilities. How much would you pay to increase your chance of wining $1000 from 0% to 5%? What about to increase your chances from 5% to 10%? The latter bet is double the chance to win compared to the former, so would you pay twice as much? Studies demonstrate that you most likely would not; you would pay proportionally more to go from 0 to 5% than from 5 to 10%³. There is substantial psychological benefit when a person moves from no possibility of winning to any possibility of winning, what researchers call the possibility effect. There is proportionally less benefit when a person moves from a small chance of winning to a slightly less small chance, and people reflect this preference in the price they are willing to pay for such a gamble.

Now adverse reactions (AR) to vaccines do happen. All of them are rare; the bad ones, such as severe allergic reactions, are exquisitely rare⁸. Note that the possibility unfortunately does exist. Given the above discussion, we know that the undecided parent will see the AR rates as much more frequent than they truly are, particularly because they are so vivid. For the same reason, he will also overweigh the specter of ARs in his risk calculation.

Availability Cascade

We can use these observations about risk assessment to explore a powerful, culture-changing process that strongly influences our response to vaccines, the availability cascade (AC). Availability refers to the degree of familiarity we feel towards a topic. We feel familiar towards things we’ve been more exposed to. If a topic is more available in our minds, then we will tend to overestimate its frequency, feel like we know more about it than we actually do, and be more likely to use what we know to draw further conclusions³.

An AC, as Kahneman defines it, is “a self-sustaining chain of events, which may start from media reports of a relatively minor event [author’s addition: or Twitter messages or Facebook statuses] and lead up to public panic and large-scale government action³”. This is not a belly-flopping Corgi video that you laugh about at work the next day; this is a piece of news that changes your daily life. This is a viral idea that becomes a plague. Broadly speaking, this happens when a story catches the attention of a subset of people who become concerned. The media reports the concern as a news story itself, which reinforces the concern in more people. The cycle repeats until the issue gains so much momentum, it has to be addressed on a large scale. I find it interesting that it’s called a cascade, which may evoke the gentle image of a waterfall in many people’s minds. However, I don’t think image does the idea justice. I see the process as more powerful and chaotic, more akin to the violent cascade of radiation in nuclear fission.

Let’s use MMR causing autism as an example. In 1998, a researcher makes up a bunch of stuff, writes a paper, submits it to a respected medical journal and it gets published (and later retracted). This is, unfortunately, not too unusual an event. The news media prints an article about the paper. A portion of the population that was already suspicious of vaccines hears about the article and starts to make a ruckus. A pretty person with a loud voice lends her celebrity to their concerns. The controversy between nerdy scientists with their pocket protectors and taped glasses who say vaccines are safe and the supermodel who just knows for certain that vaccines caused her child’s autism is too juicy for the news media to ignore. So the coverage intensifies, adding undue legitimacy to the controversy. The anti-vaccination arguments begin to bloom and spread like a mushroom cloud –“toxins!, mercury!, overwhelmed immune systems!, government cover-ups!” With the force of a bomb, they impact parents at their deepest fear, the safety of their child. There the radioactive ideas remain, sizzling with intense doubt. This doubt ignites our risk assessment strategies. The affect heuristic, loss aversion, fear of regret, overestimating and overweighting small probabilities all burn brightly in the concerned parent’s mind. The process is repeated millions of times, in the minds of anyone who hears such arguments. Governments, doctors and scientists respond with a slew of non-made-up studies which state that the MMR vaccine does not cause autism. Unfortunately, the facts do not fix the fears because they do not survive the cognitive processes of risk assessment. So the cascade continues, its explosions echoing through history, its shockwaves reverberating into the future.

The Facts do not fix the Fears

If there is main point for healthcare providers it is this: facts are not communication. Too often, doctors sit with patients and tell them the facts of their illness and how to treat it. The patient returns 1 month later having done nothing the doctor suggested and we blame it on non-compliance. Each fact a patient hears has to navigate the gauntlet of our cognitive machinery. If we do not communicate with an appreciation for people’s loss aversion, heuristics and biases, or terribleness with probabilities, then we are not communicating with a human brain, we are speaking to ourselves. The only way to do this is both unfortunately cliché and extremely powerful: listen. By listening, we can identity the patient’s cognitive process and speak not only to their intellectual gaps, but also to their doubts and fears.

If there is a main point for anybody with an opinion about vaccines it is this: we all use these same cognitive mechanisms, therefore we are all at risk of the same thinking errors. By extension, we are all wrong about a lot of things a lot of the time. There are members of our species that came up with scientology, believe that Reptilian overlords run the government, and think the Twilight movies are actual artistic achievements, and now this species is debating the merits of vaccines. It should surprise no one that there are people who conclude wrong things, nor should it surprise you when you are one of those people. If we understand this, we can approach debates with humility, understanding we are not so different than our opponents. After all, it’s certain that one of your beliefs appears to someone as anti-vaccination beliefs appear to you. Now don’t get me wrong, this is a serious issue, and we are ultimately debating over the health and safety of our kids. But in order to convince someone why they are wrong we have to first understand why they are wrong. We have to understand the quirky shenanigans of cognition and humbly acknowledge that no matter which side of the debate, we all have similar brains that are quite fallible and, therefore, quite human.

References

1. Smith PJ, Humiston SG, Marcuse EK, et al. Parental Delay or Refusal of Vaccine Doses, Childhood Vaccination Coverage at 24 Months of Age, and the Health Belief Model. Public Health Reports. 2011;126(Suppl 2):135-146.

2. Rottenstreich Y, Hsee CK. Money, kisses, and electric shocks: On the affective psychology of risk. Psychological Science. 2001;12(3):185-190.

3. Kahneman D. Thinking, fast and slow. Macmillan; 2011.

4. Cappelen A, Mæstad O, Tungodden B. Demand for Childhood Vaccination – Insights from Behavioral Economics. Forum for Development Studies. 2010;37(3):349-364.

5. Slovic P, Finucane ML, Peters E, MacGregor DG. Risk as analysis and risk as feelings: Some thoughts about affect, reason, risk, and rationality. Risk analysis. 2004;24(2):311-322.

6. Finucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgments of risks and benefits. Journal of behavioral decision making. 2000;13(1):1-17.

7. Lichtenstein S, Slovic P, Fischhoff B, Layman M, Combs B. Judged frequency of lethal events. Journal of experimental psychology: human learning and memory. 1978;4(6):551.

8. Medicine Io. Adverse Effects of Vaccines: Evidence and Causality National Academies Press 2012.

On Vaccines 2: Risky Feelings

2015-07-05T13:10:00.001-07:00

What keeps people from vaccinating their kids against potentially deadly vaccine-preventable diseases (VPDs)? In the last post we discussed how we make medical decisions. A classical model of decision-making is that a person measures the risks and benefits and makes a choice based on which is greater. While true in a limited sense, this theory does not tell the whole story. Last time we examined how a human brain evaluates the benefits of vaccinating. Here we will discuss the hugely important topic of risk assessment and its role in judgment and decisions.

The Experiential and Analytical Systems

Figure 1: The Experiential and Analytical Systems.

(Slovic et al., 2004)

Since risk assessment is a mental process, we need to discuss the structure of our mind before we continue. In recent decades, cognitive psychologists have described two different, parallel systems that we use to make decisions. The first system is the Experiential system (ES)⁵ which utilizes associations, intuitions, and emotions to make decisions. It is quick to make judgments and loathe to verify them. It extrapolates from minimal information and integrates the data in the larger context of what is known, felt, and thought (Figure 1). The second system is the analytical system (AS). It is logical and methodical in its evaluation of data. It is slower than ES and responsible for fact checking it. It is concerned with being correct, not quick. ES tends to be the process we use more in everyday decisions. It can be very reliable when the patterns and associations it’s evaluating are familiar. We see 8 kinds of peanut butter on the grocery store shelf. ES knows we like the Jif with the red cap and striped label and quickly identifies it. AS evaluates information more carefully. Money may be tight, so you look at 2 different HEB coupons - one gives 20 cents off sausage flavored mayo if you buy two Jif cans the other gives two free bags of potting soil if you buy the HEB brand peanut butter – and AS decides which is the best deal.

Thinking Errors

The important thing to understand about both systems is that they each have weaknesses. To think quickly, ES employs mental shortcuts, “heuristics,” which are prone to make predictable errors in judgment, “biases” (the main subject of Kahneman’s award-winning book Thinking Fast and Slow³ which I shall reference frequently). In the peanut butter example, you employed a pattern recognition heuristic that said, “red top and striped label = Jif”. While most likely a reliable conclusion, the fact remains that a knock-off brand could use similar packaging. To confirm its authenticity you have to read the label. Cheap brands might find that 1 in 10 people do not check the label and exploit this heuristic for their own gain by selling red-topped “Piff”. We discussed heuristics in the last post while talking about benefits of vaccination. Vividness, immediacy effect, and affective reasoning all fall in this category. Heuristics also play an important role in risk evaluation, as we shall see below, and are worth understanding to avoid making erroneous judgments.

AS’s weakness is that it is lazy. It is often content to let ES draw the conclusions, especially if the conclusions “feel right,” what psychologists call “cognitive ease”³. You end up with inferior Piff peanut butter in your basket because AS was content with the available information; the packaging, the size of the jar, the syllables and cadence of the name were consistent with Jif. Had it been so inclined, it could have made you slow down to read the label to check its accuracy. It could have gone on to evaluate whether cheaper Piff was a more intelligent purchase than more expensive Jif and avoided the disappointment you will feel at home when your sandwich tastes like cardboard. In this instance, its contentment with its cognitive ease superseded its desire to be correct.

Below we will talk about how ES and AS evaluate risk. We will talk about ES more because I believe its activity impacts everyday risk evaluation more than AS. Plus, we are assuming that vaccinations are proven safe and effective. This is an AS conclusion based on evidence and logic; a conclusion outside the scope of this post (see the linked up disclaimer above.)

Affect Heuristic

We discussed the affect heuristic in the last post, except I called it “affective reasoning” because we didn’t have the language of heuristics. Affect, our feelings toward a topic, dramatically alters perceptions of risks and benefits. Paul Slovic, one of the foremost researchers in this area, demonstrated an inverse relationship between our perceptions of risks and benefits based on our affect: positive feelings magnify benefits and diminish risk while negative feelings do the opposite⁵. Researchers demonstrated this by measuring people’s response to information about either the risks or benefits of nuclear power. If a person was convinced that the benefits were higher for nuclear power, they downplayed the risks. If they were told the benefits were low, then the risks were perceived as higher. The same relationship was true for risk perception – information describing nuclear power as more risky decreased the perceived benefits and information describing nuclear power as less risky increased the perceived benefits⁶.

These findings are due to how ES integrates the information, including emotional information, pertaining to the topic “nuclear power”. You see, ES has a habit of answering questions it is not asked, particularly if it can answer an easier question instead of a harder one³. The question “is nuclear power safe?” could be answered by evaluating safety data of power plants in a country, disease rates near the plant, security information, etc., but this is information that is either not available to ES or requires lazy AS to compute. If ES can instead answer the easier question, “how do I feel about nuclear power?” then it can arrive at a conclusion! Its favorite thing! And in general, you feel good about things that have many benefits and little risk and you feel bad about risky things with little benefit. Therefore, if you feel good about nuclear power, then you will tend to think it is a great technology that does not pose a threat to society. This relationship holds for quick judgments requiring ES (the same researchers showed this relationship increases under time pressure⁶), so if you’re reading this and thinking that you can see how it is beneficial AND risky, you’ve engaged AS in the discussion and are no longer using the affect heuristic.

This has compelling implications for vaccine acceptance. The negative portrayal of vaccines has gained prevalence in our culture. Even if you love vaccines, you’ve heard the negative propaganda and thought how frightful it would be if it were true. Vividness comes into play here. Just as we discussed before that VPDs are not prevalent and therefore not very vivid, so autism, autoimmune disease, crying children, or whatever your vaccine injury of choice are quite prevalent and quite vivid. Such negative images have a way of clawing into our brains and nesting there.

Imagine a Well-Meaning Mommy who has heard the scary, negative propaganda about vaccines, but between 3 kids and 8,000 dirty diapers, has not had time to critically evaluate the information. She comes into my clinic and I say its time for shots! At that moment in her brain, ES’s eyes pop open. ES looks around suspiciously, thinking it’s heard something about vaccines before, and spots the TV interview with super hot whatsherface who said something about toxins and hurt children. It also recalls the conversation with a fellow mommy proudly raging against vaccines for whatever reason. ES acknowledges these memories aren't necessarily reliable information; however, what is reliable is that these interactions make her feel uncomfortable toward vaccines. Mom begins to feel a rising discomfort that she can’t quite put her finger on. I happily explain to her all the great benefits of preventing VPDs, unaware that such statements sound empty to her compared to the growing dread of shoving a needle into her child and giving her toxins. She politely declines, saying she’s just not comfortable with vaccines at this moment. Mildly surprised, I ask what makes her uncomfortable. With growing confidence she says she feels they’re risky and she’s not sure if her child needs them. I sit back dejectedly, wishing she had read this blog post so we could discuss the affect heuristic.

People’s stated reasons for vaccine refusal differ widely, but it is surprising how frequently I hear “I’m not comfortable”, as if your intuitive feeling alone is a good reason to ignore over 100 years of vaccine research. Such is the power of the affect heuristic - positive and negative feelings not only convince us to make decisions based on little evidence, but also, once decided, create justifications for it.

More on our cognitive relationship to risk in the next post.

References

Smith PJ, Humiston SG, Marcuse EK, et al. Parental Delay or Refusal of Vaccine Doses, Childhood Vaccination Coverage at 24 Months of Age, and the Health Belief Model. Public Health Reports. 2011;126(Suppl 2):135-146.
Rottenstreich Y, Hsee CK. Money, kisses, and electric shocks: On the affective psychology of risk. Psychological Science. 2001;12(3):185-190.
Kahneman D. Thinking, fast and slow. Macmillan; 2011.
Cappelen A, Mæstad O, Tungodden B. Demand for Childhood Vaccination – Insights from Behavioral Economics. Forum for Development Studies. 2010;37(3):349-364.
Slovic P, Finucane ML, Peters E, MacGregor DG. Risk as analysis and risk as feelings: Some thoughts about affect, reason, risk, and rationality. Risk analysis. 2004;24(2):311-322.
Finucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgments of risks and benefits. Journal of behavioral decision making. 2000;13(1):1-17.
Lichtenstein S, Slovic P, Fischhoff B, Layman M, Combs B. Judged frequency of lethal events. Journal of experimental psychology: human learning and memory. 1978;4(6):551.
Medicine Io. Adverse Effects of Vaccines: Evidence and Causality National Academies Press 2012.

On Vaccines 1: Hear no Measles, See no Measles, Think no Measles

2015-05-24T16:20:00.000-07:00

In this multi-part blog we’ll examine the cognitive processes involved in deciding to vaccinate a child. Specifically, I want to answer the question, “what prevents people from arriving at the truth?” It's important to note that I presuppose the truth about vaccines has been established. I take it for granted that vaccines are beneficial AND safe. I’m in good company with this assumption as the vast majority of the scientific community, doctors, and even parents agree¹. I am not interested in debating specific claims about vaccines themselves. If you are in the vaccine-refusal crowd, I would like to refer you to the incredible amount of reliable resources available from accomplished scientists, trusted pediatricians, and world-renowned hospitals. My purpose here is to discuss why, despite very strong evidence that vaccines are safe and almost miraculously effective, people put their children's health at risk by declining to vaccinate them.

Vaccines. Are. Awesome.

In order to make any medical, financial, or life decisions, one must first examine the benefits of the choice. If a parent consents to allow their child to be stuck by a needle and injected, it better be for a good reason. So what are the benefits of vaccines? This question is both surprisingly easy and oddly difficult to answer.

The easy answer: vaccines can save your child from dying of a horrible, vaccine-preventable disease (VPD). As an example, these potential deaths include but are not limited to:

1. Liver failure (hepatitis B)

2. Dehydration from diarrhea (rotavirus)

3. Respiratory failure from chocking on snot (pertussis)

4. Respiratory failure from full body contractures (tetanus)

5. Respiratory failure from choking on bacterial goobers in the throat (diphtheria)

6. Respiratory failure from invasive bacterial disease (pneumococcus)

7. Respiratory failure from a swollen epiglottis (h. flu)

8. Respiratory failure from paralysis (polio)

9. Brain failure [encephalitis] (measles)

10. Meningitis (meningococcus)

11. Cancer (HPV)

12. Smallpox

…and this is not an exhaustive list nor does it include the multitude of complications each VPD may cause.

Let me highlight these last two.

First, smallpox. Smallpox killed an estimated 300-500 million people in the 20^th century (see the sweet graph I made). Do you know anything about smallpox? No? Me neither! I know nothing about it because it no longer exists on earth except in laboratories. And we have vaccines to thank. Through wide-scale vaccination campaigns, endemic areas were targeted and the disease was eradicated from the world. I invite you to sit back for a minute and marvel at that thought.

Now Let’s talk about the human papillomavirus (HPV) vaccine. Through the use of a shot, we can prevent cancer, the Emperor of All Maladies. HPV infects the cervix of women and causes inflammation, which over many years promotes cancerous changes in the cervical cells. Worldwide, cervical cancer is the fourth leading cause of death from cancer for women, causing about 260,000 deaths per year, or 1 in 14,000 females. And every single one of those deaths is preventable. With the vaccine we can prevent the cancer from ever forming. Think about it: no chemotherapy, no needing your uterus removed or your abdomen surgically explored for lymph nodes, no risk of cancer, all because 4 decades earlier you were vaccinated.

So there are significant benefits from vaccines. Everyone enjoys not dying from horrible diseases, even those who are anti-vaccines. Given the benefits, why not vaccinate? The answer lies not in what the facts are, but in how the human brain evaluates them.

Vivid Outcomes

If you thought the section above was mildly graphic, it was intentional. Research demonstrates that the more affect laden an idea, the more detailed and vivid with emotional content, the more likely the human brain is to pay attention to it. Advertisers, journalists, and Buzzfeed have long known this fact and it is now wreaking havoc on every form of social media: “I thought it was just a 3-armed homeless raccoon until 1:37 and then waterfalls flowed from my eyeballs.”

Vividness makes a fact more real to the brain. To demonstrate this, researchers measured the amount participants would pay to avoid a chance of receiving a small electric shock². The probability of the shock varied between participants. Some had low probabilities of being shocked while others had high probabilities. Those who faced a 1% chance of a shock were willing to pay $7 to avoid the shock, which was proportionally more compared to those who faced a 99% chance and were only willing to pay $10. In other words, the factor that most influenced the price was the mere possibility of a shock while increasing probability was comparatively undervalued. Electric shocks are vividly unpleasant. The fact that the probability existed, however small, was enough to make it real in the minds of the participants and worth paying to avoid.

Our perception of statistics is also subject to vividness. Above, I gave a concrete number for cervical cancer deaths, 1 in 14,000 females. I could have expressed it as 0.00007% of all women; however, the human brain is terrible with such percentages, which are translated as “negligibly small”. In the former representation, people focus on the 1 person and tend to ignore the denominator of 14,000, making the chance seem much larger³. Comparatively, 1 person at risk is much more compelling than a difficult-to-visualize small percentage of people.

Now, this explains why I described the benefits the way I did, but it does not explain why people do not vaccinate. The issue is that while the benefits can be quite vivid, they are not on people’s minds. Part of this is the fault of the success of vaccines. Few people living today know the terror of smallpox, so in absence of obnoxious descriptions of its evils, it has lost its vivid force. The same goes for the more relevant VPDs like measles. When infection rates fell, measles faded into the background of parental worries because few people had to watch their child suffer from it. Inevitably, people started questioning the benefit of the shot because the threat was no longer real to them. Unfortunately, measles does not care how real you think it is. So the benefits lose their affective power when they are not salient issues in people’s minds. Of course, it can become real again as the recent affect-rich measles outbreak at Disneyland demonstrated with its flood of media attention and angry Facebook statuses. It is my hope that more kids do not have to become affect-laden images, but given how quickly we forget current events, it seems that will inevitably be the case.

Immediacy Effect

People also evaluate benefits by how long it takes to realize them. As a general rule, we tend to value short-term benefits more than long-term benefits, a phenomenon researchers call the immediacy effect⁴. Studies consistently show that when faced with the choice, people will choose a smaller denomination of money if they receive it sooner compared to a larger sum paid later. The short-term holds more promise to give you pleasure in the time that actually matters, the present. Furthermore, the short-term has a greater chance of actually happening compared to the long-term, where there are more chances for a hope to go unfulfilled. We experience this effect every day in the form of procrastination: “I should do my taxes that are due in 3 months but I’ll probably just sit here and watch this video of goats yelling like humans instead.” The future deadline of taxes holds little value compared to the hilarity of those goats. Similarly for vaccines the benefit of avoiding a disease is sometime in the future, but the pain of watching your child receive a shot will happen right now in front of your eyes. Depending on how the parent evaluates the situation, she may value avoiding tears now more than avoiding a disease she’s never seen before at some uncertain time in the future

Ambiguous Probability of Benefit

While people may acknowledge that avoiding VPDs is generally a good goal, a parent may dispute the probability that he or his child is in any appreciable danger from them⁴. The benefit of vaccines is easily demonstrable on a population level; however, at an individual level a person may perceive that his risk is minimal. If you couple this doubt with a perception of increased risk from the vaccines themselves, then the scales will tip strongly in favor of forgoing the shots. The fallacy of this thought is that, while certain diseases like polio occur very infrequently, if this mindset was prevalent throughout the population, then your risk profile changes as the disease becomes more prevalent (e.g Parents at Disneyworld thought the chance of their child contracting measles was basically zero). Statistics of disease rates are a slippery measure, as decisions made on such statistics will change the rates themselves.

A related situation to frequency is when parents doubt severity of the disease. A very popular argument against the measles vaccine is that…measles schmeasels, amIright! In other words, it’s a fever, cough and rash, big deal. This is based on a popular view of how the disease manifests but fails to acknowledge the epidemiological data. All disease present in spectrum of severity and measles is no different. 1 in 1000 kids with measles will die from it in developed countries, and if you’re vitamin A deficient in a developing country, it could be 1 in 4. When you take into account the other complications, days hospitalized, sick days from school or work, then you can see how easily measles becomes a big economic and public health burden in areas with low vaccination rates.

I know I said I wouldn’t slog through the weeds of specific arguments, but these are illustrative of a larger point. The human brain can very easily 1) manipulate statistical data for its own purposes and 2) downplay statistical data if a representative mental image is present.

Affective Reasoning

It’s a peculiarity of human reasoning that, despite the lip service we give to rationality, our judgments can be partly or entirely based on how we feel toward the topic. Cognitive psychologists call the role that emotions play in reasoning the affect bias⁵. Research shows that negative feelings towards vaccines will cause someone to underestimate potential benefits while overestimating potential risks. These feelings do not need to be based on data. A negative anecdotal story about “vaccine injury” on the Internet might change perceptions more than a ratio of numbers on paper because the story makes us feel scared while the numbers make us feel tired. What’s more, our general feelings, unrelated to the topic at hand, can also affect our judgment. We will discuss the affect bias and risk assessment at length next post, but here let it suffice to say that if we feel negatively towards vaccines, we are more likely to undervalue its benefits.

Summary

So vaccines are awesome and their primary benefit is not dying from VPDs. People evaluate these benefits along certain parameters. Vividness and affect-laden imagery make people perceive benefits as more real. Because VPDs are rare, they are not salient in people’s minds and thus they lack vividness. People also value short-term benefits over long-term benefits. Because preventing VPDs are a long-term benefit, they are undervalued compared to the short-term benefit of avoiding a child’s discomfort. People may doubt the need for the benefits because many people will never suffer from VPDs. These rough statistical evaluations focus on isolated cases while ignoring the wider context of risk that may increase because of such decisions. Our feelings may shape our decisions regardless of any benefit that exists. Affect bias is a decisive yet oftentimes invisible factor in our judgment process.

Those of us on the pro-vaccination side may have difficulty understanding how the clear benefits of vaccines can be ignored by the anti-vaccination crowd. However, we can understand that a statement of fact does not imply a conclusion. The fact has to survive a mental obstacle course before it has meaning to a human brain. We may not agree with their conclusion but we can appreciate the process because we go through it as well. Moreover, we can understand that a statement of benefit does not determine an appropriate choice. People who smoke, ride their bikes without a helmet, or choose to watch cat videos instead of studying for an upcoming test know this tension well. For vaccinations, benefits are only part of the story.

Next time...
Risk, the flipside of benefit, plays a powerful role in decisions. In the next post we will examine the human brain’s relationship to risk. The relationship is complicated, filled with so many emotions and selfishness it deserves its own reality show. Most importantly, beyond demonstrating how we make health decisions, our relationship to risk illuminates an aspect of our mental life that is central to what makes us human.

References

Smith PJ, Humiston SG, Marcuse EK, et al. Parental Delay or Refusal of Vaccine Doses, Childhood Vaccination Coverage at 24 Months of Age, and the Health Belief Model. Public Health Reports. 2011;126(Suppl 2):135-146.
Rottenstreich Y, Hsee CK. Money, kisses, and electric shocks: On the affective psychology of risk. Psychological Science. 2001;12(3):185-190.
Kahneman D. Thinking, fast and slow. Macmillan; 2011.
Cappelen A, Mæstad O, Tungodden B. Demand for Childhood Vaccination – Insights from Behavioral Economics. Forum for Development Studies. 2010;37(3):349-364.
Slovic P, Finucane ML, Peters E, MacGregor DG. Risk as analysis and risk as feelings: Some thoughts about affect, reason, risk, and rationality. Risk analysis. 2004;24(2):311-322.
Finucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgments of risks and benefits. Journal of behavioral decision making. 2000;13(1):1-17.
Lichtenstein S, Slovic P, Fischhoff B, Layman M, Combs B. Judged frequency of lethal events. Journal of experimental psychology: human learning and memory. 1978;4(6):551.
Medicine Io. Adverse Effects of Vaccines: Evidence and Causality National Academies Press 2012.

On the Utter Improbability of My Daughter's Existence: A Math Poem

2014-09-07T07:54:00.001-07:00

My daughter should not exist.

The probability that I would choose Rachel to marry:

1 in 5

She’s awesome and I’m a nerd with very few prospects.

The probability that Rachel would choose me to marry:

1 in 10⁴

She’s awesome AND popular with many prospects AND I’m a nerd.

The probability of my daughter inheriting her particular genetic makeup from her parents:

1 in 10¹⁴

I’m so thankful we didn’t have one of those trillions of other possible kids.

The probability that my parents would make me:

1 in 10¹⁷

Aren’t they lucky.

The probability of my successive ancestors existing, starting from the dawn of the human race:

1 in 10^28,161

For comparison, the total mass of the universe is 10⁵⁵ grams.

The probability the universe exists at all:

1 in 10¹²⁵

That’s it you say?

Well a googol is 10¹⁰⁰. So this number is the equivalent of 10²⁵ googols.

The probability of my daughter coming into existence:

1 in 10^56,467

There are only 10⁸² atoms in the universe.

So that’s like finding one particular atom in 10^56,385 universes of atoms.

Snowflakes, lightning strikes, grains of sand, and lottery winners have nothing on my daughter.

She’s a mind-boggling, brain-melting, exponentially-absurd impossibility.

In other words.

She’s a miracle.

Awwww.

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The nerdy fun doesn’t have to stop here! I made a spreadsheet explaining how I derived my numbers. I invite anyone interested to look through it and make improvements. Just let me know what changes you make. I want to let Audrey know precisely how special she is, so help us out math people.

On Kids, Violence, and the Israeli-Palestinian Conflict

2014-08-14T13:42:00.002-07:00

A rocket explodes.

The force of the explosion causes air molecules to vibrate against each other. These vibrations spread in a wave, each air molecule rubbing up against the next, communicating the atmospheric inheritance of the bomb. The vibrating wave eventually arrive at a young boys ear, where it bounced around the ear canal, finally striking the tympanic membrane at its end. Shortly after the membrane begins to vibrate, bones behind it follow suit, sending the event deeper into the young boy’s body. Eventually the vibrations make it to a fluid filled canal in the inner ear. As it spreads down this narrow corridor it comes into contact with microscopic hair follicles which beat back and forth, struggling against the explosive legacy. In response to the struggle, ion channels in the base of the follicles open, turning the sound vibrations into electrical impulses. These signals shoot down an attached nerve, aimed directly at the brain.

If you’ve followed the news recently, you know that Israel and Hamas are engaged in a vicious conflict over control of Gaza. Hamas, citing grievances over a stern Israeli blockade of the region, has fired nearly 3500 rockets at Israeli cities since the conflict began in mid-July. Israel has responded by conducting thousands of airstrikes on targets in Gaza and sending in ground troops to destroy Hamas’ network of underground tunnels. This is not a new story line as similar fighting has occurred between the two groups time and again ad nauseam. This conflict has been going on in its modern form for more than 7 decades. With such a long history of incredible violence, how do we begin to measure the impact of this conflict?

The traditional way is to tell the story in numbers. In the press, this is primarily described by numbers of people killed and displaced. The best estimates (and good, truthful estimates are really hard to come by) I have read say around 2000 Palestinians have been killed and 425,000 displaced by the fighting. More than 12,000 Gazan homes have been destroyed and economic costs have been devastating. Israel has suffered 3 civilian and 64 military deaths (to be fair, while the numbers are smaller, they also suffer the daily consequences of living under fire from rockets for the last several years). Of particular note is the number of kids affected by the campaign. UNICEF estimates 400 Palestinian kids have been killed (20% of total Palestinian casualties) and 375,00 have been displaced (79% of refugees) (Source here and here). Commentators, peace activists, and war hawks alike throw these numbers around as ways to assess the conflict’s impact on the people, community, nation, local economy, or what have you.

My contention is that, while describing a horrible situation, these numbers tell a limited story. Death and displacement describe what is happening now, but do little to communicate the human experience of the war or the future consequences of these events. We could further discuss economic cost, poll numbers, conflict length, and even DALYs (an awesome, but limited measure of disease burden used by public health officials), but we would still miss a certain human experience element that such analyses inevitably leave out. I would like to propose a novel mechanism for measuring conflict impact that both communicates the deleterious experience as well as predicts the negative consequences of such conflicts. And of course with me, the answer is a pediatric answer.

There is an emerging concept in the world of Pediatrics about the role that stress plays in childhood development. A landmark study from 1998 looked at more than 17,000 kids and how they responded to adverse childhood experiences (ACE). ACEs are defined as experiences such as abuse, neglect, and household dysfunction. Researches classified the number of ACEs a kid had and looked at associations with health behaviors and disease outcomes. The results were stunning. The number of ACEs a kid experienced correlated with adverse health outcomes in a dose-dependent manner. In other words, the more ACEs, the unhealthier the individual was as an adult. This association was true for health behaviors such as increased drug abuse, alcohol abuse, smoking, risky sex, teen pregnancy, and partner violence. Moreover the association held true for health outcomes of some of the most common causes of morbidity and mortality such as heart disease, liver disease, lung disease, depression, STDs, fetal death, and suicide (Source). This study provided clear insight about the effects our experiences have on our health.

From this study, a science of pediatric stress has blossomed. The foundation of this science is the fact that the body has robust mechanisms to respond to and cope with stress. The stress caused by ACEs overwhelms the body’s ability to cope and so has been termed “toxic stress” (TS). Research has demonstrated numerous biological changes associated with TS. Cortisol is a hormone released from your adrenal glands to help your body cope with stress by raising blood pressure and blood glucose levels and mediating activation of the “fight-or-flight” response. Studies have shown that kids who experience TS have prolonged elevation of cortisol levels. Long-term exposure can cause many adverse consequences such as immune system dysfunction, muscle tissue breakdown, electrolyte imbalances, and neurological damage. Concerning this last effect, fancy brain imaging studies have shown that prolonged cortisol exposure causes actual changes in the architecture of the brain areas associated with fear and emotion regulation (amygdala), memory and emotion integration (hippocampus), and decision-making and action control (prefrontal cortex). While this is an overview of stress from 10,000 feet, doctors generally cite these mechanisms as the biological mediators of the adverse health outcomes associated with ACEs and TS (If you have extra nerd time, here's an awesome PDF overview, here's a more technical paper from the AAP).

In split seconds the explosive message reaches the young boy's brainstem. From its protected vantage point at the base of the skull it disperses the message up and throughout the cerebrum, the command center. The auditory cortex hears the message and sends it to the hippocampus to try to remember where such reverberations had been heard before. The hippocampus remembers the destructive effects of such a sound and passes it along to the amygdala to decide how it should feel. The amygdala instantly knows the only feeling to be felt is fear. As it passes the message down the line the amygdala sounds the alarm, letting the reserves know it was time to act. From a distance, sitting on the kidneys, the adrenal gland hears the alarm. Cortisol and adrenaline come pouring out of the gland into the bloodstream, preparing the body to act. At the same time, the prefrontal cortex activates, sending sparks of cognition to the muscles, preparing them to go. The boy’s eyes dilate, sweat glistens his brow, his heart starts pounding, his muscles tense. Meanwhile the message reaches the black box of his consciousness. As his attention shifts to the explosive sound, he can only think one thing: danger.

The fascinating thing to me is how this should expand our narration of health and disease. Normally, when there is something wrong with our bodies we (both as lay people and as doctors) explain it as a present tense state of being – “I have a cold”, “You are a smoker”. This, of course, is the most natural way to talk about the state of our bodies, but it has the effect of anchoring our focus to the present without giving much thought to the proximate causes of such states. When we do explain causes, we tend not to go back too many degrees from the present: “why do I have a cold?”, “Because you took care of the snotty kid down the street yesterday.” It is not within our mental purview to explain how the kid got the cold from sticking a toy in his mouth at the mall, which became infected when a janitor touched it after blowing his nose in the same snot rag all day, who in turn had been infected by…. and so forth. The beauty of TS theory is that we now have a strong anchor point in the past and a plausible biological mechanism over time to expand the depth of our disease narration in the present.

Now let’s finally return to our discussion about measuring conflict. I said above that I want a measurement that communicates the experience and the consequence of conflict. Stress is the perfect way to communicate both of these. A body’s response to subjective experience over time has measurable consequences, both in terms of biological changes and life outcomes. Such a discussion would have a more emotional impact than statistics. We can all relate to the experience of stress and thus understand to some degree what it is like that these other humans are undergoing this experience. It would also be more longitudinal than just quoting death totals and economic costs, as we could extrapolate from the present time not only those effects, but also the myriad health, emotional, and psychological consequences as well. With time and further research, perhaps we could even delineate how such acute stressors cause changes in culture, sociology, government, religion, etc. Humans are the basic functional unit of all of these structures, so a dynamic view of how humans change over time in response to stress would do much to inform initiatives that prevent, mitigate, and repair the damage of such horrible situations.

What would such a measurement look like? I propose the base value would be “Toxic Stress Units” (TSUs). We could take random samples from the population of pre- and post-conflict cortisol levels, fight-or-flight response reactivity, and neuronal metabolism of the specific brain areas mentioned above. We could index these values into a basic unit and then measure the increase of TSUs caused by the conflict. Longitudinal studies could look at how adverse health (or economic, political, etc) outcomes correlate with TSU levels over time. Once we develop a good understanding of TSUs, public health experts could use them to craft policies on how to approach post-conflict development, peace activists could use them to decry the evil-yet-specific, horrendous-yet-measurable effects of war on children, and policy developers could use them to account for the comprehensive burden that conflicts will have on the major political and economic structures of a nation.

And how long would all this take? Probably decades to forever. I literally started thinking about this last week and as far as I know, there are no such discussions in the literature. So it has not progressed beyond the stage of a fanciful thought in my mind (well I guess now it’s a speculative blog post). But I do think it is interesting and worth chewing on.

There is a last, larger point I will make from all this. While toxic stress units are not yet a real thing, the horrible pain we inflict on each other certainly is. In the Jewish Old Testament there is a word for peace that is transliterated as “shalom” (and, though I’m less familiar, Muslim texts have a similar word, “Salam”). This word means something beyond a mere absence of hostility. Shalom has been defined as “a comprehensive well being” or “universal flourishing, wholeness, and delight—a rich state of affairs in which natural needs are satisfied and natural gifts fruitfully employed, a state of affairs that inspires joyful wonder as its Creator and Savior opens doors and welcomes the creatures in whom He delights. Shalom, in other words, is the way things ought to be.” I believe through this discussion about adverse childhood experiences, stress, and health outcomes, we’ve skimmed the surface of this idea. There is a way things out to be, there is a right relationship between ourselves, our world, our Creator, and our fellow man. Disruption of these relationships feed back on each other to cause disease, and wars, and death, and destruction, and elevated TSUs. The Israeli-Palestinian conflict has been ongoing for more than 7 decades. There is no stopping it if we cannot change how this conflict is seen and what this conflict is about. By talking in terms of TSUs, we might shift the focus from winning a battle to promoting shalom. By focusing on shalom, then the answer is not a geo-political reconfiguration, but rather a human and relational restoration.

Over the years, his body becomes veteran to the sound of explosions. His ears are attuned to its nuances, his hippocampus remembers well what it foretells, his prefrontal cortex is practiced in its response. Cortisol is his constant companion and epinephrine an old friend. And then there’s the amygdala. Long ago it replaced fear as part of its response with something much stronger. The amygdala learned to numb the pain, to blunt its response, by washing him in that most potent of anesthetics: hate. It is hate that now bends the young man’s knee. Hate that feels the weight of the weapon on his shoulder. Hate that lowers his head to take aim. Hate that flexes his finger and hate that pulls the trigger.

And the rocket explodes.

On Fatherhood and Ebola

2014-08-02T14:06:00.002-07:00

My daughter was born amidst the worst Ebola outbreak inhuman history. Throughout Guinea, Sierra Leone, Liberia, and Nigeria the Ebola virus is wreaking havoc. It spreads through contact with bodily fluids. It can cause you to bleed out of every hole in your body. It has a mortality rate of 60-90%. It has killed an estimated 700 people, including 60 healthcare workers. There is no cure. It recently made it to Lagos, Nigeria - the largest city in Africa and a major hub for international travel. Public health infrastructure in the region is shoddy at best and health officials are having trouble containing spread of the infection. It’s already an epidemic and it’s looking to get a lot worse. This was the world my daughter, Audrey, was born into.

However, be it through Providence or just luck, she was born in Texas to two parents who have never even been to the region. Insulated by geography and a strong public health infrastructure in the United States, I do not have to worry about her contracting the virus. And yet, I sort of do.

So I am a 1^st year pediatric resident at a large children’s hospital in Texas. Along with my MD, I have a master’s degree in public health and so have a reasonable understanding of epidemiology and infectious disease response systems. Intellectually, I know the minuscule risk of her ever contracting the disease and yet emotionally, I still feel unease.

To understand my feeling of unease, I first want to understand all these new parental feelings I’m experiencing.

We’ll start here: I am really, really, really fond of my baby. She wiggles around, farts, eats, and makes weird grunting noises when she feeds. And it’s incredible. I love her. The interesting thing to me is that, prior to her existence, I did not feel this feeling (I felt abstract love for a future, possible child, but not specific love for this child). So my love for her and this feeling I have came into existence with her existence. Moreover, my love for her did not take from feeling of love toward anybody else in my life. So the new measure of love was added to the love I already feel for everyone else in my life. Therefore, I can conclude my love for my daughter is both new to my socio-emotional identity AND added to my previous amount of felt love. Or we can say I feel both a new type of love and more love than I have felt before in my life.

Furthermore, I love her and feel a strong aversion for her discomfort. We’ll call this feeling risk (a negative feeling from understanding there is potential for her to experience discomfort). We can treat this feeling the same way we treated love above. So this feeling of risk is both new to me AND makes me feel more risk than I have ever felt before.

This is the problem: with love comes risk. I realized this first when I got married. When it was just me by myself, although I didn’t want harm to come to me, I did not feel as much of this feeling of risk. For example if I was an action hero, the super villain would have no one he could threaten to throw in a pool of badger-sharks (barks) if I did not surrender (this is just for the sake of example, of course I would maybe surrender for you mom…). When I married Rachel (wife), all the sudden I had this really valuable externality, and I started feeling unease over situations I had not previously. Here's a more real life example: I’ve desired to be a missionary doctor for a long time, but getting married has made me rethink the kind of contexts we might look to live in. Because of my love for my wife, this new feeling of risk was added to my life.

Now I have a little, wiggly girl that I am responsible for. Now the feeling of risk is huge! Greater in magnitude and in power than I’ve ever felt in my whole life.

Which brings me back to Ebola. Yes, we are many degrees of separation from the virus. Yes, the chances of her catching it are tiny. And yet I love her, and therefore I want what’s best for her. Moreover, I love her, and therefore I do not want what’s bad for her. She was born into a world where Ebola runs rampant, and wars are multiplying. I don’t want her to experience these things. I don’t even want her to face the CHANCE of experiencing these things. And yet I love her and cannot imagine her not being here. In this present world. With me. I wouldn’t have it any other way.

Such is the odd intellectual-emotional tension, the strange cognitive dissonance, of love. My feeling love means my feeling risk. It’s the steep ridge of an emotional mountain all parents walk. I suppose I am just beginning to step out onto it.

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Welcome to the blog. As I said, I’m a 1^st year resident Pediatrician. More importantly, I'm husband to an incredible wife and dad to an incredible daughter. Here I hope to periodically discuss both the science and experience of being a parent. Along the way I hope to include my non-expert interests in theology, politics, philosophy, current events, 90s cartoons, and dude stuff. I like to think of this as a scientifically-based mommy blog for bros – meaning there will be no Pinterest references ever.

Pediatric Admissions

Moral Dissolution through Moral Indignation

Sunday Prayer, after the election

A Prayer on the Eve of the Election

Taming your inner troll: The 4 rules of sharing political opinions responsibly on social media

More people need to post their political opinions on social media. There I said it.

On Botswana

Movement 1: Medical Missions as an Act of Selfishness

Eulogy: Land that Drinks the Rain

On a Christian Solution to the Syrian Refugee Crisis: Who is my neighbor?

On Combination Chemotherapy: Hope through Death

On Vaccines 3: Fear as Fission

On Vaccines 2: Risky Feelings

On Vaccines 1: Hear no Measles, See no Measles, Think no Measles

On the Utter Improbability of My Daughter's Existence: A Math Poem

On Kids, Violence, and the Israeli-Palestinian Conflict

On Fatherhood and Ebola