Patient confidentiality

Patient X in Dallas went to a hospital on the 27'th with a fever and was sent home. He's back, with ebola. If I understand ebola correctly, he was contagious on the 27'th. I gather the authorities are trying to trace his contacts, but apparently the public isn't allowed to help. Remember the Boston bomber search, with the police wanting everybody behind doors to avoid danger? Eyes on the street was what spotted him, not door-to-door police.

I wonder how long it will be before parts of patient confidentiality get waived. We paid a pretty high price for not being more aggressive with quarantine (and closing the bathhouses) with AIDS. It wouldn't have solved the problem then, but it would have made it smaller.

I think the authorities are going to need help. At some point we're going to have to ditch confidentiality in favor of public health for some diseases--this would be a good time before things really get started.

How closely does the appearance of the virus correlate with fever? When exactly do you start to become contagious?

They can quarantine the family in the hospital and monitor them through all the stages of the disease. Maybe that's why the CDC team flew out there.

We talked about this at the table this evening, and it occurred to us that he might have picked it up riding in a taxi. Think sweaty seats--very sweaty seats.

Very different values

We generally try to make sure disagreements don't inflate into violent disputes (despite the revolutionary origin of the country). Editorials cluck-cluck about the partisan divide we have, though they celebrate it quietly: "our party is principled, theirs is obstructive." "Moderate" is a nice label to wear.

I started reading The Constitution of Athens, and in Chapter 8 find this about the rules confected by the famous Solon:

And seeing that the state was often torn by faction, and that some of the citizens from indifference stood aloof, of his own motion he passed a law specially directed against them as follows—that anyone who, when the state was divided into parties, did not take up arms and side with one or the other, should be deprived of his political rights, and have no part in the state.

Distributed doctoring

UPDATE: Prepositioning medicines won't work very well. They will deteriorate in the heat and humidity (want to bet the bottles won't be opened from time to time?). You would have to re-distribute regularly--possibly annually.

One of my favorite scenes in the movies is the engineers around the table in Apollo 13.

I wish I had a team of engineers and nurses.

Ebola is, of course, out of hand in Liberia/Guinea/Sierra Leone now. The centralized medical centers were overwhelmed and eviscerated. They are trying to open secondary centers. USAID is trying to bring in ebola management kits to distribute to the villages.(*) The kits aren’t quite complete enough but they have the right idea.

Treatment has to happen at the extremely local level: village or neighborhood. Without that presence people don’t buy into the system, and in any event there’s nowhere near enough beds even if you could transport everybody to the hospital without infecting another half dozen people on the way.

There are not enough doctors or nurses. There won’t be. All you have available is family members, with advice.

Cell phones are widely known and used, and though smart phones aren’t nearly as common as the candy-bar models this can help spread the word among the skeptical. But this is just the start.

---

Here’s the challenge: given local resources (in the slum or in the village), how can we arrange for medical care while minimizing the risk of ebola infection to others?

A few features seem to be inevitable. Homes are crowded, so the patient needs to come out of the home and stay in a more isolated setting. One member of the family will be taking care of the patient—so the isolation area needs to have room for pairs. The caregiver has to assume that the patient has ebola, and so buckets of bleach water have to be available.

The patient probably doesn’t have ebola, so the kit is deficient. It should also have malaria suppressants and vermifuge and some anti-diarrhea tablets and some rehydration salts and maybe a few other things as well. The average caregiver will have no idea how to use these things. I’ll get back to that. (Tylenol might be more dangerous than it is worth unless the kit has only a little--that's a judgment call.)

The slums should have readier access to bleach, plastic bags, gasoline, cloth, and other useful items. The village will have more space to put an isolation building—the slums are horribly crowded—and better sewage disposal. Neither one has useful medical advice.

Engineers and Nurses:

Can one kludge procedures using cloth, plastic bags, and bleach that will let you clean a sick patient without exposing your own skin to ebola? How much bleach residue can someone with diarrhea stand, since you have to bleach the cup he drinks from? How can you use cloth and whatever to hold someone up enough to drink? What sorts of procedures can you use to wrap the dead (bearing in mind that whatever he was lying on is wet and contaminated) that won’t put you at excessive risk?

Can you make a decent mask with available cloth? How many do you need to have on hand if you have to keep soaking old ones in the bleach?

Can you make disposable bedding from leaves and branches (in season)?

What is bleach going to do to skin infections?

How much cloth is one person with the runs going to need?

If the patient is bed-ridden, what can one use for a bedpan?

If the patient is not bedridden, how can one kludge a latrine in the slum? Since the waste is potentially deadly (even without ebola), this isn’t a trivial problem.

Other ideas and questions--straw men and otherwise.

Beef up those medical kits. I’m assuming the information pamphlets are cartoons, since most people can’t read. The medicines need to be brightly and distinctly colored so they can tell them apart easily. Probably everybody has worms, so dosing everybody in the village on general principles is probably harmless and might increase overall health.

Create medical teams that just answer cell phone questions. You need a lot of them, because there will be a lot of questions and a lot of languages. Their job is not to provide care but to explain how to use the souped-up medical kits. They in turn will not be doctors or nurses; they’ll be working mostly from scripts. If they get stumped they call for advice from medical central (which might not even be in the country). Not all villages will have a cell phone to call with. Can't solve that problem here.

The circulating education teams have to demonstrate all the details of all the procedures. This means that it will take a long time to finish a circuit. Folding cloth to make a support or an impermeable mitten is something that needs to be practiced a little. So long as one person gets it, the team has to rely on that person to train the others as needed since they can't stay for too long. Cartoons are all very well, but there’s no substitute for trying procedures out yourself (even cartoons aren't as clear as their creators dream). The teams will have to resupply the medicines from time to time. Some villages can only be reached by a few day’s walk. Some slums are dangerous.

I'd thought that for somebody in a village with ebola a trench filled with leaf bedding would be useful, but since there won't be a diagnosis (probably ever) I don't know if this would be suitable. For a one-off treatment site it might be OK for easing cleanup.

If a man dies you need to bury or burn his contaminated clothing and bedding. This will be a bit of a sacrifice, and in the rainy season (like right now) difficult. How long can you soak a filthy shirt in bleach before it is safe enough for someone else to inherit?

If the people intensely dislike the smell of chlorine bleach on the departed one, maybe perfume would help mask the smell, and also mask the fact that the person hasn’t been bathed as thoroughly as custom demands.

Sometimes liquid latex is available from rubber trees—can that be used to make cloth less permeable?

In the slums, the city is going to have to clear some areas out to make room for isolation buildings and latrines. This will make people angry. If you compensate those whose houses were razed, the neighbors will be angry that they didn't get a share. Money allocated for compensation will leak away before it gets to the people. You just have to deal with the anger somehow.

This will need lots of volunteers with working knowledge of tribal languages. You can probably find some in churches.

The isolation buildings don’t have to be any fancier than anything else in the area—in fact it is probably a bad idea to have them be too good since there will be squatters in the slums. The shelters have to keep the rain off, fresh air in (insofar as there is any), and the patients out of the draft and separated from each other. Latrines outside, places for paraphernalia where the caregiver can keep an eye on them so they don’t get stolen (the slums are slums). There need to be a lot of these shelters, since a caregiver will likely have other obligations to other family members and can’t spend 24/7 at the isolation building—so these can’t be far from home.

What kind of landscape is needed for siting an isolation building?

Try to recruit burial team members from the slums. You may have to pay by the body or they might not show up.

Water is a problem--too big to solve on a useful timescale for stopping ebola.

UPDATE 27-Sep: See this story about makeshift protective gear.

---

(*)

SIEGEL: That kind of gear and information is in kits that will soon be distributed by the U.S. government in Liberia. But as NPR's Nurith Aizenman reports, the home health care kits come with mixed messages.
NURITH AIZENMAN: Here's what's in these kits...
NANCY LINDBORG: It's a bucket that contains a sprayer, which is used for disinfectant, rolls of bags for capturing any infected garments or items, gloves, a gown, a mask, soap, chlorine.
AIZENMAN: Nancy Lindborg is a top official at USAID. She says the agency's plan is to distribute the kits to 400,000 households across Liberia. The first 50,000 kits are arriving next week. And here's the question - can these kits help slow this outbreak?
Kits like this have been distributed in previous Ebola outbreaks, but never on this scale. Dr. Daniel Bausch is an infectious disease expert with Tulane University and the U.S. Navy. He's advising the U.S. government on the current Ebola outbreak, though he's not working directly on the home kits.
DANIEL BAUSCH: In previous outbreaks, the question was is it better to try to take care of people at home with these sorts of kits or should we really focus on getting people into an Ebola treatment units? But that's not an option now.
AIZENMAN: There are very few treatment centers in Liberia. So people are taking care of their family members at home. They don't have a choice. President Obama is promising to build 17 new treatment centers with a total of 1,700 beds. But that's going to take time.
BAUSCH: Until we can do that, I think that we have to be honest. And we have to offer people what protections and what care we can even though it's far from ideal.
AIZENMAN: But USAID says that the kits are not meant to be used to provide treatment. For instance, they don't contain Tylenol for fevers or rehydration salts to help replace fluids lost through vomiting and diarrhea. Officials say the most important item in the kit is an information pamphlet telling people how to protect themselves. Dr. Bausch says that while using items in the kits like gloves or surgical gowns won't completely protect the family members and friends of someone with Ebola, every little bit helps.
BAUSCH: If we can cut down - rather than having five infected people from a sick person in a home, if we can cut down to three, obviously that's a good thing.

The director of the king

Solomon wrote "The king's heart is like channels of water in the hand of the LORD; He turns it wherever He wishes." Of course, he was the king at the time, and the book of Proverbs is well known to be a book of general rules of thumb rather than absolute promises. An even less reliable authority said in reference to the kingdoms of the world and their authority "To you I will give all this authority and their glory, for it has been delivered to me, and I give it to whom I will." You might be inclined to discount the word of the Father of Lies, but Jesus spoke of the hostile "prince of this world."

I've heard quite a few people opining that things would be better if some of Our Group could get elected and change the moral climate of the country. Sometimes their anointed one becomes the ruler (I have kin who campaigned for ∅bama), but for some reason it never quite works out to be as uplifting as they hoped. Do I hear someone laughing in the background?

---

FWIW, I've sometimes wondered what the conversation was about when Jesus told his disciples about the temptation in the wilderness.

Stroller changes?

Back in the days when we used a stroller, we made sure it collapsed. Even the twin stroller (a double-wide, to keep a todler and a baby more or less in one place) folded down fairly compactly, though with treacherous projections. I saw strollers on the bus, too--generally folded down when they were brought on.

These days I see a lot of strollers on the bus, and even on the sidewalks--double strollers (fore and aft, the double-wides are, thankfully, out of style) as often as not, and none of them apparently easy to fold up. The double strollers almost invariably have just one child aboard. The weight, volume and square footage per child is much larger than before.

Is that because strollers are so much cheaper, or because nobody worries about folding them up anymore?

My sampling may be biased, since most of the strollers on the bus are with women going to/from the homeless shelter (no car, no need to compress), and many of the rest are with people touring the square, who may not be representative.

Still, the new style seems much bigger and more padded, and I'll bet harder to clean.

Golf

Eldest Son had an intriguing idea: imagine playing golf on Perelandra.

I wonder if you can emulate that in a water park or a mostly enclosed bay...

The Idea of the Holy by Rudolf Otto

Rudolph Otto’s The Idea of the Holy begins by suggesting that those who have never experienced anything like this will have no idea what he is writing about, and may as well just put the book down. That’s dramatic advice, but fair—especially since the choice of words that follow is apt to be extremely confusing.

He, or perhaps his translator, uses the term non-rational to describe the experience of the numinous. What he means is that you cannot model the numinous and wrap your mind around it. Encountering the numinous is encountering something “wholly other.” Terms like majestic, terrifying, powerful, and so on do not, at first apply. The experience goes the other direction, as we try to express what we have known in symbols other people (and we!) can understand.

Thomas Aquinas wrote massive and thoughtful analyses of the foundations and implications of the faith which generations have benefited from, but one day he had a vision, laid down his pen, and said that everything he had written before was so much “straw.”

This experience of the holy Otto sees (and I think correctly) as the origin and source of power of all religions. Even the purely artificial religions—burning incense to the spirit of the emperor or worship of the Communist Party Revolution are piggy-backing on more spontaneous religions (communism is often described as a Christian heresy).

Although he does not explicitly say so, Otto seems to be describing at least three kinds of interaction with the numinous, and possibly four.

1. The Isaiah or Job version, testified to by many prophets and mystics of many faiths—an overwhelming connection to something more real that you are: overwhelming and yet somehow desirable. The fate of Semele echoes the sense—you cannot look on God and live. Not because you are unclean or sinful (though that can play a role) but because you are finite. And if I may stoop to a mathematical analogy, not just finite in some dimension but finite in the number of dimensions.
   

   The people of the Gerasenes asked Jesus to go away—perhaps because they worried about future financial setbacks, but more likely because they were encountering something holy and were afraid.
   

2. Another form of encounter is like this, but less focused. It also is unsought. For example, in the forest there comes a sense of something numinous and awesome, and the forest seems to be a holy forest because of it. I’ll go into that a little more in a moment.
3. In yet another form the numinous encounter is sought after, and things of majesty or beauty or even asceticism are used to prepare the worshiper to encounter what, in the final analysis, can only be initiated from outside us. Our effort is not always successful, of course. But this isn’t obviously bad: I’ll discuss that briefly later too.
4. Another form is logically available, though Otto doesn’t address it. The encounter can be with something secondary but still superior and “other” though not with the ultimate reality of God. For example, encountering an angel could be a numinous encounter.

Otto’s history of religion stands Frazier on his head. The notion that religions develop when a chief tries to inspire awe in his tribe to solidify his control begs the question of what this awe is and where it comes from. It is much more probable that the kind of encounter of the second type is common, and that the religions often come from trying to figure out how to live in light of those experiences. Otto refers us to the testimony of missionaries who find ready acceptance and understanding of their very high understanding of God even among animist cultures seemingly utterly immersed in attempts to manipulate lesser spirits.

The type 2 experience would seem to lend itself to creating a local shrine to commemorate and to visit in hopes of retrieving a type 3 experience: in the forest, by the stream, to the sky--whatever seemed to be the trigger for the original experience. Of course the result is generally some kind of idol, which as a creation of man is less than man and far less than God.

I’ve suggested before that polytheism is the compromise you get when different tribes with different gods met. It is possible that this represents instead the different experiences of the numinous within a single tribe. In either case, I expect it to have arisen syncretically rather than organically, and that true devotion, as opposed to box checking, would be to just one god of the pantheon. (The devotees of Krishna come to mind here.) Polytheism would seem to lend itself to the same kind of superstitious box-checking you find in animism: wear blue, right foot out the door first, and don’t forget to dump a little wine by the lingam and you should be OK for the day.

Of course Christianity has suffered from the same box-checking problem, if the complaints of centuries of preachers and priests are any guide. And I gather from the history of Sufism that Muslims recognize the same problem. But when one welters among many gods, they all tend to become limited and small.

The tendency is almost always to degrade rather than elevate; I believe Otto is correct in locating the origin of religions in encounters with the numinous.

Otto distinguishes between these encounters in part by looking at the side effects. Does the experience communicate a clear message, as Isaiah’s did? Does it leave behind simply a “This place is sacred” or does it have moral implications? And he adds another condition—the more spiritual the better.

This last reflects a sad defect in the book. He seems to think that the “wholly other” can make an impression on a human spirit but not on matter. He doesn’t like the idea of miracles at all and isn’t shy about denigrating them.

He also illustrates his descriptions with quotes from Hindu scriptures, suggesting (I’m not expert enough) that nirvana’s negative description reflects the “wholly other” / no way to tag it with words aspect of the numinous.

One very interesting omission is “Are we made to encounter the holy in particular ways?” From the observation that the experience of the holy ends up being described in terms of majesty and beauty and (often) right living, the effort to represent and to appeal to God which is codified in those terms seems appropriate. A hymn describing God’s power does not have the same dramatic character as the overwhelmed cry of “Holy, holy, holy is the Lord,” but that doesn’t make it inappropriate, or even necessarily inferior if that is a mode of approach to God that we were made for. Would, for example, Aquinas have had the vision at the end of his life if he had not dedicated his work to God all those years?

Read it. Subject to his caveat.

And another caveat—avoid the Kindle version. It was taken from a scan, and the OCR imbeds footnotes without distinction from the text, often mistakes “n” for “w” and suchlike, and you don’t want to know what happens when it hits Greek or Hebrew terms. It was probably taken from the same source as this. Hard copy is a better bet.

I’m told C.S. Lewis considered this one the influential books in his life.

Chutzpah

was defined as the attitude of the man who, having murdered his parents, threw himself on the mercy of the court as an orphan.

It could also be the attitude of a man editorializing on how the appeals court was "asking for trouble" when it reinstated Wisconsin's voter ID law. Yep, there's not much time left. And remind me why there was a delay?

The old tradition holds that the dead vote in Chicago and the cows in Southern Illinois, and there were certainly some curious voter turnouts in several counties around the country in the last election. On the other hand we're assured that it is all smoke and mirrors--that true voter fraud is almost never proved, and therefore almost never happens. Though that syllogism seems to have a little gap or two in it somewhere...

Will such laws reduce fraud? I look forward to learning that.

Will they reduce turnout? They'll certainly reduce the derelict roundup vote, which probably isn't a significant factor in most races. The turn-out-the-vote machine works best in densely populated cities; making sure the people on your block have IDs is just one more step for the organizers--not even a speed bump, really, given the work involved in making sure everybody gets an absentee ballot and suggestions.

Now that I think of it, if there's a significant reduction in the absentee ballot turnout in certain districts that will probably answer the question about reducing vote fraud. You'll have to connect the dots yourself, though.

On reading a newspaper's science column...

"The child asks for information, and we satiate his curiosity with words. Who does not know how we satisfy ourselves with the name of some strange bird or plant, or the name of some new law in nature? It is a mystery perplexing us before. We get the name, and fancy we understand something more than we did before, but, in truth, we are more hopelessly ignorant; for before we felt there was a something we had not attained, and so we inquired and searched: now, we fancy we possess it, because we have got the name by which it is known, and the word covers over the abyss of our ignorance."

Frederick William Robertson

Small Small Thing

While at my sister's home we watched "Small Small Thing" about a rape of a little girl in Liberia. She isn't the only one.

In the movie one of the doctors explains how the war built up a culture of rape (wars tend to do that) and subsequent frustration when the now-disarmed fighters feel powerless and want the perks they used to have. That's nice and plausible, but I'd think the crimes would be concentrated where the ex-fighters wound up. There wasn't any hint that the uncle (or the other men in the stories mentioned) was anything but a long-time member of the village--and the village stuck together to protect him.

A driver, taking the team up-country to the girl's family (and the uncle who raped her), talked about rape of children, and said something that startled me: "It was worse before the war." He said a lot of men did it to get power and money--presumably magically.

In Southern Africa (Wikipedia says sub-Saharan Africa) there's an ugly belief that sex with a virgin will cure AIDS. That suggests that magic really is one of the motives there.

There's another possibility--that cultures turn nasty when faced with a superior culture. The Atlantic article on rape in Alaska wants to blame their sky-high incidence of rape in the tribal areas on colonial efforts to disrupt the native culture, but I wonder if this is part of a reaction against inferiority. I'm told that some guys (not all, or even a majority) get psyched up for battle and violent sex at the same time. (And that others regard women as a reward of conquest, which isn't the same thing. I've not been in the army, much less in combat, and have no first-hand observations.) If a similar reaction drives the rape of children in villages, then there should be a before and after, and maybe it would have been observed. Aborigines? Newly found South American tribes? It doesn't seem perfectly convincing to me, but maybe I just don't have a clear enough understanding of the dynamics.

They know it's wrong, or they'd not try to hide it as hard as they do. But there's always some excuse. The guy is the only able-bodied hunter, and they'll starve if he dies or is imprisoned--I get that one, though there still ought to be some way of shaming him. But blaming the teller rather than the do-er for shaming the family?

At this distance, as an outsider, I have no idea what to do. Pray, yes. In this country I can denounce the glorification of violent sex (a staple of some music genres) and other trends, but abroad?

My mother wrote an AIDS prevention pamphlet aimed at girls, warning of the dangers of taking up with sugar daddies. I tried to write something for men, but realized it relied too heavily on combating desperation with some notions of chivalry--which is a western concept we haven't tried to either cultivate or export lately. But if sex is tied in with magic--my concept was completely hopeless.

And it keeps happening.

Moses or Ipanema?

Her stride is cultivated grace, her hair elegantly coiffed, her skirt cut to swirl above her knees just so, her back slightly arched for best projection.

But she does not walk in joy, granting a Mona Lisa smile to her admirers. Her head is bowed as if rapt in prayer to the tablet in her hand.

It shines, but her face does not.

Deadly force and race

An interesting study on the use of deadly force by police found that participants (an earlier study used policemen) felt more threatened by black suspects but were slower to pull the trigger on them than they were on white or hispanic suspects. In consequence, the rate of one type of error (shooting at innocent suspects) was lower, and the rate of the other (failing to shoot in time at a baddie) was higher.

James’ study is a follow-up to one in which she found active police officers, military personnel and the general public took longer to shoot black suspects than white or Hispanic suspects. Participants were also more likely to shoot unarmed white suspects than black or Hispanic ones and more likely to fail to fire at armed black suspects.

"In other words," wrote James and her co-authors, "there was significant bias favoring blacks where decisions to shoot were concerned."

This seems to make sense if both the sense of threat and the delay in analyzing the situation both stem from unfamiliarity with the body language and clothing signals. I'd guess the more unfamiliarity, the more delay.

I'd like to see if this is symmetric; if blacks have a similar delay vis-a-vis hispanics, for instance. I'm not sure if "white culture" is ubiquitous enough to provide enough familiarity: quite a few people I've known have lived in relative bubbles. If it isn't symmetric, then I'd start looking at the effects of social expectations on behavior. But I guess there'd be a similar effect.

Statistics show that police shoot ethnic and racial minorities disproportionately to their population.

But the last comprehensive look at the racial makeup of justifiable and non-justifiable shootings was a 2001 study using more than two decades of U.S. Bureau of Justice data, said James. And while statistics show black suspects are shot at more frequently than white suspects, the 2001 study found black suspects were also as likely to shoot at police as be shot at.

Recall that this most recent study was not of law officers, but ordinary citizens.

When confronted by an armed white person, participants took an average of 1.37 seconds to fire back. Confronted by an armed black person, they took 1.61 seconds to fire and were less likely to fire in error. The 240-millisecond difference may seem small, but it’s enough to be fatal in a shooting.

I got to be in one of those situation simulators when I participated in the local "Citizen's Academy" program. We were informed that we novices were allowed to hold the "weapon" at ready, but the police had to keep it holstered and draw. We weren't all that fast. It turns out a lot of bad things can happen in a second--one way or another.

I wonder what the followups will show.

Magnetic field motions in the Sun

This article from NASA is worth reading. Our satellites can determine the polarization of light from different parts of the Sun and figure out what the overall magnetic field direction is in different places. And, over time, it changes. It looks like bands form at high latitudes and migrate to the equator in about a 19-year cycle. In addition they have a new aspect of the Sun to monitor: "They noticed that ubiquitous spots of extreme ultraviolet and X-ray light, known as brightpoints, prefer to hover around the vertices of these large areas, dubbed “g-nodes” because of their giant scale." Mapping the behavior of these and of the magnetic bands suggests that the 11-year sunspot cycle is a side effect of the larger cycles.

The exact mechanism isn't clear (at least to me, and I think to them also), but finding new patterns like this is what scientists dream about. The equator, when those vast bands cancel, just has to have some wild magnetohydrodynamics going on...

And no, I didn't know that sunspots migrated to the equator.

Screen insects

I don't know how many of you remember xroach: an X-windows game that would generate a lot of images of roaches which hid behind your terminal windows or browser or what have you. When you iconized a window the roaches revealed would scurry around the screen looking for a new place to hide. You could click on them to squish them. Minutes of fun--but much more amusing if you could distract some unsuspecting soul and invoke it on their machine.

The old flat-screen I'm using at work has several layers, and an ant got in between them somehow. All morning it wandered to and fro, looking at all the backwards text. (Not that unix commands are that much odder forward...)

Slowing down

My sister asked me to transfer to DVD a video her late husband made 29 years ago, of my eldest two children when we were visiting them in Louisville. (He was preparing a tape for my parents who were in Africa.)

There's no drama: the most exciting part is wondering if Eldest Daughter will hit anybody with the miniature baseball bat. There were many details I'd completely forgotten over the years: the ducks, the swan, the peacocks, the pillars, even the shirt I was wearing.

Ripping it last night was half an hour of watching them do the simple things: exploring and enjoying. My Better Half watched it this evening; just quiet fun remembering.

A narrative line is important, and dramatic tension too, but sometimes you can do without both.