Melania Trump learns about Cambridge Public Schools

“Dear Mrs. Trump” is a letter from a Cambridge Public School librarian to Melania Trump, who sent some Dr. Seuss titles to our fair city:

Our beautiful and diverse student body is made up of children from all over the world; from different socioeconomic statuses; with a spectrum of gender expressions and identities; with a range of abilities; and of varied racial, ethnic, and religious backgrounds.

Yearly per-pupil spending in Cambridge is well over $20,000 [the statistic is correct, but most of the money is spent on administration and pensions; actual in-classroom spending is a small fraction of the total]

we still struggle to close the achievement gap, retain teachers of color, and dismantle the systemic white supremacy in our institution. [but if white students achieve more than students of color in the Cambridge Public Schools, isn’t the system actually working to increase “systematic white supremacy”?]

You may not be aware of this, but Dr. Seuss is a bit of a cliché, a tired and worn ambassador for children’s literature. … Another fact that many people are unaware of is that Dr. Seuss’s illustrations are steeped in racist propaganda, caricatures, and harmful stereotypes. … Scholar Philip Nel’s new book, Was the Cat in the Hat Black? The Hidden Racism of Children’s Literature, and the Need for Diverse Books, further explores and shines a spotlight on the systemic racism and oppression in education and literature.

The librarian offers a list of ten books in return, e.g., “In this gentle story, Haitian American Saya’s mother is incarcerated because she has no papers. … doesn’t shy away from the realities … the trauma of saying goodbye at the detention facility.” and Separate Is Never Equal: Sylvia Mendez & Her Family’s Fight for Desegregation. Transgender issues are represented by The Boy & the Bindi. (She left off Yo Soy Muslim: A Father’s Letter to His Daughter, prominently featured at the Harvard Bookstore last night.)

[Separately, the librarian complains that “many of us can’t afford to live in the city in which we teach,” but of course if she didn’t have a job she would be entitled to free apartment from the Cambridge Housing Authority. Alternatively, any school employee who studied Massachusetts family law should have been able to figure out a way to live anywhere in Massachusetts without working.]

Readers: Was the Cat in the Hat black? What about Thing 1 and Thing 2? Also, how did the Cat get hold of the alien robot technology that he used to clean up the house after his visit?

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Why isn’t our government running a shuttle service to get people out of Puerto Rico?

I’ve been getting a lot of emails from friends who have friends or relatives trapped in Puerto Rico. With food and water supplies questionable, they’re looking for ideas on how to get out. Unfortunately there are only a handful of flights operating daily from the main San Juan airport. I checked the JetBlue web site and it seems that there is ample capacity on flights out of nearby places such as the Dominican Republic and the Turks and Caicos. This leads me to wonder why, as part of the relief efforts, the government hasn’t rented a Boeing 767 or similar-sized plane (300-400 passengers in single-class configuration) to run a $100/person shuttle service to get people to Punta Cana, D.R., Provo, etc.

If the argument is “Those other countries don’t want a lot of refugees camped in their airports” then we can send Obama and Hillary to explain to them how accepting refugees boosts a country’s economic growth. If our brightest political minds are unpersuasive, seats on the shuttle could be limited to those who have a confirmed prepaid reservation for an onward flight.

There are charter companies operating privately in Puerto Rico right now that can do this, but they operate small planes and therefore can’t make a real dent in the queue of people who want to leave and are willing to pay to leave. Tradewind is a reputable example. They currently have two PC-12s flying out of San Juan. Each plane can hold a maximum of 9 passengers, depending on seating configuration. It is roughly $4,500 to get a full planeload from SJU to Punta Cana, including all of the fees on both ends (approximately $1,000 in fees; a good preview of what the U.S. system might look like after the airlines take over Air Traffic Control). I contacted Tradewind and their schedule is getting tight, but they had availability for next-day flights.

In the old days when something bad happened in a remote location, a government would send a big ship to pick up its citizens who wanted to get out. Why not do the same thing this week in Puerto Rico, but updated to “big plane”? (Though I guess if the airports are maxed out, it would also work to load people onto cruise ships for the short trip to a nearby island with good airport capacity.)

“Puerto Rico’s main airport is barely functioning” (CNN, 9/26) says “On Monday there were only 10 commercial flights between San Juan and the mainland United States, with 10 more scheduled for Tuesday,” and “At the same time, many more military, charter and relief operation jets are also flying in and out of the airport, according to the FAA.” It seems as though the main obstacle to getting people out is a refusal to relax bureaucratic requirements: “Airlines are having difficulty printing out boarding passes that fliers need to go through TSA checkpoints and board flights.” But what is the likelihood of terrorists making their way to Puerto Rico in order to blow up a shuttle flight to Punta Cana? Why not collect $100, make sure that nobody is bringing an actual gun on the plane, and lift off? Load up with food and water from Club Med Punta Cana and come back. Repeat. We were able to do this for the Berlin Airlift with vastly more primitive equipment. Despite passengers often being armed, nobody hijacked an aircraft that was taking them out during the Fall (Liberation?) of Saigon.

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Trump: the Opera

Here’s a NYT Op-Ed that typifies the point of view of Americans who supported Hillary Clinton: “Tyranny of the Minority”.

Since Donald Trump’s cataclysmic election, the unthinkable has become ordinary. We’ve grown used to naked profiteering off the presidency, an administration that calls for the firing of private citizens for political dissent and nuclear diplomacy conducted via Twitter taunts.

See also “Billboard calling for Trump’s impeachment goes up in California” (CBS):

“There’s this pattern that seems to repeat: Trump does something absolutely unacceptable, unethical, just the thing you could never imagine even the worst of our previous presidents doing,” Kurtz said. “There’s this wave of outrage — it happened after Charlottesville, it happened even before he was elected when he admitted to sexually assaulting women — and then it settles down and his base is still with him.”

Is there an artistic medium for dealing with cataclysmic and unthinkable events? Where naked profiteering can be just another character trait? Where sexual assault is part of an ordinary day at the office? Let’s consider Tosca. Scarpia, the Chief of Police, uses torture to root out a political dissenter. He uses his position of power and privilege to get sex out of Tosca.

Conclusion: only opera is big enough to handle the character of Donald Trump. I think that I will need readers’ help in fleshing out the action, but I am going to start…

Act I, Scene 1: United Chorus comes on stage singing “America the Beautiful.” Sixty percent wear blue shirts and forty percent wear red. Trump and Hillary enter stage right and stage left. Hillary and Trump sing over and in between the verses of “America the Beautiful,” gradually ruining the song. The chorus is pulled apart into two groups, sorted by shirt color, each one behind a candidate.

Act 1, Scene 2: Bill and Hillary at home. Hillary sings about her Christian faith and how an omnipotent and benevolent God has selected her to lead the American people. Bill quietly sings “A redhead at breakfast, a blonde at lunch, a brunette before dinner.” (will become known as “The Intern Song”; tune from Don Giovanni’s Madamina, il catalogo è questo). Every 2 minutes, a foreigner arrives to empty a wheelbarrow full of cash for the Clinton Foundation.

Act 1, Scene 3: Debate. Trump repeatedly chants “Build the Wall.” Hillary sings a complex and hard-to-hear ballad about gender equality, foreign policy, fair government-determined pay rates, and higher taxes for the rich.

Act 1, Scene 4: Election Night. Stage divided by a wall in the middle. Right side depicts inside the Trump campaign headquarters; left side shows Hillary’s HQ. Hillary sings “New Drapes,” about her redecoration plans for the White House. Trump sings “It’s all Rigged.” Towards the end of the scene, Hillary, drawing on the profound Christian faith expressed in Scene 2, laments that God has forsaken her: “Oh why does Donald Trump have a friend in Jesus?”

Act 2, Scene 1: A derelict warehouse. Used syringes and trash litter the floor. Warm humid mold-containing air piped into the opera house to stifle the audience. Signage reading “JFK International Arrivals.” Trump tries to push passengers with headgear back into the jet bridges while singing “Your goats and camels are lonely at home” (tune lifted from Di Provenza il mar, il suol chi dal cor ti cancellò, Germont’s sentimental song about “the sea and soil of Provence” in La Traviata). Stage left: Tropical courthouse in Hawaii. Judge in the courthouse, with Hillary silently standing behind him, pulls the arriving passengers past Trump via long strings. Back of the stage: Canadian flag and Justin Trudeau standing next to it singing “You’re all welcome in Canada.”

Act 2, Scene 2: Chorus back on stage, a mixture of red and blue, once again united, singing “River of cash, keep flowing.” Chorus members cycle through the Social Security office to pick up SSDI checks, the physician’s office to get OxyContin prescriptions, and the pharmacy to pick up their Oxy, handing over their $3 Medicaid co-pay. Trump and Congress at the front of the stage. Trump sings “Repeal Obamacare” and Congress responds with “We will, we will!” This is repeated for a couple of hours, Robert Wilson-style, while the river of cash keeps flowing (enters at top left of stage and disappears into a pit marked “hospital” in the center) and the chorus keeps getting their OxyContin bottles. Just before the curtain comes down, a lone figure in a purple shirt labeled “Libertarian” comes on stage, the cash river falters, and the lone figure sings “Why would you vote to spend one day out of every five working to pay for your health care?”

Act 2, Scene 3: Stage split up into thirds: San Francisco Bay Area, Harvard University, New York Times editorial board. All singers unite in a chorus of “We’re so smart; why doesn’t he listen to us?” Hillary scolds from the balcony.

Act 2, Scene 4: Synagogue. Trump wears a kippah and, accompanied by Jewish family members, attempts to walk into Rosh Hashanah services while singing “Oh what a friend we have in Yahweh”. The family is blocked by chorus holding up signs condemning Trump’s anti-Semitism. Standoff until clock chimes 12 and protesters rush to the other side of the stage for an anti-Israel rally (signs flipped around to condemn Israeli apartheid system).

Act 2, Scene 5: White House. Stage left: Beautiful Melania sings sweet soprano lullaby to angelic Barron. Center: Aides attack each other with knives. Stage right: Trump sits on solid gold toilet holding Android phone and singing out a succession of Tweets.

Act 3: *** this is where I need reader help ***

Grand Finale: House lights down. Orchestra pit, previously completely hidden from audience, is raised by hydraulics until it is higher than the stage. In the darkness, the conductor turns around to face the audience. Spotlights on the raised orchestra pit. Audience sees that all musicians and the conductor are wearing Vladimir Putin masks. The curtain falls and the hall is plunged into darkness.

Readers: What did I miss? What goes into Act 3?

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Everyone in New Jersey needs a second job next summer

Boring but potentially important: http://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2017/09/state-retiree-health-care-liabilities-an-update shows that folks in New Jersey will need to work a second job during the summer of 2018 and give all of their wages to the state government to pay the hoped-for cost of health insurance for retired state government workers.

Figure 2 of this report calculates, as a percentage of personal income, the amount that state and local governments have failed to set aside for likely health insurance costs. (Of course the actual amount could be much less or much more depending on future health care costs, longevity of retired workers, etc.)

Note that the states depicted are not directly comparable. For Massachusetts, for example, the percentage shown covers only state workers and not local government workers or teachers. For New Jersey and Alaska (workers there will need to work a second job for another year and pay state taxes on that second job at a 100% rate), on the other hand, the percentage shown covers all categories of retirees.

I remain curious why voters don’t rebel and, via referendums, forbid politicians from promising to pay unknowable amounts to retired workers, as opposed to having 401k-style retirement provisions in which the taxpayer contribution could be calculated without input from God (regarding human longevity 50 years from now, health care costs 50 years from now, interest rates 50 years from now, etc.).

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Medical School 2020, Year 2, Week 4

From our anonymous insider…

This week will cover mycology (study of fungi) and parasitology.

Our professor, a 60-year-old ID doctor with thick grey hair, used to go overseas six months of every year to treat rare disease outbreaks, including the 2014’s Ebola outbreak in Sierra Leone. He is celebrating his forty-fifth year of teaching medical students! When he went to medical school, Latin was an admission requirement. This would have been quite helpful in memorizing the 70+ pathogens covered during the previous three weeks as well as in pronouncing medical terminology. Instead of using textbook images for these diseases, he uses pictures of his own patients. During an investigation, he goes to the patient’s house and workplace to investigate potential exposures. One student’s summary: “He’s basically Dr. House!”

Dr. House likes to look at the big picture. “We think history is all about human actions. False. Two-thirds of the cells in our body are bacteria. We are the Uber for bacteria. Genghis Khan was about to conquer all of Europe. His army caught Yersinia pestis in Turkey. The Russians did not stop Napoleon’s army. Napoleon caught dysentery from Shigella outbreaks.” Several students are planning to read Guns, Germs and Steel on his recommendation.

Fungi are dimorphic organisms. At colder temperatures, fungi grow as the familiar mold, creating small inhalable spores. At body temperature, these spores convert into a circular yeast structure. Lectures detailed the three categories of fungi: dermatophytes (fungi that love keratinized tissue such as skin, nails and hair), systemic (fungi that can result in body-wide infections), and opportunistic (fungi that do not cause infections unless the patient is immunocompromised). Only dermatophytes are transmitted from person to person.

This block tends to evoke exotic diagnoses from students. “I’m going to get histoplasmosis [systemic fungal infection]!” exclaimed Straight-Shooter Sally after she removed an unwanted bird’s nest from her potted plants. “As I was throwing it in the trash, the nest broke in half. I inhaled all the bird poop and dust!” After class it is not uncommon to hear, “Do I have a rash on my hand? Do I have syphilis?” One student after class asked Dr. House to inspect his foot. Dr. House had commented, “People who get athlete’s foot just on the nail, not the foot, are more likely to have diabetes.” The student asked, “Do I have diabetes?” Dr. House replied, “You’ll be fine. Remember to never treat your own children. I was convinced my kids had meningitis when their first 103 degree fever occurred.” He ended with a joke: “If athletes get athlete’s foot, what do astronauts get…? Missile toe!”

Parasites are divided into protozoa (microscopic eukaryotic single-celled organisms) and helminths (macroscopic eukaryotic multicellular organisms). With only two days of lecture, we focused on the most common parasites, especially malaria. A common theme of this block is that many symptoms of disease are not caused by the pathogen-killing cells. For example, the watery diarrhea of Clostridium Difficile and Cholera are caused through a toxin-mediated mechanism releasing water into the lumen of the gut. The nonspecific flu-like symptoms of most viruses are not caused by cells dying but the systemic host immune interferon response. Malaria, caused by the protozoa Plasmodium, is an exception to this rule. Plasmodium infects and lyses (ruptures) red blood cells after replicating inside them. Different plasmodium species have different lysing rates giving a classical cyclical fever/anemia pattern ranging from 48 hours to months. Dr. House recounted how as late as the 1920s, syphilis was treated by giving the patient malaria (P. vivax)! The malaria would cause such a high fever it would kill Treponema pallidum. After the syphilis was cured, they would give chloroquinolone to cure the malaria.

We also learned about how the Rockefeller Foundation was founded to address the epidemic of Necator americanus (Hookworm) in the South (see http://www.pbs.org/wgbh/nova/next/nature/how-a-worm-gave-the-south-a-bad-name/). Hookworm is a helminth that latches onto the gut lumen where it produces eggs that pass out in the feces. When a human walks barefoot through a field of fecal-contaminated soil, larvae penetrate into the foot. “Farmers would use human feces to fertilize the field where children would play barefoot.” Once inside, the worm travels through the blood to the lungs, travels up the trachea to the pharynx, and finally is swallowed into the gut. Each hookworm drinks 0.3 mL of blood per day. “The problem is you are not infected with just one hookworm, but thousands. Losing 30 mL of blood per day will cause severe iron-deficiency microcytic anemia.” Over time, this produces lethargy and mental retardation. It is estimated that 40 percent of school-aged children were infected with hookworm in the early 1900s. The Rockefeller Foundation led a massive public campaign that focused on schools to eradicate hookworm from the South.

Dr. House described the waterborne parasite called Cryptosporidium . “Crypto is all through the DC water system. It is resistant to chlorine treatment.” The immune system is normally able to contain the infection. However, some of my AIDS patients before HIV antivirals would have 60 bowel movements a day due to cryptosporidium. These people would live on the toilet, and die from dehydration and malnutrition.” Dr. House couldn’t end lecture without showing us live video, captured during a colonoscopy, of Ascaris (“Giant Roundworm”), which can grow up to a length of more than a foot in the human gut (https://youtu.be/HOaZCkA8Zvk).

Classmates were particularly interested in another waterborne parasite Naegleria fowleri, the “brain-eating amoeba.” Naegleria is found in warm lakes, including in the U.S. It is thought to gain access to the brain through the cribriform plate (thin bone separating the brain from nasal cavities) under barotrauma or a pressurized injection of infected water, e.g., falling during water skiing. I was conversing with a female hematologist in the hallway later than afternoon. She commented, “I will never swim in a lake out of fear of getting Naegleria.”

Our patient case: Grandma Martha, a 68-year-old female accountant with degenerative disk disease in her lower back. Her daughter brought her to the ED for worsening back pain, neck stiffness, and headache over the course of weeks. On physical exam, she showed diminished lower extremity reflexes. Dr. House explained, “Before you can order a lumbar puncture (“LP” or “spinal tap”), you have to rule out increased intracranial pressure which could cause herniation of the brain.” An MRI revealed several inflamed lesions of the meninges without evidence of increased intracranial pressure. LP results showed decreased protein, decreased glucose, and the presence of neutrophils in the CSF. Gram stain on the cerebrospinal fluid was negative (no bacteria observed). “The LP results were suggestive of a bacterial meningitis. However, her presentation did not fit. Bacterial meningitis is typically a very rapid onset of symptoms.” She was started on empiric antibiotics until culture results could be obtained. “I was driving home that evening listening to the news on the radio. They were reporting about an outbreak of contaminated steroids. I turned the car around. Not everything on the news is Fake News.” Several chuckles were heard in the audience.

Back in 2012, Martha had been getting regular epidural steroid injections for back pain. At least one was supplied by the New England Compounding Center (NECC) and, due to a profit-motivated sloppy approach to sterility, had been infected with the fungus Exserohilum rostratum. “We didn’t know how to treat it. No one had ever seen this before.” Dr. House added, “It is extraordinary how quickly the local health departments and the CDC responded. Within 48 hours of the first diagnosis, the CDC was calling patients.” (753 patients were injected with contaminated steroid; 234 developed fungal meningitis and 64 died. See https://www.cdc.gov/hai/outbreaks/meningitis.html.)

Martha was started on an aggressive antifungal regimen including amphotericin (known as “amphoterrible” due to its severe side effects including kidney failure) and voriconazole. “The challenge with fungi and parasites is that our immune system does not do a good job of killing it. Instead, they typically wall off the lesion to contain it. We did not know if our drugs could reach these lesions. We also did not know about the risk of recurrence. How long should we treat the patient?” Martha was in the hospital for 70 days, and continued treatment for another two months. She has fully recovered from the ordeal.

“I was fortunate compared to several other people who live with long term complications from the meningitis. Or who died. I know several people who have dealt with recurrent meningitis episodes,” explained Martha. A student asked about the recent 9-year prison sentence for the NECC co-owner and pharmacist Barry Cadden. “What would you say to him?” “Well, I wouldn’t say anything to him. I would punch him the face,” chuckled Martha. Her daughter jumped in, “I would punch him too.”

I had lunch outside with six classmates. One commented that “Medicine was really the Wild West a few decades ago. Could you imagine discovering these unknown disorders like hookworm?” Straight-Shooter Sally added, “The best part would be getting to name all these symptoms! How badass would it be to name Toxic Megacolon [severe, potentially lethal, distension of the colon that can occur when an antidiarrheal agent is administered during an active C diff infection.]”

Luke got in a heated discussion with Type-A Anita about her two years as an intern at the American Federation of Teachers. She was describing her work “empowering teachers in local communities across the globe.” Luke asked if these teachers were American. Anita responded that they were foreign teachers. Luke asked, “Why should American teachers be forced to pay dues to a union spending money on issues that are not relevant to them?”

Our group then walked over to the hospital’s SimLab, which is led by a retired nurse and EM (emergency medicine) resident. We practiced running a Code Blue where a patient was in cardiac arrest. The main purpose of the simulation was to introduce us to standard communication skills such as “call-backs” (acknowledging an order with a clear read-back) and SBAR (situation, background, assessment, recommendation) hands off. Lanky Luke had run EMS for all of his undergraduate career. The rest of us had no idea what we were doing. The first simulation round we were sent without any guidance to resuscitate a dummy. Over time we got the rhythm of running a code. Two people focus on chest compressions, one person performs breaths, one person runs the monitor and defibrillator, and one person records events. I learned that if you are performing chest compressions correctly you can actually feel a pulse from the compression in the femoral (leg) artery.

What do people who don’t go to medical school do with $300,000 of college education and $300,000 of taxpayer-funded K-12? One of my undergraduate classmates on Facebook this week:

if you’ve been paying attention, you probably know I haven’t been the same since November 9, 2016. things changed not only in this country but also in how I view myself within that context. i joked that if Trump won I would leave the country…

well, now it’s time to follow-through on my promise. after weeks and weeks of trying to figure out what was next, I finally realized that I had no idea and couldn’t figure it out while remaining in my last job and in my last city. so as many of you know, I left DC and my job [social media analyst for advertising agency] …

but now the time has come for me to say goodbye to what used to be my home and is now just the place I try to avoid claiming. i hope to find myself in the coming weeks and months and find what makes me truly happy, in both work and in my personal life.

to that end, I am saying goodbye to the US of A and hello to everywhere else! i do not know where I will end up and although it’s a bit scary, I know I’ll

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When can NFL players stop protesting the national anthem?

A few weeks back, I wondered When can a church take down a Black Lives Matter flag?

The NFL players protesting the “Star-Spangled Banner” raise the same question, I think. If we assume that their protest is only about police treatment of African-Americans, what are the criteria for declaring victory and ceasing the protest? I hope that everyone can agree that even one citizen mistreated by the police is one too many. Does that mean the protest must continue until there are zero incidents of alleged mistreatment of any citizen with dark skin? Over what period of time?

Or has this morphed into a protest about Donald Trump? So it can stop once the hated Trumpenfuhrer leaves the Reich Chancellery?

Or has it been expanded into a protest against social injustice? Then it has to continue until our society is deemed just?

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Natural disasters another good reason to let Canada take our would-be refugees?

After two weeks on a cruise ship I’m catching up on the news. A reasonable high-level summary seems to be that Earth is trying to shake off 325 million human parasites by trashing the U.S. with hurricanes, flooding, tornadoes, and other severe weather.

Back in January I wrote Why accept any refugees to the U.S. if they are welcome in Canada? after Canada offered to accept an unlimited number of refugees conditioned only on their being rejected by the U.S. I’m wondering if the idea makes more sense in light of recent weather events.

What is the value of obtaining refugee status in the U.S. only to be wiped out by a hurricane, monster thunderstorm, rising sea level, or tornado? Canada is too cold for tornadoes, big thunderstorms, and hurricanes. It is well inland and elevated from the rising seas. Most Canadian provinces should be net beneficiaries from global warming, e.g., through a longer and more productive farming season.

Not only does Canada have a far lower crime rate than the U.S., but at least central Canada seems like a far safer place from a weather risk point of view.

Readers: What do you think? If we sincerely have the best interests of refugees in mind, is it time to print up “You will be a lot safer in central Canada” signs for our borders?

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Medical School 2020, Year 2, Week 3

From our anonymous insider…

Virus week. Long days of lectures followed by three hours of studying old material on infectious bacteria in the evenings.

“The more I study, the less I know,” reflects Gigolo Giorgio, the class alcoholic frequently found on the dance floors of downtown clubs. One classmate asked Giorgio, “Is Campylobacter jejuni gram-positive or negative?” We were all impressed when Giorgio responded, “Gram-negative.” We were stunned: “How did you know that!” He answered, “Well I haven’t heard of it, and I’ve only studied gram-positives.”

This block is particularly challenging because the material doesn’t build on previous lessons. I feel more behind each day. “I’m still on gram-positive bacteria! I have not even started gram-negatives!” wails a classmate as we begin virology.

If you model a physician as an information processor, the result of this block is a database that is indexed in only one direction. For example, we study by investigating the properties of each pathogen one at a time. We can reliably regurgitate information from yesterday about a single bacterial species. However, when we attempt to develop a differential based upon symptoms, we have difficulty identifying potential culprits. For example, both S. pyogenes and an acute HIV infection can lead to sore throat. There were many blank faces when we were asked, “What are the common causes of sore throat?” Fortunately electronically implemented databases can be indexed in multiple ways. This is what gives clinical-assistance programs, e.g., UpToDate.com, their power to boost physician efficiency, especially in regions where ID doctors are scarce.

A 60-year-old internist who specializes in herpes and whose two children are also practicing physicians at the hospital introduces virology to us with four hour-long lectures. The Internist introduced infectious disease: “ID is not rocket science. It’s an approachable field if you have the interest and dedication to learn a lot of diseases.” Jane actually shadows the son and mistakenly thought he would be teaching us.

There are three types of viruses: RNA, DNA, and retrovirus. RNA and DNA viruses hijack host cell machinery to produce proteins of their own design. Retroviruses actually insert their own DNA into host cells.

A basic virus is a small particle containing genetic information (DNA or RNA) that encodes for its infective vector (the proteins that enable the virus to get into cells and reproduce). These proteins include the structural capsid protein(s), the polymerase(s) used to replicate the genome, and critical docking proteins to allow access into the host cell. The mode of transmission is restricted if the virus is enveloped in a lipid bilayer. “Enveloped viruses have an easier way to get into cells, but are much more susceptible to drying out on a surface. Non-enveloped viruses can last for days on a surface.”

The internist asked the class, “What is the difference between herpes and love…? Herpes is forever.” Herpesviridae is a large class of enveloped DNA viruses that include herpes simplex (genital warts and labial cold sores), varicella zoster (chickenpox and shingles), and the college-drag epstein-barr (“mono”). “Sixty to seventy percent of the population is infected with HSV1 [herpes simplex 1, mouth cold sores],” said our lecturer. “Most people do not have reactions, but some people have outbreaks, particularly under stressful conditions. Does anyone want to tell their story about cold sores?” Two students volunteered that they have outbreaks, particularly around exam week. They both have a prescription for the antiviral drug acyclovir, which can reduce symptoms if administered during the beginning of the outbreak (typically a tingling or burning sensation). Herpes viruses remain latent in sensory nerves until the immune system is weakened. Reactivated virus will travel to the skin to cause an outbreak.

Shingles, caused by the latent varicella, will typically infect only a single dermatome (region of skin innervated by a single spinal nerve). We also learned about flaviviridae, which causes several nasty tropical diseases, including Dengue, Zika, and Chikungunya. “Each of these is transmitted through the same Aedes mosquito, so it is possible to get multiple outbreaks simultaneously. I’ve had patients with two at once.”

A number of students thought the viral lectures would have been more effective after a dermatology block (scheduled in two weeks). The early symptoms of viruses are typically nonspecific, with the exception of some characteristic rashes. For example, we looked at pictures for the common rash-causing diseases of childhood (measles, scarlet fever, rubella, slapped cheek and roseola) without having an understanding of what pathophysiological mechanism is causing these lesions.

The ID physician spent about 30 minutes on the hepatitis viruses. “There is now a ninety-five percent cure rate for all genotypes of Hep C. It’s truly unbelievable the surge in drug innovation. Five years ago we had almost nothing. Now there are over 12 drugs.” He commented how the first Hep C drug recently dropped in price to remain competitive as it only covers a few genotypes compared to the newer drugs.

Why are there are so many genotypes and viruses? Some viruses purposefully use an error-prone polymerase (enzyme used to replicate DNA/RNA) to accelerate their mutation rate. For example, influenza pandemics occur when a “genetic shift” arises that is sufficiently different from previous strains so that past exposure provides no immunity. This also means the influenza viruses make up to 10 percent null copies, incapable of infecting, but that is okay for an organism that is expending someone else’s energy.

We also learned that many cancers are thought to be a result of past viral infections. For example, cervical and anorectal cancer are almost entirely attributed to sexually-transmitted human papillomavirus (HPV) infection. This is a DNA virus and the cancer-causing strains are primarily HPV 16,18,31, and 33, which are covered by the Gardasil 9 vaccine (ideally administered to both males and females at age 11-12). Viruses typically induce a cell growth state to increase DNA and RNA replication. Some viruses even encode proteins that suppress growth inhibitors such as tumor-suppressor gene p53.

Wednesday and Thursday featured lectures on HIV led by a quirky, cynical ID physician specializing in HIV patients and speaking in a voice that was a bit like Brian Boitano’s. “Do you think he is gay?” a student asked after lecture. Type-A Anita quickly responded, “Of course he is gay. He treats HIV patients.”

HIV is a retrovirus with machinery to integrate its viral genome into the host genome. HIV’s genome encodes for (can produce) only nine proteins. Gp120 is a glycoprotein inserted into the cell membrane envelope that allows the virus to bind to CD4, a protein found on specific white blood cells. When bound, the hidden Gp41 aggregate to bring the viral envelope closer to the host membrane and eventually fuse allowing access to the host T cell. Other host proteins are necessary for viral fusion, including CCR5. One student sent a case report to the class GroupMe about an HIV-positive individual inadvertently cured of HIV when he received a transplant of bone marrow that lacked this protein. (http://www.nejm.org/doi/full/10.1056/NEJMoa0802905).

Two lectures were dedicated to managing HIV. The ID physician began: “My patient was diagnosed with HIV around age 40. She was confused until her husband admitted that for decades he would go on business trips and have unprotected sex with men. She got a divorce.” A student whispered, “I wonder if health insurance survives after divorce?” (Answer: depends on the state; see Real World Divorce)

The ID physician continued, “You are now supposed to prescribe antiviral drugs to anyone with HIV as opposed to those below a CD4 count threshold. Europeans still wait for a low CD4 count to develop, probably because of the cost of these drugs.” HIV antivirals, if taken regularly, are able to wipe out detectable virus particles in the blood and return CD4 count to normal. “There was a study conducted in West Africa where married individuals with one HIV-positive partner was treated. They evaluated how many HIV-negative partners contracted HIV over several years. Almost no one who adhered to the medication regiment passed the HIV to their partner. Some partners tested positive for HIV, but it turned out to be a different genetic strain. The partner had to have caught it from someone other than the spouse.”

We also learned about HIV prophylaxis treatment. At-risk individuals, such as healthcare workers in a high-risk region, or high-risk sexually-active individual, are prescribed HIV antivirals to prevent transmission. “If you are stuck with a needle from an HIV-infected patient, TELL SOMEONE. If you get started on prophylaxis drugs within 48 hours, we can basically guarantee a zero percent transmission rate. You have to hit the virus before its genome is integrated into CD4 T-cells.” One classmate asked, “Are there certain regions of the country where all gay people should be on prophylaxis?” The lecturer was slightly confused, but responded, “No. Assess the risk. If someone is having unprotected sex with two-three different partners a week, yes. If they are in a monogamous relationship, no. Also it depends on what insurance they have.”

A few classmates discussed afterwards if medical education weights HIV too much compared to more common viral infections. Less than 1 percent of the world is infected with HIV. In the US, 1.1 million individuals are HIV-positive, about 0.3 percent of our 325 million population.

Our patient case: Taylor, a 41-year-old black female, presents to the ED in respiratory distress. She reports worsening shortness of breath and persistent cough over the past 4 weeks. Chest x-ray shows glassy white highlights on the normally black air-filled lungs. This suggests diffuse intralobular infiltrates (infection in numerous spots within the lungs; a typical pneumonia is just one big spot). She is admitted and placed on antibiotics. However, her pulmonary function continued to deteriorate and she is transferred to the ICU. Her CBC revealed elevated lymphocytes with a CD4 T cell count less than 100. She is immediately started on antifungal medication to address a suspected Pneumocystis jiroveci infection. HIV test is positive.

Her two-week hospital course is challenging. Because of her low immune function from the HIV, she arrived at the hospital coinfected with several viruses. Then once in the hospital she acquired a conventional pneumonia from intubation and urinary tract infection (UTI) from the foley catheter. She makes a full recovery and is discharged for outpatient follow-up.

Taylor, now 55, is energetic and recently became a grandmother. “At the time of the diagnosis, my three children were 14, 16, and 21. I was in complete denial. I went to four doctors in town to get another HIV test. I finally accepted it while talking on the phone with my internist. I dropped the phone and wept. My children came into the kitchen and asked what was wrong. It felt impossible bringing this up with them.” Once Taylor acknowledged her HIV, she quickly began antiviral treatment without serious side effects. Her CD4 count has improved to normal, and she has not been hospitalized since the above episode.

How did your friends and family react? “I was severely depressed for several years. I’ve been on every single antidepressive that you can think of. You never know who will be there when you are most vulnerable. My best friends were the first to flee. Three of my siblings still do not speak with me. My sister will occasionally visit me, but she refuses to hug me, or let me see her children. People, especially in my community, remember the 1980s epidemic. They think if they touch, or even come near someone with HIV they will get infected.”

“I told my oldest son a few months after my diagnosis. He asked, ‘Do you know who did this to you?’ I told him the truth. ‘Yes. The man knew he had HIV, but still slept with me. When I found out and confronted him, he moved far away.’ I was scared my son would search him out and attack him. I fortunately calmed him down.”

How about coworkers? “I do not tell my coworkers about my health. I get my work

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Are things really that bad in North Korea?

I don’t watch television so most of my news comes from scanning headlines, following links suggested by friends and readers, etc. The impression that I’ve gotten from U.S. media is that North Korea is a starving prison camp. But this Wall Street Journal video shows a clean, organized, and modern city. Having recently returned from trash-strewn Casablanca, I would have guessed that North Korea is wealthier than Morocco (the CIA says otherwise). Presumably the rural areas of North Korea are not as prosperous as the city toured by the WSJ reporters, but that is also true in Morocco and in the U.S. for that matter.

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Why do they play the national anthem at football games? Do other countries do this?

I checked the news to see what was happening in Puerto Rico, curious to know when the millions of fellow citizens who live there might get electric power back, for example. The leading headlines, however, were all about football players refusing to stand for the national anthem and Donald Trump offering his opinion regarding this behavior. (To Americans who worship their president as a demigod on Earth, of course it was very exciting to receive President Trump’s opinion!)

This leads me to ask… if Americans are going to fight about how to behave during the national anthem at football games, why play the anthem at all? Football is not a governmental ceremony, right? It is plainly possible to play an epic game of football without first hearing the “Star-Spangled Banner” because that’s precisely what happens at the Cleary family’s vacation home in The Wedding Crashers. What happens in other countries? Are national anthems played before European soccer games, for example?

[Separately, folks who refuse to respect the U.S. national anthem as a protest against the treatment of black Americans might be on the right track. Slavery in Europe had ended by 1000. Britain abolished slavery throughout its empire in 1833 (Wikipedia). If the American Revolution had never occurred, in which case we’d not have our own anthem, black Americans would have escaped at least one generation of slavery. On the third hand, do these anti-American football players have a practical plan for re-joining the United Kingdom?]

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