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Many people muster strong opinions about Oscars - not I. Having enjoyed some of 2012's awarded movies, I watched the Oscars with appreciation, albeit distracted by the din of our crowd. The only thing that always disappoints me, every year, is how many important subjects and films get left out. The 2012 documentary movies "Escape Fire" and "The Waiting Room" focus on healthcare in the U.S.

"Escape Fire"

Escape Fire airs this weekend on CNN. The film isn't shy about its agenda, as one commentator puts it: "We don't have a healthcare system, we have a disease management system." The disease management system in the U.S. comprises many industries - pharmaceutical, insurance, hospital chains, and doctors' groups, so the film covers a lot of ground.

Doctors and patients dependence on pharmaceutical drugs gets shown via an arresting story of a veteran being weaned off of painkillers. The pharmaceutical industry's economic calculations, deadly to patients, are recounted by Dr. Steven Nissen and the familiar story of Avandia. The insurance industry's stake in it all is discussed and memorably captured in a shot of all the insurance company representatives sitting around the table negotiating Obama's healthcare plan. The filmmakers somehow patch together an optimistic if controversial package of solutions for the impenetrable seeming morass they depict. A Safeway executive marshals employees to exercise and lose weight. Media-popular doctors hold forth with various remedies.

The story thread I appreciated most was that of a primary care doctor. To her dismay, time with patients kept being shortened to meet new economic demands. Supervisors told her to "get her productivity up", so she changed jobs more than once, hoping for a position that allowed her to adequately care for her patients.

Aside from patients, primary care physicians have taken the toughest hit in our *efficiency* driven system. There aren't enough of them, and the care in some parts of the country has become so slapdash it's dangerous. Yet at the bottom of every health article, at the end of every pharmaceutical ad, in every news piece about this or that medical research is a bright, incongruous little instruction: "Ask Your Doctor". As if. As if we had the same level of medical intimacy and trust, just technologically superior, as when my great grandfather worked through nights, house to house in his little town.

Interestingly, the system depicted by the riveting film "Escape Fire", however sickly, is what the healthiest patients get, those who have the very best insurance in a places chocked full of excellent hospitals. Fifty million uninsured patients in the U.S. don't get that.

"The Waiting Room"

Which brings us to the excellent film "The Waiting Room", by Steven Nicks, shortlisted in the top 15 Oscar picks. The movie's setting is Oakland, California's Highland Hospital waiting room, over 24 hours. It focuses on a different aspect of the problem than "Escape Fire" and takes a different tone. If on the continuum of polemic reporting, Michael Moore's "Sicko" scored a 9-10, "Escape Fire" might get a 6-7, and "The Waiting Room" would score a 0-1. Healthcare has been ruthlessly politicized in the U.S. and most people will bring some opinion to this film. In turn, the film strives to be empty of politics. It provides details for its characters, but doesn't do voice-overs, doesn't judge, and doesn't demand your defined conclusion.

Deplore the public cost of diverse homeless populations plagued by addictions, unemployment, poverty and in need of medical care? Those people end up at Highland Hospital. Disdain college grads who don't pay for health insurance? They too, sit in this waiting room. Despair a healthcare system that allows people to get sick and sicker until they end up in emergency rooms instead of getting primary care? Those sick people are here. Agonize how social services have been ruthlessly cut in poor cities? Highland Hospital helps these people also.

They sit shoulder to shoulder in our emergency rooms - our institutions of last resort. Every age, gender, and nationality, they're all here, men plagued with chronic labor-related injuries, primly dressed women abruptly out of work, twenty-year olds surprised by tumors, stroke victims who couldn't afford medicine, kidney dialysis patients from other states, and alcohol/drug addicts living on the streets.

But the film doesn't run all their stories together like I just did, in a big forgettable jumble. It follows each person. How did a little girl with tonsillitis end up in the emergency room instead of in primary care? Her parents are separated, but both show up at the hospital. Her dad lost his job and missed his day with her yesterday on account of transportation. He anxiously hops around her during intake. His son died at two. The nurse, half his size, counsels him to settle down so he doesn't scare his daughter. The girl seems numb to it all.

Triage

Whatever you feel about their plight, whatever sentiment or opinion, the frenzied emergency room healthcare system doesn't have time for any of it. Sentimentality? No. Compassion? Yes. Medical technicians and intake nurses and doctors and interns triage when all beds are full and patient tempers are short. They treat patients as best they can, when specialists have months long waiting times, when "non-profit" hospitals turn away poor patients, and when community safety-nets like churches run out of giving.

The outcomes at Highland Hospital can stretch the boundaries of adequate medical care. Fresh gunshot wounds get run into a trauma room, a steady stream of community catastrophes delivered by ambulance, while men with not fresh but unhealed gunshot wounds groan for hours, days, in the waiting room. A homeless man occupies one bed for too long because he has no place to go. Someone who can't get surgery seems pleased with a pain med prescription. This is where the 50 million uninsured people who are not short-changed in the scenes of "Escape Fire" land sometimes enduring hours of wait before they see a doctor.

At discharge, patients summon fragments of pride. They negotiate payments and answering questions about unemployment checks and family resources awkwardly, over a small desk, everyone caught up in unfortunate circumstances. "The Waiting Room" captures the tension of these situations in a refreshingly empathetic way.

If the movie doesn't hammer home a message, it embraces realism. A new doctor, stunned, is told what to say to a family, told exactly which forms of the verb "to die" to use. After one trauma team struggles to save a gunshot wound victim, they attach a tag to a fifteen year old's toe and he gets wheeled into the morgue. We read a small sign next to the refrigerator door: "Put The Body in Any Available Space".

The film, being so good, won't say this, but economically, ethically, and psychically, everything that brought this Oakland boy to that place costs society. Whatever your politics - in every way, it costs you.

Escape Fire and The Waiting Room, two films highly worth seeing.

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The Waiting Room played all over last fall, and aired on PBS. It is now playing a few other places around U.S., and is also available for purchase. The film team also produces an interactive multi-media site.

Part III: "Do The Inuit Know Something That North Carolinians Don't?"

Polar bears are the largest carnivorous land mammal, yet they can look so cute in pictures -- fuzzy cubs playing in the snow, peering out with little black eyes -- or majestic adult bears floating on pieces of iceberg, fearsome yet vulnerable. Long part of the Inuit culture, the bears live on the polar ice and hunt seals - for decades, the Inuit hardly ever encountered polar bears. But these days they've become dangerous nuisance in villages. Scientists predict that two-thirds of the polar bears will be gone by 2050 due to rapidly melting sea ice. Concerned about their plight, conservation groups have taken them on as cause. Coca-Cola has made the polar bear a mascot as friendly-looking as Winnie-The-Pooh.

Polar Bear
by Louis Agassiz Fuertes (1920) (via Wikicommons, Public Domain).

In March, polar bear trade will be a subject of the 40th anniversary Convention of International Trade in Endangered Species of Wild Fauna and Flora (CITES). Scientists in the U.S., Russia and other countries argue the polar bear (Ursus maritimus) should be up-listed as "threatened to extinction", which would impose greater restrictions on trade. But the proposal has its opponents. Once the inconspicuous lone hunter roaming vast stretches of the deserted Arctic, the polar bear is now swept up in world politics.

In our last two posts, we compared the Inuit nations' acceptance of climate change to the attitude of North Carolinians in the United States. The state's leaders dogmatically deny science, then depend on federal and state money and technology to help them recover quickly after frequent hurricanes. The Inuit, on the other hand, can't order-up big Arctic snow-makers and magical Zambonis to build-up and resurface collapsing tundra. They've long been adapting to environmental changes, from DDT in their food sources to the effects of climate change that cause ice and fish and elk and berries to disappear before their eyes. Unlike U.S. politicians, the Inuit joined scientists in force last year to urge stricter carbon emission regimes at the Doha talks.

The Inuit refer to anyone south of the Arctic as a Southerner, as in: "Southerners tell us our food has mercury, slow down eating it... If our food is contaminated we will be affected, but we have little choice." To them, North Carolinians are southerners, most scientists are southerners, and in fact we're all southerners. Imploring us to change our carbon emitting ways, they'll say: "We cannot exist purely by making money, if we do not have our environment we do not survive..."

Southerners' Impositions

But it's not as it appears, a fairy tale about the wisdom of the doomed natives versus the cavalier ignorance of southerners, strip-mall blazing our carbon emitting ways across earth. As we pointed out about the Tuvulans in a climate change story years ago, it's never so simple. It's true, North Carolinans ask Congress to roll back the law that says buildings erected on beaches can't be covered by federal insurance; and it's true that the Inuit sometimes agree with scientists. But ask the Inuit about the polar bears.

Actually you don't have to, the Inuit will tell you. For background, in 2008 The US Fish and Wildlife Service put the polar bear on the Endangered Species list as a "threatened species" based on studies of polar bear population counts and rapidly melting Arctic ice. But the Inuit consider themselves custodians of the polar bears. Part of their heritage, the bears also feature in lucrative hunting businesses. The Inuit reject scientists' predictions of the polar demise. "Southerners often have a narrow perspective, based only on studies..", one man said. Others say the polar bears are endangered by the scientists themselves:

• "It's Southerners, meddling with caribou, polar bears and whales that endangers animals. This handling and tagging is what harms animals. Wildlife biologist are the ones endangering wildlife."
• "The bears are entering our communities because they can't hear. Helicopters are damaging their hearing and now they hunt by smell alone. That draws them into our villages."
• "Bears that are tampered with and handled or tagged will act aggressively, break into cabins and destroy snowmobiles."

Hungry Polar Bears

Males polar bears weigh 1,000 - 1,700 pounds (250-771 kg), so encounters in villages can be frightening. One man out on his snowmobile checking his fox traps one day, when, as it seemed: "a snowdrift alongside the trail reared up and became a large polar bear...". The bears will stalk children and kill sled dogs. Residents of Hall Beach, Nunavut, Canada grapple with this problem on a daily basis, as a local paper recently reported. The mayor explained that bears wander hungrily into towns when they smell walrus meat stored underground to age and ferment. After reading the article, citizens from other Inuit towns wrote in offering suggestions like building community storage lockers. One commented: "We are seeing bears everyday here also (Arviat). Lots of bear patrol and lots of rubber bullets. Put your meat caches away, pick up the seals from your yard. The bears will eventually move on."

Polar Bear Warning, Longyearbyen, Norway, via Wikicommons.

So while some Inuit blame the scientists for the disappearing bears, the presence of all the marauding bears has other Inuit doubting the scientists about polar bear population decreases.

In their insistence that polar bear populations are healthy, the Inuit are joined by people who don't accept the science on climate change. Denying the polar bear is in danger goes hand in hand with denying climate change, as in, the ice is not melting therefore the polar bears are not disappearing, or vice versa. Frequently, they'll say that populations have increased since the 1950's or 60's or 70's'. But scientists point out that polar bear counts back then were unreliable and that laws curtailing hunting helped sustain populations. In addition to making up their own polar bear counts based on mythical estimations of previous counts, they make up other "science" too. The say the polar bear will adapt, for instance, as if adapting was more like shedding a sweater than evolving over thousands of years.

It's fair to say that getting accurate counts of bears is challenging. The same features that allow bears to sneak up on seals and lunge at unsuspecting snowmobile riders also make them difficult to count by some methods. Last year the Nunavut government did an aerial survey that many claimed showed bear populations growing, and the Nunavut government also increased their hunting quotas. But they used different survey method from previous surveys, so no comparison could be made. Further adding to the complexity of it all there are 19 subpopulations of polar bears in five nations, not all equally imperiled.

Regardless, scientists don't disagree about the species' fate. Ice that's disappearing faster than scientists predicted means that climate change will catch up with today's already shrinking polar bear populations. Scientists estimate that there are about 20,000 bears left. Each year about 600 are hunted by the Inuit in addition to what's taken by poachers.

Polar Bear Economics

With predictions that two-thirds of the population will be gone by mid-century, prices for polar bear hides have skyrocketed. Of course, as demand increases and supply decreases, the Inuit see opportunity.

In their quest to deal with the polar bears on their own terms, the Inuit have found some odd bedfellows, as people usually do in these situations. For example in Alaska U.S., when the U.S. Fish and Wildlife Service designated 187,000 square miles of land as protected critical habitat for polar bears, Alaska's native groups (not Inuit) joined oil and gas interests and the State of Alaska and successfully sued to stop the plan.

As for the Inuit, to protect their hunting interests, they vehemently oppose up-listing the bear in the CITES regime, contrary to what his recommended by the U.S., Russia, and other countries. They say: "the Inuit have been directly witnessing the effects of climate change in the Arctic...and are observing more Polar Bears than ever before..." Scientists dire predictions about polar bears, they say, are "claims not based on reality and fact but on misinformation and fear mongering." Joining them, the World Wildlife Fund doesn't support the CITES ban, calling it a distraction from the main goal of mitigating climate change.

In addition to protecting their hunting businesses their also trying to keep hungry bears out of their villages, with the help of some big companies. The town of Arviat, Nunavat (pop. 2,800) has built a fairly elaborate system for bear control. Electric fences help keep bears out of places like dumps and chained sled dog areas. The town pays someone to ride around the perimeter from October to December on an ATV from 12AM to 8AM every day to chase away polar bears. The program is a World Wildlife Fund initiative funded by Coca-Cola. The company has put millions of dollars into various polar bear conservation initiatives. So when it comes to climate science and economic self-interest, do the northerners and southerners have more in common then they would think?

Part II of "Do The Inuit Know Something That North Carolinians Don't?"

In a previous post, we contrasted North Carolina's leaders' silencing of climate science in favor of coastal development, to the adaptations of the Inuit, who are dealing with scarcer food, weakening tundra that makes hunting treacherous, and melting moraines crashing through their towns. Of course this climate change narrative is a bit simplistic, so it's informative to look a little more closely at some of the communities involved. Compared to the Inuit, North Carolinians have the resources to ameliorate the harsh consequences of storms, which are becoming increasingly common and ferocious with climate change. But it wasn't always that way.

Boat On The Tracks ( NJ Transit).

In August of 1893, back when storms were referred to by numbers, that year's "Hurricane 2" struck the South Carolina coast. Raking over the barrier islands, it moved on through North Carolina before heading up the East coast. In South Carolina, at least 2,000 people died, more than 30,000 homes were lost, and hundreds of thousands were left homeless, displaced, starving, and sick. There was no such thing as "disaster relief", so help was not on the way. The impoverished post-bellum nation couldn't help the Sea Island settlers, mostly poor African-Americans. Finally in October, Clara Barton stepped in with her newly founded Red Cross and began a ten month relief effort -- fledgling compared to what we think of disaster relief today. The economic impact on the islands and coastal region from what's now called the Sea Islands Hurricane lasted decades.

Now, over a century later, economics demands that communities recover more quickly than in Clara Barton's day. Our ability to predict storms, mop-up, and rebuild has vastly improved. Necessarily so, as storm after storm hammers the East Coast, eroding beaches, carving out new water inlets, and smashing man-made structures to bits. We efficiently patch things back up and continue on as we were. Devastated coastal communities assume large-scale aid of the sort that only organizations like the Federal Emergency Management Agency (FEMA) can provide.

Topsail Island, North Carolina

Among the increasing hazards of climate change in the US, scientists predict more storms and rising sea levels. Since the US has 95,000 miles of coastline, their predictions demand attention. However, some businesses and states like North Carolina insist that global warming doesn't exist. They deny rising seas and carbon emissions, then act as if emissions don't need to be curbed, as if storms aren't perilous. They march forward, business as usual. This denial obviously helps the auto and energy industries, and perhaps less obviously, tourism and housing development.

North Carolina has the sixth largest coastline in the US, a boon for development and tourism but a total bust in storms. Barrier islands like Topsail Island are particularly vulnerable. Until the mid-20th century the island was basically uninhabited, used for years to graze herd animals, then as a military missile practice zone before being turned over for private development in the mid-20th century. A burgeoning tourist industry now brags that it's a relaxing island with an exciting past. Supposedly it was named "Topsail Island" because once upon a time the topsails of pirate vessels could be seen from the beaches. But these myths of past excitement probably pale to the future excitement that's in store for Topsail Island.

Since the 1980's, people have accelerated building and rebuilding of homes and businesses despite all evidence that if the storms had their way the island might just wash away. During Hurricane Irene, Topsail Island lost a third of its beach area. While it's a popular tourist destination, it's now also a poster-child for disasters and costly beach redevelopment, and even a field-trip destination for college biology classes studying the results of perennial beach erosion and reconstruction. Beach owners in the most exposed town, North Topsail Beach, lose 2-3 feet of beach per year and scientists have dubbed the town "the most hazardous [community] on the East coast" because of its precarious geography.

Beach Renourishment - Costly...Futile?

As we all know given the recent battles over Superstorm Sandy aid, storms are costly. In 1989 Hurricane Hugo cost the U.S. ~$5.1 billion. Hurricane Floyd cost $4.5 billion, Tropical Storm Irene: $16.6 billion, and Superstorm Sandy is predicted to cost over $50 billion dollars. In 1996 Hurricanes Betsey, Bertha, and Fran made landfall on the North Carolina Coast and did so much damage to Topsail Island that the state considered banning construction, and one senator said that the town of North Topsail Beach should have never been more than a state park. Lucky for residents, perhaps, FEMA produced $14 million dollars of funding for federal projects, $6 million to areas that were technically not supposed to get federal money. In 1997, 217 properties on Topsail Island had been built 2 or more times, at a cost to the federal government of $!0.9 million.¹

Keeping sand underneath the East coast communities is increasingly challenging and expensive. North Carolina doesn't use seawalls and jetties, which scientists show excacerbate erosion problems. When beach is lost to erosion, engineers build the ground back up with vegetation, and berms and beach "renourishment" using dredged material or imported sand. The erosion and shifting sands from storms also cause waterways and inlets to "migrate", sometimes by miles.

Topsail Island Overwash, Hurricane Fran 1996. (USGS).

So after the power has been restored, the dead counted, the injured hospitalized; after shelter has been found for displaced people, and destroyed roads and homes have been rebuilt, engineers must also reconstruct dunes and beaches, and redredge wayward inlets and waterways.

In November, 2012, the town of North Topsail Beach began to dredge an inlet channel that had migrated and filled-in to the point that the Coast Guard deemed it unsafe for boats. The construction project will also renourish some of the disastrously eroded beaches, where some condominiums are currently being prevented from washing out to sea by huge sandbags. The cost of renourishing about two miles of beach is ~$9 million. The long-term project will take place over the next few decades, funded with over a billion dollars of federal, state and local funding, and a multi-million dollar bond issued by North Topsail Beach.

The "Most Hazardous" Town on The East Coast Implores Congress to Say It's Not So Hazardous

Funding for such large projects is always controversial. Of course if you have a house in the town of North Topsail Beach, say, you want to protect your investment and keep your costs down -- if you live on the beach. But citizens of North Topsail Beach who live inland don't think they should have to pay for projects that will benefit only beach dwellers. North Carolinians who don't live on Topsail Island complain that their tax dollars are going to island towns whose citizens pay low taxes.

Nationally of course, people are increasingly disturbed about the amount of money FEMA spends bailing out storm soaked communities. However, the leaders of the town of North Topsail Beach (NTB) still don't think the government is doing enough.

On their website, the town recently posted a sample letter for residents to send to their congresspeople. The letter urged Congress to pass two bills on in the House of Representatives, H.R. 4311, and one in the Senate, S. 3561, that would overwrite the intent of a decades old Federal Act that minimizes development in vulnerable coastal areas.

The bills refer to a Republican sponsored act authorizing Congress to establish the Coastal Barrier Resources Act (COBRA), signed by President Ronald Reagan in 1982. The aim was to identify uninhabited land that was ecologically vulnerable and prone to damage by natural disasters. The act barred structures built after 1983 from participating in the National Flood Insurance Program. COBRA helps protect potential home buyers from purchasing home that would be destroyed in a storm, and also protects taxpayers from footing the bill for costly recovery costs after inevitable storms destroy vulnerable coastal areas.

Parts of Topsail Island were designated COBRA zones, including most of the town of North Topsail Beach. Despite the designation, the town continued its development. North Topsail Beach now claims that the government "erroneously" designated it environmentally precarious. The proposed laws would free parts of the town from the COBRA designation. Because of "this mistake" the letter complains:

"instead of paying nearly $1,400 on an annual basis for an average home worth $250,000, [homeowners] pay close to $10,000 for coverage in the private market. Tourists considering purchasing or renting vacation property in our Town shy away from doing so as a result of the stigma associated with high mortgage rates and the false belief in a higher flood risk in the area.

Reading the comment threads with titles like "Topsail Beach Erosion" on popular tourist sites, I'm convinced visitors don't harbor "false beliefs", they actually see the erosion. For years, similar U.S. Senate and House bills, all requesting that the town's maps be redrawn, have been proposed. The site GovTrack.com gave S.3561 a "1% chance of being enacted", and when the 112th session of Congress concluded, both of these bills died, as they have in previous years. So maybe the soft target of the letter is potential buyers or current homeowners clinging to hope that the erosion is a figment of everyone's imagination?

In the meantime, the very expensive dredging and renourishment projects continue, so if you're interested, there are lots of island properties for sale. Caveat Emptor.

¹America's Most Vulnerable Communities edited by Joseph T. Kelley, Orrin H. Pilkey, and J. Andrew G. Cooper (2009) American Geological Society of America (GSA). Boulder, Colorado.

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Acronym Required has written on Climate Change before. Here's a sampling of articles:

"FEMA, Storms Ahead?"

On Climate Change denial: Sea Change or Littoral Disaster

"NRDC Founder on Why the US Fails to Take Action on Climate Change."

Denial Will Live On During Climate Change, But the River May Not."

Business and Climate Change: "Carbon Emissions Disclosure Project"

Ice core research to study atmospheric conditions 650,000 years ago: "Holocene Days"

Politics and climate change: "Will Loose Lips - Or Global Warming - Sink Ships?".

Carbon emissions regulation after Katrina: "The Environment & Katrina-Slick Oil Fallout"

Drought in the "Amazon", and in "Australia".

Science research communication and climate change: "Research, Politics and Working Less", and "Science Communication".

In Christopher Buckley's 1994 over, Thank You For Smoking spokespeople for the gun, alcohol, and tobacco industries meet-up to commiserate and brainstorm about public relations challenges and strategies. They dub their little group the "M.O.D. Squad" - Merchants of Death. At one of their meetings the three brainstorm about how to deal with the press in the aftermath of a mass shooting in a church. Nick, the novel's protagonist, works for the tobacco industry in a "research" organization, Polly works for alcohol companies, and Bobby Jay Bliss represents the gun industry.

Bobby Jay: To them, my ten-year-old's BB gun is an "assault rifle." He held up his fork. "To them, this could be an 'assault' weapon. What are we going to do, start outlawing forks?"
Nick: "Forks?"
Polly: Forks Don't Kill people, people kill people. I don't know....Needs work.

Later he tells his M.O.D. Squad pals about how he was listening to a talk radio show, when he heard a woman who was at the church call in to say she had a clear shot of the gunman but had to leave her gun in the glove compartment because of the laws. He realized he could use her for some PR and recounts his trip to her home in Carburetor City, Texas with a camera crew.

Bobby Jay: "I had her hairdresser come over. She wanted to do her makeup but I wouldn't hear of it. I wanted her eyes red from crying. We dabbed a little onion under the eyelids, nothing wrong with that, just to get her in the mood, get those ducts opened up"
Nick: "Onion?"
Bobby Jay: "Didn't even need it. Soon as she saw those color police photos I was holding up for her off camera she started bawlin' like a baby...she gets to the part about how she had to leave her pistol in the glove compartment. Then she looks right into the camera, right in your face, and dabs the corner of her eye -- and that was not in the script -- and says, 'Why won't our elected lawmakers just let us protect ourselves? Is that too much to ask?'"

He tells how he used the footage to dramatize a story about Second Amendment rights and combat calls for gun control. In the novel, the piece was used to urge citizens to call their congressmen. All total fiction.

Gun Control - Can We?

2012 has been another year of gun killings, the latest being the mass murder at the Sandy Hook school in Newtown, Connecticut. After each mass shooting, gun control is discussed for a while, before anger and anguish peter out. As we write, just days after the tragedy, Senator Feinstein has vowed to renew assault weapons legislation. Will we actually do something this time?

If you look at people's interest via the program Google Trends¹, just as a rough proxy, it doesn't look optimistic. On July 20th, a gunman in Aurora, Colorado killed 12 and injured 58 in a movie theater, and on July 21st, the day after the shooting, "gun control" searches peaked. They also increased after the Oak Creek, Minnesota Sikh Temple shooting (6 people killed and 3 injured) on August 5th, and after the Empire State Building shooting August 24, 2012 (2 people killed and 9 injured). But nothing ever happened. Politicians mourned before cameras, tipping their heads to wipe a tear off their cheeks, then did nothing.

Google Trends shows the relative frequency of one or more search terms¹.
The graph shows the frequency of the term "gun control" in the US for July and August, 2012. (Google)

Of course, in addition to these mass murders, there's the baseline murder rate, the quotidian murders of bystanders, husbands, wives, girlfriends and boyfriends, mothers and fathers - thousands of deaths. Chicago had almost 500 murders this year, roughly half the murders of 20 years ago, but much higher than last year despite the 10% lower overall crime rate. Like Newtown, Connecticut, Chicago has struggled to get guns off the streets, and every attempt, from banning handguns and shooting galleries to disallowing concealed handguns, has been fought by gun owners and lobbies, often successfully.

Cord Jefferson described Chicago's struggle with gun violence last summer, and Marc Lamont Hill discussed the multifaceted nature of the problem here at HuffPost. Both suggested that there's a lack of attention to inner city high gun violence because the murders are often associated with black men and gangs. I don't doubt that.

But people's overall attention to gun violence is sporadic, like their attention to climate change. When a hurricane destroys lower Manhattan, do New Yorkers' worry more about climate change than when a hurricane destroys some island in Asia? You bet. What about when familiar, safe-seeming places like movie theaters and schools become frequent targets of mass murderers? Are we more terrorized by deranged people armed with military grade firepower intent on taking out entire pop-corn eating movie audiences than by inner-city murders? Apparently. Then Newtown, Connecticut happens. Who is more innocent and more vulnerable than children, and what place is presumed more safe than a suburban grammar school?

The frequency of the search term "gun control" in the US, 2004 - 2012.(Google)

After a seven year old kid was killed in Chicago last summer, Mayor Rahm Emmanuel warned gangs to "take your stuff to the alley", but "don't touch the children of the city of Chicago, don't get near them". The nation seems to have a similar response to last week's Newtown killings. The Google Trends report for "gun control" after Newtown is off the charts compared to any other gun related incident in Google Trends' 8 year history. The question is, will the concern be sustained enough to force the slower, more tedious task of legislative action?

The frequency of the search terms "gun control" (blue), "climate change" (red), and "kittens"(gold), in the US, 2004-2012 (Google)

Gun control will not solve all the violence, all the problems. But it's a start. We can no longer bide politicians who cower before gun money, wantonly abandoning constituents who then die in deadly fusillades discharged from automatic weapons, or survive traumatically -- the six year old girl who "played dead" under the carnage of her Sandy Hook classmates in Newtown. Journalists should examine their leniency towards the lily-livered politicians who serve up excuses for action.

The challenge will be that we're so easily distracted, and gun makers, lobbyists and politicians bank heavily on our fleeting interest. The trends work in their favor. Distractions come as competing headlines, cute kittens, and as heartfelt, canny, or vicious arguments from people who support unlimited lethal power. We get a barrage of confusing information, some of it deliberately misleading - various headlines yelling that the root cause is violence in the media, or mental illness, or misinterpretation of the Second Amendment, or that the problem is too multi-faceted and big to tackle, that laws don't/won't work, well they work but Australia is different, the NRA wields too much power...All of this mutes resolve.

But when little boys are offering to lead classmates out of a school besieged by gunfire because they "know karate", we must do more than wax eloquently about our seven-year old heroes. Can politicians be courageous? Can they be heroes? Or do we have to go to historical movies like "Lincoln" to see that? Can citizens and journalists muster the guts to hold our politicians the slightest bit accountable for our reasonable safety?

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¹ Google Trends has been used to make predictions about disease outbreaks, here are some studies. The program has improved significantly since we last looked. Of course it has also been mocked.

Part I: Our Way of Life

When scientists predicted that the sea-level would rise 39 inches along the East Coast by 2100, North Carolina lawmakers promptly drafted legislation instructing state coastal development planners to ignore that science. The legislators said climate change was a "phobia" of scientists that would "quite frankly kill development on the coast". As one lawmaker put it, "nothing proved to me that they can prove those astronomical sea-level rises".

The audacious denial of science caused an uproar from aghast researchers and citizens. So North Carolina lawmakers revised the bill slightly, asking for further study, very slow study, with a report due in 2015. In 2016 they will consider the report, and until then North Carolina towns can act as if there's no tomorrow, as if the seas aren't rising. North Carolina Governor Bev Perdue commented that she thought each town should be free to draw from their own science studies. She allowed the new law, AB 819, to pass without her signature.

This year scientists also studied the effects of climate change in two vast Inuit regions, Nunavik, in northern Quebec, and Nunatsiavut, in Newfoundland and Labrador. They published their findings in a 300 page report: "Time For Action To Deal With Climate Change In Nunavik and Nunatsiavut". The report, aimed at Inuit policy makers and citizens, was featured in the region's Nunatsiaq News, where the summary of findings and recommendations filled the entire front page of its online edition.

Inuit Regions Map (by Statistics, Canada 2007 w/ permission)

The Inuit Way Of Life

The Inuit seem to take a different approach to dealing with climate change than the North Carolinians - for one, they don't doubt it. The report describes how scientists work with Inuit of all ages to exchange knowledge and plan for climate change, although for years, while other nations argued the reality of global warming, the Inuit were busy adapting, because they had to.

They've been living through global warming changes since the 1990s, so the results of climate change are a fact of life. Spring arrives earlier each year, fall later. Berries that the Inuit harvest are being crowded out by other shrubbery. Caribou herds shrink as the once abundant animals migrate north or starve. Glaciers have lost significant mass, and the ice that the Inuit traveled over safely for generations is melting in unexpected places, sometimes killing unsuspecting hunters. The Inuit believe the climate scientists' predictions, that precipitation will increase 10-25% and temperatures will rise of 3-4 degrees Celsius.

Perma...frost

For generations, the Inuit hunted and fished - caribou, seal, Arctic Charr, narwhal, and game birds. Children were taught to read and understand the clouds, the snow, the ice floes, the glaciers, and the animals. Through to the mid-20th century, the Inuit were nomadic, as this 1959 piece dryly depicts, and as one man recounts in the film "Inuit Knowledge and Climate Change": "As we were traveling my mother went into labor, and my father quickly built an igloo...that was the way of life".

Their way of life changed in the mid-20th century, when they established permanent communities. They still hunt, know their ice floes and live close to the environment, but they're no longer nomads, building igloos of frozen snow blocks in the winter and erecting tents in the summer. Instead they build homes in towns, often on permafrost. Permafrost was once a sound foundation, but it's now affected by climate change, as residents of Pangnirtung, Nunavut were abruptly reminded one spring.

A river runs through Pangnirtung, and one morning residents awoke to thunderous rushing water that tossed boulders ahead of it, raucously carving channels through the permafrost down to bedrock, causing river banks to cave in, and taking out two bridges that connected the town. As one person described the chaos:

"Every single night there was a new event. There was a new crack opening, stuff collapsing. It was amazing to see, just fascinating. It looked like an earthquake. There were a lot of elders down there, and they were really upset. There is a lot of history in pieces of the river for them. They would clean sealskins there and polar bear skins, and they would remember people being at those places, and those places don't exist anymore. There were elders in tears."

Kids in Pangnirtung wrote about that event, the melting glaciers, the falling bridges, the sewage that had to be dumped into the ocean.... The kids don't wonder why it happened, don't ask whether this particular event is from global warming, they write: "This is what happened in Pangnirtung...because of climate change. We really need to stop what we are doing to this planet."

The Royal We...Who Suck It Up

In the US, climate change seemed to sneak up on us more slowly. Many people live and work inside and only glance occasionally at the weather out their windows. We've always had storms, so it was hard to say whether any one was a harbinger of climate change or not. Hurricane Andrew in 1992? Hurricane Katrina 2005? Irene, 2011? Sandy, 2012? The fires in the West, the floods in the Midwest, the tornadoes in the Southeast?

Mother with Baby Carriage
Cape Dorset (2002) by Ansgar Walk (WikiMedia Commons)

Although we've had plenty of warnings from scientists as well as obvious weather changes and events, the US has been disastrously slow in acknowledging climate change. Maybe this is why the extreme weather of the past few years has seemed abrupt and shocking to citizens as well as to politicians surveying the damage with pathos. When North Carolina was hit by 92 tornadoes one Saturday afternoon in April, 2011, devastating towns and communities, Governor Bev Perdue told the New York Times that she was "nearly in tears touring damaged areas".

Legislators like those who lead North Carolina argue their right to ignore science. They help constituents ignore science too, by facilitating efficient mop-up and rebuilding in the wake of ever more severe disasters. After the tornadoes Governor Perdue assured people via the New York Times that, "she had been in contact with President Obama and anticipated that a federal state of emergency would be declared by week's end"...and had also "met with the director of the Federal Emergency Management Agency (FEMA)..." Many farmers lost their crops and machinery and buildings and may not have had insurance; many families' lost their homes when tornadoes blew them to bits. But North Carolinians were stoic, Perdue said: "We understand how to face adversity and suck it up".

The Inuit may be in an even more precarious position, sucking-it-up-wise, than North Carolinians. As one Inuit said: "We cannot exist purely by making money, if we do not have our environment we do not survive...." The Inuit cannot control the carbon emissions of Canada and the US, or those of burgeoning emitters like China. They must muster whatever mitigation measures they can, such as those suggested in one government pamphlet: "The Homeowner's Guide to Permafrost".

They can also cajole and plead, as they did at Doha, for reduced carbon emissions and compensation from emitters to help with mitigation. Inuit leader Mary Simon has said: "If we think small, our actions will be small, like decisions made by children. But now, our world has to think like adults. We must act more intelligently. Our world leaders must do the same."

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(To Be Continued...)

Today is 25th World AIDS Day, so more people than usual spent time last week reading about the world's progress conquering AIDS. In good news, deaths from AIDS have declined. In Sub-Saharan Africa they have declined by 32% in the last 5 years, continuing an excellent trend. But how do we perceive the progress? We wrote on World AIDS Day, 2009 about how Google tried to correct our search "HIV infections decrease", to "HIV infections increase".

The first search phrase, ending with "decrease", yielded only 1,940,000 results in .22 seconds, whereas the second, ending with "increase", gave 3,550,000 results in .18 seconds.

If Google was tracking a trend, they were wrong, because by 2009 HIV infections had decreased by 15% in 10 years. But we in the world were very accustomed to bad news about HIV infections and AIDS, as Google documented. Today, three years later, there's even better news for HIV/AIDS - on the drug development front, as well as on detection, treatment, and prevention fronts. That was an example in 2009 of how false bad news overwhelmed positive news (via a Google algorithm)

Today, the bad news is that people still die of AIDS all over the world - in Russia, China, Asia, Africa, and the US, where public health officials recently recommended that people ages 15-64 be tested for HIV. African countries, especially in Sub-Saharan countries, still have the most cases of HIV infected people, and many of people aren't being treated for what is basically affordably treatable. But how should we talk about this bad news? That is the subject of this post.

But the Bad News, How Shall We Put It? Shalll We Ignore It?

In the past few years an interesting conflict has arisen about news in Africa. Critics complain that Western media can't take its eyes off the cliched, ailing, and violent aspects of the African continent, thus giving an inaccurate, un-nuanced and harmful view of its many countries. Nicholas Kristof is a popular target.

The group Radi-Aid released a parody video urging Africans to give money to send radiators to Norway ("frostbite kills too"). Produced by Norwegian students, it mocks this so-called "poverty porn" in the style of the 1984 Band-Aid fund raiser. It's a charming video and relays a potent message. But realize that the Radi-Aid video mocks something that's 25 years old - as in, what can't you mock from 1984?

But beside that minor quibble, of course, I see their point, I think anyone can. If you've ever traveled, you've probably run into inaccurate media portrayals of your country that are just crazy. I remember reading an English paper in Asia that had only bizarre stories about the US, things like - Woman in Tennessee Found Herself In Closet Stomping Beetles. What? You had no idea where they found it -- could they have just made it up? Based on American TV shows, little kids would ask me if I ever got shot in a gunfight - NOO?

Cultural misconceptions are legion and universally perpetuated. I'm sure small towns in the Mid-West that occasionally get besieged by floods and tornadoes feel betrayed by the mainstream media too - Hey wait! we have great potlucks here and there's the most amazing other stuff too! New Orleans must have felt that way during and after Katrina. C'mon! Shot after shot of all those people in the stadium? It's not only Africa that's the subject of inaccurate, negative media portrayals, it's every other country, town and borough, and all subjects too - science, math, economics, election polling, women...they all have their bad day via the media and press.

Aid Solicitations, In the Eyes of The Beholder?

For African countries, a lot of so-called poverty-porn starts with international non-governmental organizations (INGOs). INGOs do use sympathy for fund-raising -- large-eyed children dragging teddy bears, or gathered around looking up at the camera pathetically, or forlorn in barren, monochromatic surroundings. To me it gets a little gross, but they use what works, what gets people to reach into their pockets and give money. These images get picked up or pushed upon the media and used as news. Here's a clear example of how deceptive this imagery can be. But these stories don't comprise all the news of any country.

Some commentators have pointed to what they say are "better" portrayals of Africa that could be used to fundraise. In one, a cute kid in a video acts out an Arnold Schwarzenegger movie, interspersed with the movie's gunfight where "2000" people get killed. The video describes him as smart and articulate, without mentioning or questioning as far as I could tell the especially violent part of American culture that the ~5 year old is copying so very, very accurately. So clearly, different people find different solicitations using kids appealing. Some people take offense to a small child holding a bowl up, but have no problem with a small child acting out extreme violence with a pretend gun followed by a plea for donations. Personally, I have as much problem with the second as the first, and would also ask while we're at it -- shouldn't we question the ethics of using a child for fund-raising at all? Or is it ok as long as the child is wearing a shirt and not holding a bowl? (Then there are whole factions of international development that abhor aid altogether and they also have some good points that I'm not going to talk about here.)

Maybe News About Malaria Shouldn't Focus on Africa, Where 90% of All Cases Occur?

To their point, many other countries, India, the US, China, have crushing poverty, but aren't necessarily defined by it, as critics claim Africa is by Western media. That may be true, but when it comes to preventable infectious disease, 99% of people who die from AIDS, malaria, and tuberculosis (TB) live in the developing world, and the center of the HIV/AIDS epidemic is still in sub-Saharan Africa, where 70% of all new infections among adults and 91% of new infections among children occur. Malaria kills about 780,000 people each year, and 90% of malaria cases are in Africa.

Such illness and death devastate families, workers, and economies. When mining companies in South Africa started treating workers for AIDS and malaria, they had a business goal, stop lost productivity. Similarly, in our global economy, Asia's and Africa's problems and successes affect the world. That means that how African nations attend to public health influences our own public health and impacts our companies that invest in Africa.

Reporting on Africa is not just about Africa, it's about us in the West too. Reporting is not a selfless endeavor. We absolutely should be reporting on Africa's "bad" news (not exclusively of course). Our public health problems (e.g. infectious disease, antibiotic resistance) derive from and are dependent on not only our own public health systems, but also those of developing nations. Our health depends on the policies, laws and regulations all nations produce and uphold for preventing and treating disease, and for drugs and pharmaceutical companies.

We understand that Africa knows investors want stable countries to invest in. African nations naturally want to discourage negative foreign media. But is it the job of responsible media to protect the image of nations? Or is it the job of responsible media, say American or European media, to report on issues that might impact (or interest) its citizens - like public health environments in countries like Africa or Asia or wherever that might promote pharmaceutical regimes that foster antibiotic resistance for instance, or public health environments that allow pandemics to spread for example?

Progress of International Development

For close to a century, international development has sought to raise basic standard of living the world over, not just Africa, but South America, Asia, Central America and parts of North America. Driven by various agendas and business interests and research, we've compiled a long history of what has worked and not worked. For many reasons, what seemed to work in Asia, South America, Central America, etc. didn't work well in Africa. In addition, various national tragedies bogged down progress there. No sooner was apartheid defeated in South Africa, for instance, then AIDS struck. Journalists weren't wrong to cover these events.

Journalists reporting these stories have also sometimes brought needed attention that often benefits the subjects. For instance media outlets reported on the 39 pharmaceutical countries that sued South Africa when it tried to import affordable AIDS drugs at the height of the AIDS epidemic. The companies eventually dropped the suit. When President Mbeki refused to acknowledge that HIV caused AIDS, the media was there. The media now has more opportunity to report positive AIDS news.

Prosperity To Spare

Recent prosperity in the west gave people the means to donate money and ideas for aid organizations. Take the Gates Foundation, founded in 1994. This 2001 Seattle Post Intelligencer article writes about how Bill Gates started slowly learning about international development and health needs in 1998:

"I had no idea," the Microsoft co-founder said. "I learned a lot about the whole vaccine miracle, about how effective they are and yet millions were still dying from these diseases.

"So we decided, jeez, the impact we could have by getting vaccines to these children and getting more funding for research into new vaccines could be just incredible."

That was only about fifteen years ago. A world business leader "had no idea" about preventable diseases in Africa. It's easy not to realize how many advances have been made in the past few decades, in part because what was unheard of in 2000 has now became common knowledge to everyone. Globalization of business has brought increasing attention to development issues that are no longer "a world away". But make not mistake, most of these ideas have been around for decades, like the fact that women's education is key to development. Vaccines have long been (albeit controversially) considered the ideal solution to diseases.

What's new is that foundations like the Gates Foundation are increasingly media savvy, and the media is increasingly in tune with the goals of development. This environment made it possible for Kristof to start writing what he did, and in many ways his articles were in synch with US development goals and rhetoric. (Part of the rational for invading Afghanistan, for instance was women's education.) But many of the most popular articles, for instance Kristof's, also opened readers' eyes to both positive as well as alarming stories outside of their mostly elite, privileged self-indulgent New York Times world view. Not a bad thing. Increasingly, global connections have eased people's ability to travel to different countries, increased curiosity about different cultures, and along with that, encouraged inclinations to want to help (I'm not going to argue whether the burgeoning aid industry is good or bad, but some of the 'wanting to help' inclinations, are selfless).

So Does Media Portray Africa Too Negatively?

A recent BBC program asked the question at a conference in Kampala, Uganda: Is media propagating negative stereotypes of Africa? The opinions were very interesting, ranging from a couple of people who that said African leaders themselves inflate problems in order to get foreign aid, to those who said that Africa was seen not as a problem but as an investment opportunity for many countries.

Of course there should be positive stories about African countries. But don't ignore the good that comes publicizing problems. While South Africa struggled with its AIDS crisis with the world advocating for its citizens, countries like China for years suppressed news of its AIDS epidemic. Other alternatives exist also, reporters and columnists who ignore and glaze over tragedy, and focus only on business that privileges the elite, and ignore those who are not in the elite. You can find those stories anywhere, if you would prefer them.

Last Thanksgiving we stumbled upon a cache of recipes politicians had submitted to the public over the years, hundreds!- quite a collection. Some were odd - "BrainsNGravy", some rich - "Chocolate Mousse", or even uninspiring - "Microwave Chicken". We commented on the penchant of member of Congress, governors, presidents, for publishing people pleasing pot-luck recipes in the face of pressing national challenges.

White House Beers
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We therefore couldn't let the holiday pass without noting the Obama family recipes popularized this year. In the Family Circle's Presidential Bake-off (a dustbin worthy mid-century tradition if there ever was one), Michelle's chocolate chip cookie recipe won a few hundred more votes than Ann Romney's M&M/peanut butter cookies. Some people excitedly noted that the bake-off winner ended up in the White House in the last four of the last five elections, popular speculation even though I'd rate it a middling B-...we ALL know that there are more accurate ways of predicting these things.¹

Home Brewers - A More Powerful Voice Then You'd Have Thought?

That fanfare was nothing compared to the excitement over the White House Beer recipes that I somehow missed last summer because the European media was more worried about the plight of Greece, and Fran�ois Hollande's ideas for taxing the rich. Apparently American home brewers submitted a Freedom Of Information Act (FOIA) for the recipe, because it was so important, and more brewers started a "We The People Petition" request for the recipe on the White House website. Unlike the hundreds of unanswered FOIA requests, and before the petition even reached the needed 25,000 signatures ², the White House published recipes for two of the three brews, an ale and a porter. They even made a very slick YouTube video explaining the whole process, part of the Inside The White House series.

A writer at the Boston Globe brewed the White House Honey Ale and reported that it was an easy recipe to follow and that the ale was "an entirely pleasant drinking experience".

Hush, Hush About the Commoners' Brew?

Beer has a solid place in American history, although a lot of quotes about beer attributed to the likes of Abraham Lincoln and Franklin Roosevelt are made-up. It is true that way back, George Washington brewed beer at Mount Vernon, and Thomas Jefferson brewed beer at Monticello. The White House ale and porter recipes use honey that the chefs get from the White House bee hives. Jefferson's beer had honey too. But the Obamas might be the first ever to brew beer in the White House, despite a long and proud tradition of beer brewing in America.

Why has no one else brewed beer in the White House? I have no idea. Although Prohibition ended in 1933, there has been a raised-eyebrow-view of drinking by White House inhabitants. Even today, there is a disdain for the type of relaxation common to everyone coming home after a long day at work. As you can see in this hilarious FOX News clip from last summer, where Hilary Clinton is described as "throwing back a beer and tearing up the dance floor at a Colombian salsa bar" by anchor Stuart Varney. Varney interviews Nile Gardner from the Heritage Foundation, who criticizes Clinton for appearing unstatesman-like on "the world stage" and the two bicker collegially about her transgresions in clipped English accents. As anyone would, Varney actually laughs at Gardiner, a British Conservative commentator, and for balance interviews a GOP strategist who tempers Gardner's intolerance, by saying Clinton deserves a beer.

This echoes a prickly uneasiness around drinking that extends back through several White Houses. Maybe it's the culture wars, or the old Protestant work ethic coming back to bite us. Some presidents either couldn't or wouldn't admit to enjoying alcoholic beverages. A few came from families of nightly beer drinkers, which I'll speculate may offer some explanation. Others, like Richard Nixon, couldn't handle alcohol. According to John Haldeman: "Often times, he would rage at his enemies, fancied and real, and imagine various revenges...one beer would transform his normal speech into the rambling elocution of a Bowery wino."³

Then there were the so-called culture wars. We wrote about Reagan's horror over "a dance" with "three bands playing simultaneously", in "Letter From Berkeley, California -- The Cliche". The Bushes also leveraged intolerance to win elections and maintain power; though, if you type in "Bush" and "beer" into Google, the search engine relentlessly auto-corrects to "Busch" (beer) - so that family's liking for beer I can't say. Apparently George W. Bush was a heavy frat drinker, but more recent photographs of him with a beer mug held to his lips tend to mention "non-alcoholic" or "O'Doul's".

Out With Arugula, in With Ale?

So is this all part of an old-fashioned uptight America in it's last throes? Paul Begala, back in January, 2012, wrote that "Romney Would Fail the Presidential Beer Test". Obama socializes easily, he observed, but when "Romney tries to relate to ordinary folks, he looks like a debutante at a cow-chip-tossing contest: he just doesn't fit in, and the harder he tries, the more ridiculous he seems". That, Begala wrote, "could have Republican's crying in their beer come November".

Maybe this whole beer-brewing thing transpired because the Obama team perused Facebook for some arugula antithesis with which to market the president. But scanning the hundreds of recipes in the repository, it's clear anyway, that the Obama White House is the first in a long history of politicians submitting recipes to offer a recipe for beer - or any libation. And even though my taste in beer is about as sophisticated as picking the one with the cool bicycle label on it, I find the White House beer distraction very refreshing.

Cheers! Happy Thanksgiving.

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¹ Regardless of the sound statistical analyses, I'll admit that I too was on the edge of my seat on election night -- and relieved not to have hang a "Despair" poster.

²Very few of these petitions succeed in getting the 25,000 signatures needed to get an official answer, it seems. The White House did answer another We The People Petition requesting that Rush Limbaugh be removed from the military media offerings, but Mr. Limbaugh has his rights, the White House explained.

³ President Nixon's Inner Circle of Advisers Author(s): Betty Glad and Michael W. Link Presidential Studies Quarterly, Vol. 26, No. 1, The Nixon Presidency (Winter, 1996), pp. 13-40

Related readings:

Carter, Paul A.: Prohibition and Democracy: The Noble Experiment Reassessed: The Wisconsin Magazine of History, Vol. 56, No. 3 (Spring, 1973), pp. 189-201

Tim Hefferman: Last Call, plus useful comments.

A few years ago, the FDA mandated tobacco companies put the labels on cigarette boxes warning smokers about the deadly health effects of tobacco. The tobacco companies sued, claiming the FDA was "compelling speech", which was unconstitutional. Last year we checked in with the legal wranglings of the case when one District Court judge ruled that the tobacco companies shouldn't have to display the images or print 1-800-QUIT-NOW on cigarette boxes.

Cigarette Warnings
via the Food and Drug Administration.

The battle over graphic picture tobacco warning labels is actually world-wide and decades old. Tobacco companies fought ferociously against the first country that tried to enforce graphic labels in 1986, fashion-forward Iceland. Today, more over 50 countries require text warnings, and a growing number are moving to picture warnings. Australia passed one of the strictest laws, as Stanton Glantz recently described:

"All the cigarette packages are going to have to be the same kind of puke-green color with the name of the company and the variety on standard type on half the pack, and the other half of the pack will be a large graphic warning label."

Graphic Labels: Nails in The Coffin?

The cigarette companies battle against these labels for a reason. Compared to text warnings, the graphic pictures scare the heck out of smokers research shows, especially people with less education.

However, through the court systems, tobacco companies have successfully bogged down governments' attempts at regulation. In Canada, the Supreme Court last year ruled that Imperial Tobacco couldn't draw the government into a class action case. Imperial had argued that the government shared the health costs of smoking since it had allowed Imperial to market "light" cigarettes. The court dismissed their argument. In Scotland, Imperial Tobacco recently challenged the government ban on displays in shops, claiming that the law is "anti-choice". Scotland's' Supreme Court - Lord Hope, Lord Walker, Lady Hale, Lord Kerr and Lord Sumption, are currently hearing arguments in the case.

In the US, tobacco companies recently asked the Supreme Court to hear their First Amendment arguments after another District Court claimed that the FDA rules were constitutional, the opposite of the previous District Court's decision. The tobacco companies have petitioned the court to decide 1) whether the FDA's label mandate violates the First Amendment 2) if the FDA is stepping on companies' free speech rights to promote "modified risk" products, and 3) whether the companies have a First Amendment right to offer free gifts and samples to entice potential smokers. The FDA has until the end of November to respond, and after that the Supreme Court will decide whether to take the case.

Tobacco: A Dilemma?

Some observers speculate whether the Supreme Court will take the case, but authors of a recent New England Journal of Medicine article think the Supreme Court will hear it. The NEJM article reviews the background of the commercial speech doctrine and the speculates various outcomes for the case.¹ The authors say commercial speech was first recognized as a lower value speech in the mid-1970's. From there, the court has enabled creep that brings the commercial speech doctrine to its current very controversial status, where it can essentially curb states' abilities to candidly warn consumers about about health risks of things like smoking.

Because of the court's commercial speech doctrine, the authors write, the FDA can best frame their arguments for the cigarette warnings as promoting consumer choice, rather than as protecting public health and discouraging smoking. This not only hobbles the FDA's ability to frame and defend their arguments for public health, the authors write, it gives the cigarette companies the advantage in defending themselves because they can argue that the FDA is not trying to promote consumer choice, rather it's attempting to influence the behavior of smokers by browbeating them.

Faced with the science related to tobacco, the health affects of smoking, and the tax burden of health costs shared by all citizens, tobacco's costly legal protests seem crazy. However, the Supreme Court has often sided with corporations, and has been quite skeptical of government regulation. As well, science and economics don't necessarily win the day over "free speech" in US courts. So altogether the FDA's idea that science derived photos inform consumers in ways that are hard to ignore, these arguments may not win. The Supreme Court hasn't seemed particularly swayed by science arguments or sympathetic to public health arguments.

So if the tobacco companies and courts continue to dither over the FDA's graphic warnings, thereby keeping them off the cigarette boxes, maybe journalists can write lots of stories about the controversy and include lots of the graphics that the smokers are missing out on?

¹Ronald Bayer, Ph.D., Lawrence Gostin, J.D., and Daniel Marcus-Toll, M.S.: Repackaging Cigarettes -- Will the Courts Thwart the FDA? November 14, 2012DOI: 10.1056/NEJMp1211522

A malaria vaccine over two decades in the making given to infants in Africa was shown by preliminary data to be 30% effective. Good news or bad news?

It depends on who you talk to. Most scientists and public health workers described the partial phase III clinical trial result of RTS,S/AS01 as disappointing, frustrating, or underwhelming, while trial sponsors, a few scientists, the government of Ghana, and KTN streaming LIVE from Kenya 24/7, remained upbeat, stressing that given the millions of malaria infections, a 30% reduction in would give the vaccine a significant place in malaria prevention.

In 2010 there were an estimated 216 million cases of malaria and 655,000 deaths, 91% of which were in Africa. In the past decade years, the concerted effort to combat malaria has decreased deaths and infections significantly, by 25%. But without a doubt, an effective malaria vaccine would be, if not the end of a horrible scourge, at least be an excellent addition to the arsenal of indoor spraying, bednets, and available treatment options. The question is, given the costs of developing and deploying a vaccine and the current economic climate, what's considered effective?

Rough Waters
via Creative Commons License.

This month's 31% results are disappointing compared to last year's results from older kids, 5-17 months, that showed the vaccine to be 55% effective. As well, the newest results from the Phase III trial, show about half the efficacy of those from the previous Phase II trial for the same-aged infants, which seemed to show the vaccine as 62% protective.

Not 55% but 30% Effective

The RTS,S vaccine targets the Plasmodium falciparum and is made with proteins from both the parasite and Hepatitis B virus that serves to enhance the immune response. So why is the vaccine now apparently only 31% effective at preventing infection and 37% effective at preventing severe disease, almost half what it was? Scientists have several hypotheses. It might be the high levels of malaria around the test centers included in this data release, or that increased immunity from mothers in the younger infants blunts the response of the infants' immune systems against the vaccine, or perhaps since the vaccine for the infants was administered with other vaccines the infant immune systems responded less vigorously to the malaria shot. What there's no question about is how tricky it is to make a vaccine that successfully combats infection from an evolving and evasive parasite that moves through different stages of its lifecycle in different parts of the human (host) body.

With the efficacy data so low, scientists were left emphasizing how safe the vaccine is (important, of course, but not exactly the point at this stage). They stress how successful of the logistically complicated and ambitious trial (across 11 centers in 7 countries). Indeed the trial logistics are impressive, important, and a huge inroad to drug testing and public health, but the accomplishment doesn't address the high expectations and promises made during last year's data release.

Glass Now Less Than Half-Full

While the results were discouraging, some scientists weren't surprised. When researchers announced last year's interim results some scientists predicted based on the data that the younger 6-12 week cohort would be less protected by this vaccine. This was one of several caveats scientists pointed out. They also warned against early incomplete data releases, stressed that the older children weren't the target group, and questioned various aspects of the 55% number. We covered some of these questions in a post -- the same caveats and questions apply to this year's data release.

Vaccine development, especially against malaria, is incredibly difficult. Although there are about 30 vaccines in development now, according to the World Health Organization's Rainbow Tables, the closest candidates are 5-10 years behind this one. This fact of course influences the biggest unanswered question: How effective does a vaccine need to be in order to be put into production? There are limits to both attention and money available for urgent public health initiatives, so realistically, funding one initiative can potentially handicap others - but then the argument always swings back -- there is no malaria vaccine right now.

Vaccine Goals - Made To Be Eschewed?

To help guide answers to this question, the World Health Organization, in concert with invested organizations including the public and private sponsors of this vaccine, established in a roadmap(pdf) a "Strategic Goal" to "by 2025, develop and license a malaria vaccine that has a protective efficacy of more than 80% against clinical disease and lasts longer than four years." RTS,S/ASO1 is no where near this. But the WHO also established a "Landmark" Goal, to "by 2015, develop and license a first-generation malaria vaccine that has a protective efficacy of more than 50% against severe disease and death and lasts longer than one year." WHO is currently in the process of updating the roadmap, but warns that the Landmark goal is not being changed.

All scientists acknowledge that only more data analysis from this trial will provide clearer answers. The WHO provides information on vaccine development and its role in assessing the vaccine in 2014-2015. Some scientists predict that the trend of decreasing efficacy after 6 months shown in the data looks ominous: "The results look bad now, but they will probably be worse later", said vaccine expert, researcher for competing vaccines, and deliverer of not-very-upbeat messages Adrian Hill of Oxford University. (But if subsequent data looked somewhat better - the situation of this year's results compared to last year's - the reaction would probably be euphoric.)

Last year when we discussed the vaccine we commented on possible later outcomes that could stem from the incredible hype around interim results releases -

"...which leads us to wonder whether mid-trial fanfare primes us react to whatever future malaria vaccine news comes along with knee-jerk positive determinism? What if the younger data shows only (say, hypothetically) 30% efficacy? Would we ever abandon the effort...?"

Commenting on the latest results, Andrew Witty, GSK CEO told reporters in a conference call "We've been at this for 30 years, and we're certainly not going to give up now".

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In other malaria vaccine news Sanaria, another malaria vaccine maker whose founders have been knee-deep in malaria vaccines for decades, recently hosted 7th graders in an event hosted by Montgomery County universities. The idea was to introduce kids to science and medicine so they don't think of people who work in biosciences as "crazy scientists", said Stephen L. Hoffman, founder and CEO of the company. Hoffman's latest malaria vaccine effort was profiled by Science in "New Hope for Crazy Vaccine", briefed by us last year. Sanaria received $3 million funding for Phase II trials last summer.

In still more malaria news, a program called the Affordable Medicines Facility - Malaria(AMFm) has been radically downsized, killed, and folded into obscurity within the Global Fund. The reasons remain a little mysterious. By all accounts, the program was successful, even "overwhelmingly successful", in lowering the pharmacy prices of drugs called Artemesin Combination Therapies (ACTs). If you contract malaria in Africa you often need to buy your own drugs. Patients will naturally buy the cheapest drugs, which happen to be those that are least effective or most susceptible to antibiotic resistance. The program made the ACTs competitively priced with monotherapies, therefore competitive in the marketplace and helpful to preventing artemisinin resistance and conquering malaria. The strategy was innovative and effective.

However, some critics claimed that this method wasn't getting the drugs to children, and that some people were buying up the drugs without a diagnosis. Defendants said these criticisms moved the goal posts, phase II could have solved some problems. But more scientists aren't at all sure why the program got cut, some suggesting that for some reason Oxfam and the President's Malaria Initiative lobbied hard against it. One contingent that is probably pleased with the outcome has been lobbying vigorously against AMF-m since its inception. The group's members are variously affiliated with pharmaceutical companies, 'free enterprise think-tanks', and target lobby efforts like "Africa Fighting Malaria", they selflessly devote their lives to promoting DDT spraying, and lobbying against generic drugs. One or more have written accounts claiming that the competitive pricing schemes employed by AMF-m used cheaper drug suppliers with inferior services -- a spurious, tedious and surprisingly effective go-to argument for decades by pharmaceutical companies lobbying against generics for the most deadly diseases AIDS, Malaria, etc.