Something Americans should be proud of

Support for Mubarak aside, our military has played a large role in educating and training the Egyptian military. Now as Mubarak is on the verge of collapse, he is almost certainly trying to order the military to crack down. The Egyptian military has refused to turn its guns on the civilians (thus far).

It would be nice if not massacring civilians was a given, but we've seen that very thing happen time and time again in dictatorships. The professionalism of the Egyptian military reflects well on the US military and the excellent job it has done in training the leaders of Egypt's armies.

The real question is whether or not the civilian leadership will successfully push for free and fair elections. My suspicion is that President Obama will do the right thing and reject the installment of another strongman to replace Mubarak. The Egyptian people need to finally have a chance to attempt to build a democracy.

Amazing how quickly things happen

Mubarak's security forces have withdrawn from the streets and are now surrounding the presidential palace. The army was called in - but is doing nothing, and if anything the soldiers are starting to take part in the protests. The protesters already smell blood metaphorically speaking in the firing of Mubarak's cabinet. They also smell blood literally. When this sort of thing was happening in Iran a couple of years ago, someone pointed out that if the government security forces are going to spill blood, they need to spill a LOT of blood. Only killing a few people just pisses the crowd off even more. Mubarak personally is a more challenging position than the Iranians were though, because Mubarak couldn't just start massacring protesters like the Iranians did without alienating his important Western allies. Its hard for anyone to know, but it seems to me that a threshold of no return has been passed. Now that the security forces are gone, there is nothing to get the crowds off of the streets. At this point I can't see how Mubarak does not fall.

Vice President Fail

Honest to goodness, what a jackass:

"I would not refer to him [Mubarak] as a dictator."

This brings me back to my go-to axiom of American foreign policy: whatever Joe Biden says, take the exact opposite and that is probably best.

I know that Egypt has been an important American ally, because we have to deal with the world as it is. That means cozying up to some less than scrupulous characters from time to time (actually, on a pretty regular basis). Nevertheless, Mubarak is certainly a dictator, and his policies are almost certainly not good for the Egyptian people. If Biden didn't want to throw Mubarak under the bus outright, he could have just declined to answer the question: "I'm going to let the Egyptians deal with their own internal affairs" would have been a sufficient response.

Egypt has been especially important as it relates to the peace process between Israel and Palestine, but even there its pretty clear that Mubarak is a net negative. This should transcend partisan opinion pretty easily - remember that this was the entire premise of the neoconservative invasion of Iraq. As the neocon story goes, Arabs are angry because they are not free, and so that anger is channeled by their leaders at Israel. If we free the Arabs and give them democracy, they can prosper and the animosity at Israel disappears. I actually subscribe to this sort of thinking, but where neoconservatives and I part ways is whether America should intervene militarily to spread democracy in Arab countries: I didn't think we should in the case of Iraq.

Back to Egypt, I think everyone agrees that Mubarak is a net negative for American policies in the region, but we keep him propped up because we are worried about a worse alternative. Perhaps our worst fear would be a Muslim-brotherhood Hamas-type government taking power, cutting off ties with Israel, talking about war, and generally destabilizing the region. That is a small risk risk if Mubarak goes, but I think we make that outcome MORE likely by blatantly supporting Mubarak, which only increases anti-American sentiment. Maybe we should take a step back and let the Egyptians go their own way, and promise to help and engage them no matter which direction they go. In the short term, they may even move in a direction that we are less than enthusiastic about, but in the longer term we can win them back.

Of course, I don't necessarily think Mubarak is going to fall, but its certainly possible, and we should be thinking about what to do if he does.

Saw this coming from a mile away

Protests in Egypt, inspired by Tunisia, coordinated with Facebook. I'm not sure how efficiently Arab governments can clamp down on social networking sites on the internet, but it could be a long summer if they can't do it very well. After medical school graduation, I was hoping to backpack through the Middle East. That is looking like it might not be such a good idea anymore. Will play it by ear I guess.

If not kicking it deep is a good strategy in the playoffs, why isn't it a good strategy for the regular season?

Watching the NFC championship I was reminded of what seems to be a relatively common phenomena in the NFL playoffs: teams are opting to kick the ball low and fast instead of higher and farther. Presumably this is to reduce the chances that the kickoff returner will run it back, but it comes at the cost of letting the receiving team get a slightly better start position.

If this increases the odds of winning a playoff game, why not do it in the regular season?

Should we cut the NIH budget by 44%?

I was watching an episode of Fareed Zakaria's GPS program the other day, and the thesis of the hour was innovation. One of the points that was made by some titans of business and innovation is the crucial role of government in research funding. Whether we're talking about 60% if not more of cancer research, the internet, the global positioning system, government research money has been behind a lot of the major advances in our society.

The Republicans want to pass budget cuts - and certainly we need them. However, they don't want to touch social security, medicare, or defense. To be politically safe, the GOP is focusing on "discretionary spending". This includes the NIH, the FBI, environmental protection agencies, education, and the list goes on and on.

We're really going to have to think long and hard about our priorities as a nation, because we can't have it all. Do we want to continue to nation build in Afghanistan? Should we continue to accept our role as the world's policeman with a 500 billion dollar military? Should the government continue to pay people to stop working at the young age of 65 (ie, social security). Or, do we want to invest in the future, by putting more money in education, science, and research?

Something tells me that the Chinese won't be cutting their education and research budgets anytime soon. Its OK though. All of the new jobs in the biosciences can be created in China just as easily. Maybe in the future we will import our cancer and other medical treatments from China like we do with toys today. The most intelligent young American scientists will compete to earn a Ph.D. spot in a Chinese laboratory. The top American medical researchers will move their laboratories to China where funding is reliable and easy to get. The pharmaceutical companies might start following the researchers over there.

The research is going to get done. It is just a matter of where.

Our lab paper: CD4 T cell mediated tumor destruction

I took a year off between my third and fourth years of medical school to do research. Part of my efforts were devoted to a large project, the results of which were published in December 2010. Here is the abstract of our paper in the Journal of Clinical Investigation:

The development of effective cancer immunotherapies has been consistently hampered by several factors, including an inability to instigate long-term effective functional antitumor immunity. This is particularly true for immunotherapies that focus on the adoptive transfer of activated or genetically modified mature CD8+ T cells. In this study, we sought to alter and enhance long-term host immunity by genetically modifying, then transplanting, mouse HSCs. We first cloned a previously identified tumor-reactive HLA-DR4–restricted CD4+ TCR specific for the melanocyte differentiation antigen tyrosinase-related protein 1 (Tyrp1), then constructed both a high-expression lentivirus vector and a TCR-transgenic mouse expressing the genes encoding this TCR. Using these tools, we demonstrated that both mouse and human HSCs established durable, high-efficiency TCR gene transfer following long-term transplantation into lethally irradiated mice transgenic for HLA-DR4. Recipients of genetically modified mouse HSCs developed spontaneous autoimmune vitiligo that was associated with the presence of a Th1-polarized memory effector CD4+ T cell population that expressed the Tyrp1-specific TCR. Most importantly, large numbers of CD4+ T cells expressing the Tyrp1-specific TCR were detected in secondary HLA-DR4–transgenic transplant recipients, and these mice were able to destroy subcutaneously administered melanoma cells without the aid of vaccination, immune modulation, or cytokine administration. These results demonstrate the creation of what we believe to be a novel translational model of durable lentiviral gene transfer that results in long-term effective immunity.

If things work well, I may have another paper out before the end of the year!

The WikiRevolution

The President of Tunisia fled the nation, and the PM took over, but now he has ceded power too.  A lot of people are discussing the role that Wikileaks played in this situation.  Obviously there was already a lot of discontent in the nation, but the relevations about the government excesses that were leaked might have pushed things over the edge.

This brings me back to a point that I made about wikileaks a few weeks ago, which is that more access to information for more people is clearly a net gain for the USA.  Secrets leaked about the USA may be slightly embarrassing but secrets leaked about autocratic governments can be lethal to those dictators.

Imagine if Julian Assange exposed leaks about everyone - the US, but also Iran, North Korea, Saudi Arabia, etc.  Imagine the populations can access that information.  What we are seeing in Tunisia is a precursor to what will happen when more people get access to more info, say via wikileaks, and can organize efficiently, by Facebook, Twitter, or whatever.  How is that not a huge net win for American values and interests?

Instead of prosecuting Assange, maybe we should be helping him.  If the US government wants to bring down the Ayatollahs we shouldn't bother with bombs.  We should just develop a version of Twitter that can't be shut down in Iran.

Middle East

"The historical significance of what happened in Tunisia is huge.  This  is the first time an Arab dictator is overthrown by a popular uprising.   It is too early to speculate whether this will or can spread, but I  think one lesson is too obvious: the Arab people has realized that  overthrowing a regime is much much easer than they had thought.   If the  Iranian Revolution had an impact on Arab politics, this will certainly  have an impact," - As'ad, at angryarab

The Blamers become the Blamees

Not a novel perspective, but here is my take: it is no more fair to blame Sarah Palin or the Tea Party for the actions of an assassin who is on an anti-government streak, than it is to blame the Muslim American community for the actions of a few Islamic extremists.

Health care reform, revisited

A senior medical student clerkship is emergency medicine, and for orientation we had a series of lectures. In one of them, the doc described a tragic case that took place in 1988. There was a migrant worker in Texas who had classic symptoms of meningitis. However, at each hospital the ambulance was turned away because the patient had no health insurance. Ultimately, the patient ended up at U-Texas Southwestern but ended up dying due to the costly delay in treatment. Meningitis is an extremely dangerous condition but is very treatable with the proper antibiotics.

A 60 minutes special exposed the recorded conversations between the ambulance and the hospitals that one after another inquired about the patient's health insurance status before turning the patient away. This led to congressional legislation which dictated that emergency rooms must treat patients regardless of insurance status. In effect, the bill gave all Americans the right to a medical exam and treatment regardless of ability to pay. This mandate was, perhaps not surprisingly, unfunded by the federal government. Almost half of ER patients have no health insurance. Given that (most) hospitals must turn a profit, the 1988 unfunded federal mandate ends up being paid for by patients with health insurance.

To me, the individual mandate of the Obama health care bill stems logically from this 1988 bill. In other words, if the individual mandate is unconstitutional, why isn't the 1988 bill unconstitutional? Republicans are trying to argue that you can't force people to buy something (health insurance). But the 1988 bill did something worse - it forces people to buy something for someone else! We can talk about personal responsibility until we are blue in the face, but at the end of the day, we as a society are not willing to not treat sick patients. That is a good thing, but someone still has to pay for that treatment. Right now, only hospitals and people with insurance are paying. With an individual mandate, even though low income citizens will require help, everyone will have some role in paying for their health insurance.

While Republicans want to repeal the ACA, they are quick to point out that they favor certain parts of the bill - for example, people should not be denied insurance based on pre-existing condition. Tell me though: If I cannot be denied coverage based on pre-existing condition, why would I ever buy health insurance? Why not just wait to see if I get sick, and only buy insurance if I do? If everyone did that, the insurance market would collapse spectacularly. The only way to prevent gaming of the system like that is an individual mandate: you cannot do one without the other.

The ACA deals with access to health care, but the real problem in this country is delivery of health care, which is often expensive and inefficient. If we are to secure the fiscal future of our nation, we need to address these serious challenges - and quickly. More health care reform is needed, not less. Repeal is out of the question, and attempts at such are just posturing. Obama should tell Republicans that if they have a better bill that they want to replace the ACA with, if they have modifications, or additions, he is all ears. Obama should challenge Republicans to put up or shut up.

Are animals capable of making conscious lifestyle choices?

Homosexuality in nature. This isn't a new discovery, yet it remains that a lot of people don't realize that animals can be gay, too. Which sort of flies in the face of accusations that homosexuality is a choice or is unnatural.