I don’t grieve gladly or for long. I have had uncles drop dead and barely paused between emails, except to reflect that the world was an ever so slightly better place for their passing. Why is the sudden loss of a pet so sad?

It surely is not because pets are innocent or selfless. JJ was anything but innocent. He was demanding and entitled. If you sat down, he jumped on you and begged to play. If you threw something, he chased it and pestered you until you threw it again. He was a terrier who thought he was a retriever.

JJ was a designer dog. We chose him carefully and made him part of the family. I was intrigued by Boston Terriers, so in 2004, following our move to Oakland, my wife and I went to watch a pack of 25 or so Bostons play in the mud (they should have charged admission — it was a riot). Two of the dogs seemed especially attractive and we learned that they were cousins from the now defunct Welcome Ranch in Potter Valley. We began a correspondence with Mike Siebert and Lauren Ash, the vet who selectively bred Bostons. They often bred brindle dogs, not traditional black and whites.

Our boys were 6 and 10 and dog-ready, so we arranged to visit Potter Valley, near Ukiah. We discovered a place straight out of Dr. Doolittle. Lauren was a vet who bred Boston Terriers, exotic birds, and Morgan horses. Within minutes, we were rolling on the floor with a dozen dogs. Mike realized that we desperately wanted an animal and that we had planned carefully how we would accomodate one (they screened owners carefully). He disclosed his secret: a pup had just been born, the single offspring of their show dog Justin. He showed us the tiny fur ball, but we could not yet hold him. Six weeks and some correspondence later, we returned to Welcome Ranch to pick up Justin, Jr, known thereafter as J.J.

Families have to make room for a dog, not unlike a new child. You restructure your daily routines to accomodate a new personality. JJ made his needs clear: he wanted to be wherever we were and he wanted to play. Always.

We took him to obedience school, which was an elaborate joke. He barked obnoxiously at his classmates, then retreated fearfully when they turned on him. Like an insecure, bratty kid, JJ was forever asserting his superiority then turning tail when challenged. He flunked every test, but gladly took the treats. 

JJ grew up to be an extremely attractive dog. His markings and personality literally stopped people on the street — a chick magnet that single men could only envy. He hated other dogs, but was fine with small children petting him.

Some of our best memories of JJ are of seeing him try to swim in Lake Merritt, where he traumatized the Canadian Geese (the only creatures more obnoxious than he was). We loved seeing him run full bore on a beach, chasing strands of kelp until his smiling, drooling mouth was covered with sand. Small crowds would gather to see him chase a ball up a hill with a determination and speed not at all typical of terriers. He slept with us, ate with us, played endless tug of war with us, and took long walks with us. He begged incessantly, tipped over every wastebasket not covered or weighted down, and treated even polite dogs as a personal threat. He was a large personality and in a household that welcomes large personalities.

He survived being hit by a car and had a titanium right hip. Most days, you barely noticed it. He survived the usual dog injuries and infections and was the picture of health until Wednesday night, when he appeared tired. He was holding his head low but not coughing or vomiting. His heart and respiration were normal. He evidenced no pain when poked and he slept well Wednesday night. But yesterday morning he was clearly weak. He may have developed acute AIHA: autoimmune hemolytic anemia. If so, his body was tacking antibodies onto his red blood cells, which tricked his spleen into removing them faster than he could make new ones. In dogs, death from acute AIHA is quick — vets cannot usually get animals stable enough for blood transfusions and the huge doses of corticosteroids that serve as immunosuppressants. I rushed JJ to the vet, who put him on oxygen but he died within an hour. We do not know what causes AIHA, but it is not especially rare in dogs — and in any case, it is just a theory that fits a lot of facts, not a clinical diagnosis.

In the previous post, written with JJ snoring loudly next to me, I quoted Steven Hawking that “Heaven is for people who are afraid of the dark”. Losing a loved one, even a pet, gives you a different perspective. Heaven is our way of remembering. Hawking should restate his theorem: heaven is for people who are afraid of forgetting. 

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If the global financial collapse has a silver lining it’s the Vanity Fair accounts by Michael Lewis of how three different European countries responded to the meltdown. We can only hope that Lewis adds to these reports and turns them into another best-selling book.

Lewis (Liar’s Poker, Moneyball, The Blind Side, The Big Short) is a genius who is studied by every serious business writer. A local guy who finds drama and comedy in high finance and sports. Lewis is funny and astute. He exposes fools with a touch so deft that they become his friends. The man appears incapable of producing a dull paragraph. 

In his Euro DisasterLand trilogy, Vanity Fair serializes Lewis’ accounts of the financial collapse of Iceland, Greece, and Ireland. In each country, cheap and unregulated money created a very different disaster. In each case, Lewis notes, “An excessive faith in free financial markets led people to be allowed to do things with money they should have never been allowed to do.”

• <Wall Street on the Tundra> describes how a group of Nordic Alpha Males pretending to be investment bankers looted and wrecked the economy of Iceland, which is now run mainly by women. 
• <Beware of Greeks Bearing Bonds> tells of Lewis’ visit to a wealthy monastery to meet monks who exploit the uniquely Greek combination of extremely generous social services and rampant tax evasion.
• <When Irish Eyes are Crying> Lewis finds a housing bubble which is a parody of the US experience. Without a single derivative, the Irish bid their real estate to spectacular levels and dump the full cost of the resulting bank collapse onto taxpayers.

Lewis brings an innocent eye to these stories of nations seized by financial foolishness. It helps that he does not have a deep background in these countries. As he did in The Big Short, he meets people who saw the crisis coming (an in some cases profited from their insight).

Lewis is of course anything but innocent. Having documented the foibles of his reckless co-workers who traded bonds for Salomon Brothers, exposed the fact-averse pretenders who ran baseball teams, and shamed willfully blind US regulators, rating agencies, and derivatives investors, he knows that the story will end badly. You know it too, but you press on because, like any mystery novel, you want to see the bad guy go down. 

Unfortunately, in matters of global finance, the victims are not always the bad guys. Lewis asks who, when the dust finally settles, pays for all of this foolishness? Iceland seems determined to bootstrap its way back by rebuilding its banks. Greece, a nation that appears even less numerate than our own, looks to be in complete denial. Ireland, astonishingly, elected to impose the full cost of brain-dead banking on its taxpayers — for now. 

This will be a fine book — but it’s not worth the wait. If you have not followed the Euro DisasterLand trilogy, chase the links and treat yourself to some of earth’s finest business journalism.

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Banks, insurance companies, and pension funds buy government bonds because they are a very safe investment. Suppose they have to choose between the bonds of:

a) Mexico. The world's newest narco-state, so beloved by its citizens that they are fleeing north in record numbers.

b) Kazakhstan, the country made famous by Sacha Baron Cohen's outrageous satire, Borat ("our main form of entertainment is the running of the Jew").

c) California, home to Silicon Valley and Hollywood. The place where the future begins. 37 million people and the world's eighth largest economy.

Trick question, of course. Mexico and Kazakhstan are the safer bets. California, like a lot of state governments, is not only in over its head — we have fallen into a deep hole and responded by digging deeper. 

How do we know? Well, you can buy insurance against the risk that a government whose bonds you own will default and not pay you back. Investors buy and sell credit default swaps to insure against this risk (the same contracts which, when untraded and used to bet on the likelihood that convoluted synthetic mortgage derivatives would default, contributed in big way to the demise of AIG and Bear Stearns, a story told elsewhere). The CDS market for sovereign risk reveals the market's view of the odds that a country or a state within the US will go bankrupt. Currently the government in the world considered most likely to default is Hugo Chavez's Venezuela, with 49% odds, followed by Argentina, Greece, Pakistan, Ukraine, Dubai, and the state of California. Investors judge Iraq to be a slight safer bet than the Golden State. Mexico and Kazakhstan are much safer bets.

How can this be? California, a $1.85 trillion economy, has borrowed $85 billion — about 4.5% of the state's GDP. Kazakhstan, a $133 billion economy, has borrowed $100 billion. Are the markets crazy? Should we all sell overpriced California credit default swaps and make some real money? California government officials seem to think so.

Markets might be wrong of course, but we might want to look a little deeper. As Spencer Jakab of the FT reports, Kazakhstan is sitting on the world's 11th largest oil reserves. It grew by more than 8 per cent annually from 2002 through 2007 and runs a nearly balanced budget. Unemployment is 6.7%, they maintain a rainy day fund equal to almost 20% of GDP and they manage their own currency. California, by contrast, has a jobless rate of 12.4%  per cent and sent me my tax refund as an IOU last year. California does not manage its own currency, so when it raises taxes or trashes the public infrastructure, people relocate to states that are better managed. 

Still, debt of 4.5% of state GDP doesn't seem like that big of a hole. Or is it? The problem that spooks investors turns out to be the obligations that California has not recorded — especially pension obligations. This is a huge problem and not just for California. According to the Pew Center for the States, America's states have collectively failed to fund a trillion dollars of pension obligations. This is if you believe the state's own math. If you rely on private sector actuarial assumptions, you get even bigger numbers. A former administrator of the Social Security system, Andrew Biggs, calculated that with private sector accounting, the states would be short $3.5 trillion. To which you can add another trillion for unfunded health benefits. When puffy conservative white guys on TV go red in the face about exploding debt, this is what they are ranting about. 

California's core problem is governance and creditworthiness, not wealth. That any state should have credit issues is from one viewpoint bizarre, since state bonds are tax deductible, meaning that California's borrowing costs are incredibly low, since the federal government provides a nontrivial subsidy. 

Is California the next Greek tragedy? So far, finance officials have dealt with the hole with a combination of deferral and denial. Deferral is understandable — if the economy improves and tax receipts rebound, the state can reduce its borrowing. But deferral represents a tiny part of the solution and the politically easy part. Mostly California has been in denial. We have denied the true cost of pension and health care promises made to retirees. We have refused to do math in public because if we did, it would be clear that we will never honor those commitments. California's public employee unions make the math politically challenging to confront. Without them, this problem would be far more manageable because health and pension benefits would be lower. 

But the rush to pile all of the blame on unions alone is misplaced: every labor contract has two signatures on it. The problem is that both public managers and organized labor responded perfectly to the incentives that we gave them. Managers continually increased union pension and health benefits because, unlike wage costs, long term retiree costs were not in their budget. Indeed, they were not even costs — they were future obligations often recorded off the books. And when the cost of future benefits was calculated, it was often minimized by a generous assumption about retirement age here and a favorable guess about interest rates there. Soon the costs don't look so bad. Managers promised to deliver tomorrow what they could not afford to pay for today (and frankly, they were out bargained. Not only did public employee benefits skyrocket, wages did as well). 

Everybody was happy until tomorrow finally arrived. Now California is very likely to elect a governor who promises to cut the budget and reduce retiree benefits. Unions will revolt. Taxes will increase in a state that already features very high tax rates and mediocre public services. The cable shouters will have their day. And large numbers of people will choose to create opportunities elsewhere. Californians have learned from earthquakes how to dig out and rebuild on solid footing. Our first step is to stop digging a deeper hole.

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I didn't go home because I did not want to expose my family to Mexican pig flu. I had not been south of the border recently, but plenty of people around here have been, so I figured my exposure was not zero.

I called my doc from the car and headed to the hospital. He called back and persuaded me to go home. Without respiratory symptoms, he wasn't worried about swine flu. I slept in a separate part of the house anyway, just to make sure. And felt better the next day.

A flu scare is not a trivial thing. In sight of my office is one of the largest wards of the disastrous 1918 flu pandemic — Oakland's Kaiser Convention Center.

But 2009 is not looking like 1918. We do not know what course the H1N1 virus will take but it is hard to build a bad scenario out of the numbers we have seen so far.

An unfortunate toddler hauled to Texas from Mexico is the only US casualty of this wimpy epidemic. Imagine if instead of one death this week, we had seen 1,400 people dead from flu — 200 a day. The media would be in a panic — and so, trust me, would everybody with a fever caused by dodgy seafood.

But 1,400 deaths per week from flu is normal during flu season in the United States. Tragic and worth fighting — but normal. Some 36,000 people die during the six cold months of each year that we call flu season.

How big a threat is H1N1? It looks like an outbreak that refuses to grow up. Last Wednesday, as I recovered, there were about 85 confirmed swine flu cases in the US. On Thursday, there were 109. Today there are 141. Mexico, which last week thought several hundred people had died from swine flu now believes that the number is 15 — and in many of those cases nobody figured out what the disease was until too late. In general, swine flu has caused very mild symptoms.

Nobody should ever turn their back on a potential pandemic virus. I keep six weeks food and water for my family in my basement, along with an assortment of emergency supplies. We have disaster plans, go bags on our cars, back up phones, and rendezvous plans. I never miss a flu shot and have faithfully issued paranoid warnings about flu risk here, here, and here. I live on an earthquake fault, trained as a paramedic, and frankly bow to nobody in my disaster preparedness. When I came home sick Tuesday, I asked my wife to scrub with alcohol any surfaced I had recently touched.

I may be a barking certifiable disaster crank (sue me, I sleep better), but as disasters go, H1N1 is not looking all that disastrous. Exponential growth of the sort that a truly contagious virus brings would have added a zero to the number of incidents every few days. Keep your fingers crossed, but if the US does not see 1,000 flu cases by this time next week, this thing is a goner. H1N1 will Peter out — at least from the headlines. Even the CDC decided not to interrupt normal seasonal vaccine production to crank out emergency H1N1 vaccines — the epidemiological case for doing so is way too weak, even if the political pressure is not. 

This turns out to be an odd virus — so odd, that I wonder if the smart move is not to deliberately become infected. The disease is trivial at this stage — less lethal than seasonal flu — but the risk is that it mutates over the summer and comes back lethal in the fall. If exposure to the H1N1 now conferred immunity later in the year, I'd consider the risk carefully. By the way, one reason that H1N1 may not be so lethal is that the virus has been circulating, thanks perhaps to bugs that got out of a germ warfare lab.

Even though health officials are calling this new virus H1N1, that's
also the type of virus that's in wide circulation today. And it has an
interesting history. It was the dominant flu virus through the 1920s,
'30s and '40s. (John Oxford of the Royal London Hospital) says it disappeared in 1957, when it was
displaced by another flu virus. But then a strain of H1N1 suddenly
reappeared in 1977.

"Now where could it have come from?" he
asks. "We reckon now, in retrospect, it was probably released
accidentally from a laboratory, probably in northern China or just
across the border in Russia, because everyone was experimenting with
those viruses at the time in the lab."

It was nothing
malicious, Oxford believes, just some flu vaccine research that broke
out of containment. The descendents of this virus are still
circulating. He notes that most people who have encountered the newly
emerged H1N1 virus seem to have developed only mild disease, and he
speculates that's because we have all been exposed to a distant cousin,
the H1N1 virus that emerged in the 1970s.

"That escaped virus perhaps will provide some benefit now in the face of this pig thing," Oxford says.

If the virus dies off over the summer, many will bow and take credit. Applaud, but don't believe it. The 1917 flu died out and came back lethal a year later. So in spite of a really impressive national (CDC) and global (WHO) response to H1N1, if the virus turns out to be too weak to spread efficiently or fails to mutate to a more viral form, our day will have been saved not by heroic human efforts but by the force of nature that shields more people than vaccines ever will — dumb luck.

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All agree that during the past year our planet grew significantly …. colder.

Over
the past year, China experienced its coldest winter in 100 years. Baghdad saw its first snow in recorded history. North America has the most snowcover in 50 years, with places like Wisconsin the highest since record-keeping began. Record levels of Antarctic sea ice, record cold in Minnesota, Texas, Florida, Mexico, Iran, Greece, South Africa, Greenland, Argentina, Chile
– you get the idea.

Here is a compiled list of all the sources, which note that the cooling
ranges from 0.65C up to 0.75C. This may seem small and yes, it is weather not climate. The Daily Tech asserted that "it wipes out nearly all
the warming recorded over the past 100 years".

Anthony Watts, the scientist who compiled the data, disputed this characterization noting that "There has been no erasure. This is an anomaly with a large
magnitude, and it coincides with other anecdotal weather evidence. It
is curious, it is unusual, it is large, it is unexpected, but it does
not “erase” anything." 

Scientists quoted by the Daily Tech
link the cooling to reduced solar activity. This, they conclude, is a much larger driver of climate change than man-made greenhouse gases. The
dramatic cooling seen in just 12 months time seems to bear that out.
While the data do not disprove that carbon dioxide is acting to
warm the planet, they do demonstrate that powerful factors are cooling it — at least for the moment.

Adds the Daily Tech

"This is not especially good news, since cold is more damaging than heat.
The mean temperature of the planet is about 54 degrees. Humans — and
most of the crops and animals we depend on — prefer a temperature
closer to 70.

Historically, the warm periods such as the Medieval Climate Optimum
were beneficial for civilization. Corresponding cooling events such as
the Little Ice Age, though, were uniformly bad news."

The New York Times has a good report here. They close with a scientist who notes that "There is this desire to explain everything that we see in terms of
something you think you understand, whether that’s the next ice age
coming or global warming." He might add that there remain plenty of sound economic and political reasons to reduce greenhouse gas emissions via efficiency improvements and alternative fuels.

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God’s eye view of Southern California, courtesy of the European Space Agency. It does not begin to tell the story of the anxiety, confusion, frustration, and loss that more than a half million people evacuees feel tonight.

My Mom evacuated the Witch Canyon fire and my brother evacuated Slide, some 60 miles away. Her house in Ramona is probably OK — his home in Running Springs has quite likely burned. We won’t know for sure until the fire is out and the dust settles. (Update: Fire stayed a quarter mile or so away from Mom but burned brother’s entire neighborhood. Amazingly, his house survived.)

A lot of folks mobilized to fight these fires. It is brutal, exhausting work — unless you have 50 MPH winds, in which case all you do is get the hell out of the way. Times like this my family remembers Steve, my younger brother killed fighting a wildfire in Santa Barbara.

One piece of poetic justice: a significant share of California’s air pollution now comes from China. If the easterlies keep up, we should be returning the favor in a few days. And regardless, the sunsets are likely to be spectacular for awhile.

Best information roundup on the fires is here.

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In the tradition of commencement speeches, Gates reminded grads of their social obligations — a noblesse oblige for the 21st century social justice that is, conveniently, technology-driven.

Gates was inspired by George Marshall, whose Harvard commencement speech outlined his famous plan to rebuild postwar Europe. The Wall Street Journal reports that Gates saw a copy of Marshall’s speech on the wall of the waiting area prior to meeting with Marshall’s successor, Condi Rice.

Dr. Rice should keep her visitors waiting more often. In his
evocation of Marshall, Gates was thoughtful and eloquent. In the manner
of commencement speakers everywhere, he denounced complacency — this
time by asserting that complexity is the underlying foe. Even a guy as
smart as Gates cannot always tell the two apart however. To hear him
evoke the untold suffering of poor children is to recall Joseph
Stalin’s cynical smear that "a single death is a tragedy; a million
deaths is a statistic". Gates:

I left
Harvard with no real awareness of the awful inequities in the world -
the appalling disparities of health, and wealth, and opportunity that
condemn millions of people to lives of despair. I learned a lot here at
Harvard about new ideas in economics and politics. I got great exposure
to the advances being made in the sciences….

But humanity’s greatest advances are not in its discoveries- but in how those discoveries are applied to reduce inequity. Whether through democracy, strong public education, quality health care, or broad economic opportunity – reducing inequity is the highest human achievement.

Imagine,
just for the sake of discussion, that you had a few hours a week and a
few dollars a month to donate to a cause – and you wanted to spend that
time and money where it would have the greatest impact in saving and
improving lives. Where would you spend it?
For Melinda and for me, the challenge is the same: how can we do the
most good for the greatest number with the resources we have.

During
our discussions on this question, Melinda and I read an article about
the millions of children who were dying every year in poor countries
from diseases that we had long ago made harmless in this country.
Measles, malaria, pneumonia, hepatitis B, yellow fever. One disease I
had never even heard of, rotavirus, was killing half a million kids
each year – none of them in the United States.

We were shocked.
We had just assumed that if millions of children were dying and they
could be saved, the world would make it a priority to discover and
deliver the medicines to save them. But it did not. For under a dollar, there were interventions that could save lives that just weren’t being delivered.

If you believe that every life has equal value, it’s revolting to learn that some lives are seen as worth saving and others are not. We said to ourselves: "This can’t be true. But if it is true, it deserves to be the priority of our giving."

So we began our work in the same way anyone here would begin it. We asked: "How could the world let these children die?"

The answer is simple, and harsh. The
market did not reward saving the lives of these children, and
governments did not subsidize it. So the children died because their
mothers and their fathers had no power in the market and no voice in
the system.

But you and I have both….

All
of us here in this Yard, at one time or another, have seen human
tragedies that broke our hearts, and yet we did nothing – not because
we didn’t care, but because we didn’t know what to do. If we had known
how to help, we would have acted.

The barrier to change is not too little caring; it is too much complexity.

Gates,
finally in possession of his college degree, closed with a challenge
that made him sound like a child of the sixties not a recipient of an
honorary Doctorate:

Members of the Harvard Family: Here in the Yard is one of the great collections of intellectual talent in the world. What for?

There
is no question that the faculty, the alumni, the students, and the
benefactors of Harvard have used their power to improve the lives of
people here and around the world. But can we do more? Can Harvard dedicate its intellect to improving the lives of people who will never even hear its name?

Let
me make a request of the deans and the professors – the intellectual
leaders here at Harvard: As you hire new faculty, award tenure, review
curriculum, and determine degree requirements, please ask yourselves:

Should our best minds be dedicated to solving our biggest problems?…

When
you consider what those of us here in this Yard have been given – in
talent, privilege, and opportunity – there is almost no limit to what
the world has a right to expect from us.

In
line with the promise of this age, I want to exhort each of the
graduates here to take on an issue – a complex problem, a deep
inequity, and become a specialist on it. If you make it the focus of
your career, that would be phenomenal. But you don’t have to do that to
make an impact. For a few hours every week, you can use the growing
power of the Internet to get informed, find others with the same
interests, see the barriers, and find ways to cut through them.

Don’t
let complexity stop you. Be activists. Take on the big inequities. It
will be one of the great experiences of your lives…

Now for a tasteless question: was Gates trying to outdo the outstanding "Stay hungry, stay foolish" speech that Steve Jobs gave at Stanford two years ago?

The
comparison is revealing. Bill and Steve have been competing with each
other in a very personal way for three decades — and the entire world
has benefited. Jobs still plays Athens to Gate’s Rome — always Thomas
Edison to Gate’s George Westinghouse.

Both are mellowing however, and they recently had interesting, even insightful things to say about each other when the Wall Street Journal got them on stage together at a conference near San Diego.

Jobs, playing the poet without effort, cited Paul McCartney “You and I have memories longer than the road that stretches out ahead”.
These reflections were a far cry from his famous and accurate
assessment of Gates two decades ago. Watch it again to see how far both
men have come.

      Technorati : Bill Gates, Harvard, Steve Jobs 

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Says the Daily Mail:

British scientists are on the verge of producing a revolutionary flu vaccine that works against all major types of the disease. Described as the ‘holy grail’ of flu vaccines, it would protect against all strains of influenza A – the virus behind both bird flu and the nastiest outbreaks of winter flu.

Just a couple of injections could give long-lasting immunity – unlike the current vaccine which has to be given every year. The brainchild of scientists at Cambridge biotech firm Acambis, working with Belgian researchers, the vaccine will be tested on humans for the first time in the next few months.

A similar universal flu vaccine, being developed by Swiss vaccine firm Cytos Biotechnology, could also be tested on people in 2007 – and the vaccines on the market in around five years. Importantly, the vaccines would also be quicker and easier to make than the traditional jabs, meaning vast quantities could be stockpiled against a global outbreak of bird flu.

So how does this work?? I thought that flu viruses mutated constantly, so you could not build a one-shot-prevents-all influenza vaccine.

The article claims that only surface proteins on a flu virus actually mutate — there are core proteins that don’t — so the vaccine targets one of these. I’m sure that there is a reason nobody did this earlier — but fine.

Current flu vaccines focus on two proteins on the surface of the virus. However, these constantly mutate in a bid to fool the immune system, making it impossible for vaccine manufacturers to keep up with the creation of each new strain.

The universal vaccines focus on a different protein called M2, which has barely changed during the last 100 years. The protein is found in all types of Influenza A, including the current bird flu and the virus that caused the 1918 Spanish flu pandemic which killed up to 50 million across the globe.

Zurich-based Cytos, which is also developing anti-smoking and obesity vaccines, has showed that its version of the jab stops mice dying from a dose of flu strong enough to kill them four-times over. The vaccinated animals were also spared the fever that normally goes along with flu.

Very cool. Remember breakthroughs like this the next time you curse them damned greedy drug companies.

      Technorati : Flu vaccine, bird flu, influenza 

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You get sick — so what do you do? Easy — you do nothing. Tough it out.

But what do you do when your kid wakes up with asthma? Or when you finally get good and sick? Well, you head for the local emergency room. Why? Well, it’s open — and they pretty much treat all comers. Sure they lose money — and they are not really set up for sub-acute medicine, but at least you can get an quick exam and some medicine.

Does this really happen? These guys cite the National Center for Health Statistics to the effect that half of all ER visits are for non-urgent care. My experience with the nation’s largest HMO suggests that the number was at least that high a decade ago.

Now suppose that you run the local hospital — and the place is losing money thanks to the cost of indigent care in the emergency room. So what do you do? Well, eventually you open an urgent care center and hope that its costs are lower. Often you close the emergency room. The remaining ERs get more crowded and lose more money, so pretty soon they close.

The system collapses. Is this actually occurring? The Institute of Medicine released three reports last month, after studying the question for two years. Its conclusion, as summarized by the Washington Post:

Emergency medical care in the United States is on the verge of collapse, with the nation’s declining number of emergency rooms dangerously overcrowded and often unable to provide the expertise needed to treat seriously ill people in a safe and efficient manner.

The reports — on hospital ERs, on pediatric emergency care and on pre-hospital care given by ambulance services — were embraced by the 24,000-member American College of Emergency Physicians, and its president said that the endorsement was telling.

"What other industry says, ‘Hey, look at us, our whole system is broken’?" said the group’s president, Frederick C. Blum, a physician in Morgantown, W.Va.

Two key steps for improving emergency care are regional planning and creating a standard way to measure outcomes, so that low-quality ERs and ambulance services can be identified and fixed, the committee wrote.

Emergency medical care is a legal right for all Americans. Under a law enacted in 1986, emergency rooms must evaluate and stabilize anyone who shows up. That requirement — bolstered by physicians’ ethical duty to treat the ill — has made hospital emergency departments subject to unique pressures.

The underlying cause of this crisis is well understood: the report notes that from 1993 to 2003, the U.S. population grew by 12 percent but emergency room visits grew by 27 percent, from 90 million to 114 million. In that same period, however, 425 emergency departments closed, along with about 700 hospitals and nearly 200,000 beds. The Bush administration has responded in characteristic ostrich-like fashion, not by addressing the cause of our ER emergency and not by increasing funding for emergency rooms, but by reducing the care that ERs are required to provide!

The emergency room emergency is a national scandal. It results in the needless death of Americans every day. It makes a car accident or a heart attack more life-threatening than is medically necessary. And it makes a cruel joke out of efforts to plan a medical response to a real public emergency like a flu pandemic, catastrophic earthquake, or terrorist attack.

Message to Democrat and Republican health care reformers: exploit this issue. Explaining to Americans that we have no health care safety net, whether or not we have insurance, can be a very effective wake-up call.

 
  Technorati : Emergency Care; ER;Emergency Room;Health Care

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Q: We keep hearing that H5N1 will mutate, become transmissible, and trigger a pandemic. Is this really likely?

LAST month, eight members of a family in Sumatra fell ill with H5N1 bird flu. Seven died. Chillingly, all but one appears to have caught the virus from another family member, making this the biggest human cluster yet. It is also the first known case in which H5N1 has spread from one person to another, and then another.

The family tragedy seems to have resulted from crowded sleeping arrangements, and the World Health Organization says there is as yet no sign that H5N1 has evolved the ability to spread easily among people. But virologists remain convinced that the virus will acquire this capability, and that conviction has led to a major shift in attitude among scientists and vaccine manufacturers.

Q: So why not crank up vaccine production? The standard answer is that we have not yet seen the the virus against which we are vaccinating people. There is growing interest however, in alternative approaches, including pre-pandemic vaccines.

"People are taking pre-pandemic vaccination seriously," says Derek Smith at the University of Cambridge. In May, a meeting of scientists and manufacturers at the World Health Organization in Geneva, Switzerland, recommended the development of vaccines that could be used to inoculate people before a pandemic takes hold. These, they said, must have long-lasting effects, and be "broad-spectrum" enough to work against whatever pandemic virus emerges.

Q: OK, but will these vaccines really work?

Several novel vaccines that do both are now close to testing in humans. They include the addition of immunity-stimulating chemicals called adjuvants, vaccines made of DNA instead of the virus itself, and perhaps the ultimate – a vaccine that protects against every kind of flu.

While there is no way of knowing before a pandemic starts exactly how well the vaccine will work, the risks of doing nothing could be far greater. "Stockpiling pre-pandemic vaccines is more valuable than people realise", Robert Webster of St Jude Children’s Research Hospital in Memphis, Tennessee, told a flu conference in Singapore last month. "It may not necessarily protect you from infection, but it will probably stop you dying".

Q: Not dying — I like the sound of that. So why are we not cranking up pre-pandemic vaccines?

In the past, the WHO and governments have dismissed the idea of pre-pandemic vaccination. They reasoned that no vaccine would exactly match whatever pandemic virus emerges, so any that was produced would offer only limited immunity. Most manufacturers of human flu vaccines are busy making vaccine against ordinary flu, and this seriously limits the capability to make vaccines ahead of any pandemic. Another factor is the memory of 1976, when fears that swine flu was about to develop into a human pandemic led the US to vaccinate millions of people. The pandemic never materialized, but a few of those who were vaccinated developed complications and sued the government. Such liability issues will have to be dealt with before pre-pandemic vaccination.

Despite these problems, there is now a growing realization that doing nothing may not be worth the risks. Separate modeling studies at the University of Washington in Seattle and at Imperial College London suggested that inoculation against H5N1 ahead of any pandemic, even with imperfect vaccines, could significantly cut the eventual death toll. Wait for a pandemic to strike and it will be too late. The first global wave of illness is expected to be over before enough vaccine specific to the pandemic strains has been made, and by then the virus could well have mutated into a different strain

Q: But do prototype H5N1 vaccines protect against new strains of the virus?

.. prototype H5N1 vaccines are receiving renewed attention. The US has ordered $1.2 million worth of such vaccines, while the UK has ordered 2 million doses. Vietnam plans to start making 2 to 3 million doses of H5N1 vaccine each year. Most countries plan to give it to key people, such as health care workers, if an H5N1 pandemic starts.

Studies in ferrets, the animal whose flu is most similar to the disease in humans, suggest that prototype H5N1 vaccines can offer protection against more than one strain of the virus, says Erich Hoffmann at St Jude Children’s Research Hospital.

This cross-protection is crucial. For example, the H5N1 from Hong Kong in 1997 is just different enough from the H5N1 in Vietnam in 2004 that in lab experiments using antibodies people made when vaccinated against the 1997 strain there was no cross-reaction with the 2004 virus. But when they were given an adjuvant alongside the vaccine, they made a broader spectrum of antibodies which cross-reacted so well that the people would have been protected from the 2004 virus. So using an adjuvant is one way to get the "broad-spectrum" immunity a pre-pandemic vaccine needs.

Q: Adjuvants — they sound like drugs for drugs, but if they work, I favor them. Any downside?

The problem with powerful adjuvants is that they tend to be toxic. One company, however, says it has found a way around this. Iomai of Gaithersburg, Maryland, uses enterotoxins produced by E. coli bacteria, which are applied via a skin patch placed over the vaccine injection site. From there they pass directly into dendritic cells, a type of immune cell in the skin. "It has caused no systemic toxicity in human trials because the adjuvant never enters the bloodstream," says Greg Glenn, chief scientist at Iomai. In tests on mice, the skin patch boosted the immune response to ordinary flu vaccine 100 to 1000-fold, raising hopes that adjuvant will allow lower doses of pre-pandemic vaccine to be used, stretching supplies considerably. Glenn hopes to test the enterotoxin patch with an H5N1 vaccine in humans later this year.

Q: But isn’t the fundamental problem limited vaccine production capacity?

Adjuvants do not solve the problem that vaccine itself must still be produced, while the plants capable of manufacturing human vaccine are occupied making ordinary flu vaccine. One answer might lie in the use of DNA vaccines, which unlike conventional vaccines do not contain any flu virus. Instead, they are made from loops of DNA that code for proteins from the virus. Immune cells in people translate this DNA into the corresponding proteins, which can elicit a broader immune response than the virus itself. DNA vaccines can also be brewed quickly, cheaply and in large quantities using engineered bacteria in ordinary production facilities.

Q: OK, so let’s ramp up DNA vaccine production.

The problem with DNA vaccines is that simply injecting them does not seem to stimulate immunity in people. To overcome this problem, PowderMed of Oxford, UK, coats gold nanoparticles with the DNA, then uses pressurized gas to blast them into the skin, where they penetrate immune cells directly. In May, PowderMed completed successful safety trials in humans of a vaccine against the H3 protein in ordinary flu. Antibodies to the vaccine cross-reacted with six different variants of H3 flu, the company has told New Scientist. It says it will start large-scale trials of an H5 vaccine next year, and claims it could mass-produce vaccine by 2008.

Q: But a DNA vaccine that coded for proteins found in all flu viruses would be a universal flu vaccine — the Holy Grail!

The key to the long-sought universal flu vaccine that will offer some immunity to whatever pandemic strain may emerge lies in finding a vaccine that elicits antibodies against proteins that are identical in all flu strains.

The leading target is M2e – a minor surface protein to which human immune systems do not normally mount a response. Tests on animals such as mice and ferrets show their immune systems can react strongly to it. Vaccines against such conserved proteins offer some protection in animals, although researchers at Wageningen University in the Netherlands have discovered a complication: in pigs a vaccine that targets M2e, and a second that targets M2e plus another conserved protein called NP, actually made the disease worse.

Despite this, Walter Gerhard at the Wistar Institute in Philadelphia, Pennsylvania, thinks work should continue. "Because M2e-specific antibodies have shown substantial protection in animal models, and humans don’t normally make such antibodies during infection, I believe it makes sense to develop and test an M2-specific vaccine in humans," he told New Scientist. Merck plans to do humans trials of such a vaccine this year.

Q: OK, so let’s suppose we sort out which proteins we are coding a vaccine for. Do we have enough production capacity?

Vaccinating people against H5N1 before a pandemic starts is not yet a practical possibility, because not enough vaccine is available. This is partly because all the vaccine factories are being used to make vaccine for ordinary flu.

There is, however, massive global capacity for making flu vaccine for chickens, and in April the WHO held a meeting to explore the possibility of using these facilities to make human vaccine. It concluded that the manufacturing processes and standards are not that different, and it should be possible to divert some plants. A spokesman for the International Federation for Animal Health said that companies were unlikely to do it before a pandemic actually starts. Big animal-vaccine manufacturers from Mexico and China were more enthusiastic.

Q: Lemme get this straight. We are going to be saved by veterinarians? Who specialize in chicken vaccines? Only if we are lucky and focused.

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