Here’s Part 2 of our conversation with Kenneth Alexander, M.D., chief of pediatric infectious diseases. In this second and last installment, we discuss what ordinary people can do to avoid getting or spreading swine flu, some steps that medical professionals can take, and what would constitute a flu pandemic.

Here’s a video we shot yesterday of Kenneth Alexander, M.D., chief of pediatric infectious diseases, answering common questions about swine flu.

The news of unusual swine flu cases in Mexico and the American southwest has raised concerns that the outbreaks could herald a new flu pandemic - though the anxiety level in this AP story on today’s news seems just a bit too high at this stage. Something about the tone smacks of that movie “The Andromeda Strain” - “it’s something we’ve never seen before…”

It’s important to be vigilant, but overreaction also can have costs. In 1976, the CDC instituted an emergency immunization program in response to an outbreak of swine flu. The vaccine they used may or may not have been the cause of an uptick that year in cases of Guillain-Barre Syndrome (see this for an account of the 1976 experience by the former directors of the CDC and the immunization program).

President Obama has a history of interest in flu pandemic preparedness. He co-wrote a 2005 op-ed in the New York Times on pandemic measures, and later that year I interviewed him on that subject for the Chicago Tribune. You can see the transcript here. Two passages from that interview may offer clues about how Obama’s administration will handle the latest outbreak: 

Even when the SARS scare struck, the losses were in multiple billions of dollars. And that proved to be a false alarm essentially. If something like this genuinely occurred, you’d see global trade come to a standstill. And in addition to obviously the loss of life, the breakdown of our health systems, the economic consequences would be huge.

…you hate to be Chicken Little on this thing - no pun intended. But this is actually one of those situations where getting people a little scared, and certainly getting our government a little scared is probably a useful thing. And as I said, whatever investments we make are not going to be wasted, because the likelihood of pandemic is so high, even if it isn’t this particular pandemic. 

Perhaps Obama will see the issue differently as president than he did as a senator. But his instincts seem similar to those of the people who ran the 1976 immunization program - “When lives are at stake, it is better to err on the side of overreaction than underreaction.” If this outbreak continues, we may see another test of that idea.

News outlets reported this week on a new JAMA study showing that having a heart defibrillator implanted by an electrophysiologist produces fewer complications for patients than if a doctor outside that specialty does the procedure.

I asked Martin C. Burke, DO, to comment on the article and the background that makes this important for patients and physicians, and he graciously agreed. Here is Dr. Burke’s post:

The new JAMA article regarding physician certification for implantable cardioverter defibrillator (ICD) implantation and patient outcome is interesting to me as a practicing electrophysiologist, or electrician of the heart, as well as a trainer of the next generation of electrophysiologists.

In 2004, the medical society that represents the heart electricians called the Heart Rhythm Society or HRS published criteria for certification that allowed non-electrophysiologists to implant ICDs without going through the rigors of a fellowship in clinical cardiac electrophysiology.  The electrophysiology fellowship training pathway provides a one- or two-year intense exposure to the management of heart rhythm disorders as well as training in the complex interventional procedures such as the ICD implantations and more complex cardiac resynchronization ICD implantations mentioned in the JAMA article.  The HRS certification criteria for non electrophysiologists has been used by hospitals and third-party payors to allow non-electrophysiology board eligible or certified physicians to get credentialed by hospitals to implant and get paid for such implants.

At the time of the publication of the 2004 paper, the membership of  the heart rhythm society was mystified as to why our own society would sanction such a document and essentially ‘throw under the bus’ our training pathway in heart rhythm disorders that we take quite seriously.  We as the heart rhythm society and I as a trainer of electrophysiologists have spent the last 20 plus years advancing the science and application of such devices in a methodical and expert way.  So, the logical deduction is that this policy has been the agenda of the device manufacturing companies who felt that there weren’t enough cardiac electrophysiologists to meet the needs of the public indicated for such devices.  

This is an incendiary topic as the financial implications at stake are large for all parties. Consequently there has been great controversy within the HRS membership, and it has recently bubbled into a call for our medical societies to sever all relationship with industry, a typically American over-reaction. Industry working with clinician scientists is of huge value to society at large as long as it is disclosed and managed ethically.  Of more concern to me are cases where study authors do not disclose potential conflicts of interest - a practice that remains distressingly common.

Still, patients should be assured that in science, the true path eventually becomes evident and now patients can move forward with expert device implantation and management with the best-trained physicians in the world to do so: the clinical cardiac electrophysiologists.  

This announcement from the National Cancer Institute could be very big news at cancer research centers like this one. The increase, which NCI director John E. Niederhuber described in a speech at the meeting of the American Association for Cancer Research, will be part of the economic stimulus package.

Here’s an interesting passage from the story in The Scientist:

In 2009 the agency will be able to fund the top 16% of grant applications instead of only the top 12%–last year’s payline–based on budgetary increases alone, Niederhuber said. The NCI may be able to fund 25% of applications with the added $1.3 billion that the agency is set to receive as part of the $10 billion in stimulus funding for the National Institutes of Health. 

But raising the payline is only half the story. “Economic stimulus funds give us the chance to be visionary,” Niederhuber said, adding that the NCI will seek to fund more young, first-time investigators, and will emphasize prevention and early diagnosis in the research it supports in the future. “Patients still need better treatments, better prevention, and better early detection,” he said. “We must recommit ourselves to answering that call.” 

Last Friday the Obama administration published its new guidelines for federal funding of embryonic stem-cell research, ending the Bush-era restrictions on that work.

Except they didn’t end all of the restrictions. The new rules do not allow for work on cells made via research cloning (somatic cell nuclear transfer), and they require an informed consent process that may exclude some cell lines already derived with different consent procedures. Advocates at both antipodes of the stem-cell debate found something to criticize in the Obama rules. Researcher Irv Weissman of Stanford said the rules maintain an “ideological barrier” that will hinder progress, while Douglas Johnson of the National Right to Life Committee said the guidelines herald “an incremental strategy to desensitize the public to the concept of killing human embryos for research purposes.”

For now Obama seems to have struck an ideological balance, and some conservatives are giving him credit for it. Yuval Levin, a former Bush bioethics adviser who recently appeared on this blog, wrote on Friday that the new guidelines “certainly could have been worse” from a conservative’s perspective.

At the same time, the new rules mean that federally funded research can move beyond 2001-era technology. Bush’s guidelines, which restricted funds to lines derived before August 2001, allowed researchers to work with just 21 cell lines. Obama’s rules open the door to hundreds of additional lines created since 2001, many of them with genetic defects that can help scientists understand how diseases develop.

In moral terms this may even be a clearer approach than Bush’s policy, which claimed to protect nascent life but did allow some funding of research that required the destruction of human embryos. Those rules allowed fewer stem-cell lines to qualify for funding, yet the restriction was based on an arbitrary cut-off date. Why was it moral to allow funding of research on stem cells taken before August 8, 2001, but beyond the pale to allow funds for cells taken after that date?

Levin, who also served as executive director of the President’s Council on Bioethics, wrote that by keeping some limits on stem-cell research funding, Obama’s NIH has conceded “that the destruction of embryos for research is not an innocent and unproblematic practice, but must be constrained for ethical reasons.” So far, so good. As the bioethicist Art Caplan once told me in an interview, “A human embryo may not be a legally protected person, but it’s also not just any old stuff.” Levin then goes further: “These rules raise the question of why limits are necessary, and any serious answer to that question would lead us to conclude that these rules are inadequate. ”

That’s not at all clear to me. Under Bush’s old rules, an embryo’s fate might depend solely on the date when it was created. Under Obama’s new rules, the embryo’s fate is governed by something far less arbitrary - the parents’ intentions, informed by all the options available to them. It seems reasonable to trust that whatever parents decide, they will see their embryos as something more than raw material.

[Note: This post originally contained a quotation from a private classroom setting, which has been removed at the speaker's request.]

Neuroblastoma patients recently got some of the best research news they’ve had in a while - but the news wasn’t perfect for everyone.

Word of the advance came in an announcement last month from the national Children’s Oncology Group. A Phase III trial of an antibody-based treatment for neuroblastoma (protocol ANBL0032) had found that the treatment significantly increased patients’ chances of survival. The trial was immediately halted - standard procedure in cases where a trial is so successful that it would be unethical to deny patients the treatment.

The antibody treatment yielded a striking survival gain of about 20 percent for children with the deadly form of cancer. Neuroblastoma researchers such as Susan Cohn, M.D., were elated.

“This is as successful a story as we’ve had in neuroblastoma treatment in many, many years,” Cohn told me in a recent interview. “We hope to be able to incorporate this as part of our standard approach.”

The protocol is on hold to study toxicity issues that arose in some patients, but experts hope the treatment will be available soon for more patients. The March 19 statement from COG concluded, “We now expect that this immunotherapy may eventually become a standard part of high-risk neuroblastoma treatment after stem-cell transplant.”

So what’s the downside? It’s simply the nature of such clinical trials, in which not everyone can get the superior treatment.

Patients are randomized at the start of a trial like this one; some get the new treatment, some get the standard, established protocol. Some families opt out altogether. No one knows at the outset whether the new protocol will be better, the same or perhaps worse than the existing treatment.

But it’s clear now that in this case, patients who got the new protocol stood a markedly better chance of surviving their cancer than those who stayed with the old form of treatment. A 20 percent improvement is no guarantee, of course; some patients on the new protocol died, and many who got the existing treatment did fine. Yet an outcome like this can raise a tantalizing “what-if” question in the minds of some parents. Might a child have had a better chance at survival if randomization had placed him or her in the new treatment group? What about parents who may feel guilt over not taking part in a trial that could have improved their child’s outcome?

Such doubts may be impossible to resolve. It’s difficult to imagine replacing randomized trials as the gold standard for gathering scientific evidence that a treatment works.

“You just never know until you do the study,” Cohn said. “We are so grateful to the families who are willing to participate in these trials.”

I usually disagree with Yuval Levin, but he’s one of my favorite writers about biotechnology on the right or the left. He’s thoughtful, informed and open to dialogue. He’s also fairly immune to hype about scientific advances, which ought to count as a cardinal virtue.

Yuval spent a good chunk of the Bush administration deep within the Death Star, as associate director of Bush’s domestic policy council, and before that as chief of staff for the President’s Council on Bioethics. He also did his graduate studies here at the University of Chicago with Leon Kass, former head of the bioethics council. He’s currently a fellow at the Ethics and Public Policy Center. Our talk offered a chance to get Yuval’s informed take on science and ideology, and to air out some lingering disagreements we had about the Bush administration’s approach to science policy.

Q: Your new book is all about science and ideology. How would you describe the differences in how the left and the right look at science?

Levin: The book is about what we can learn about our politics from the science debate. Science is a useful clarifying lense to look at our politics because it brings to the surface things that are often implicit and under the surface. And some of them really point to deep differences between the right and the left, especially in terms of how we look at the future. The right tends to think of the future in terms of generations and maintaining continuity, and the left tends to think of the future in terms of innovations. 

Q: Jerry Coyne said in our interview that the right is more hostile than the left to scientific thinking because the right is more religious. Would you consider that an oversimplification?

Levin: I think so, but it’s not simply wrong. There’s another level beneath it. I don’t think it’s being religious that explains why the right thinks a certain way about science. I think it’s an attitude the right has toward cultural continuity. That makes a big difference. It’s also why the right tends to be more open toward religion. On those issues where the right has a problem with science, it usually arises when science poses some kind of threat to what conservatives see as the imperative of cultural continuity, whether it’s at the juncture of generations or around society’s ability to present a picture of its own past, an argument about morals and values.

So it’s easy to see why a hard-line scientific worldview that doesn’t allow other kinds of questions to be asked and answered would strike the right as a problem. I don’t think religion is necessarily the reason for this.

Q: I think Coyne means there are certain scientific issues where your religious assumptions might lead you to discount evidence, and regard the scientific process as sort of irrelevant.

Levin: That begins from the premise that science and religion are asking the same questions, and that’s just not true. I mean, religion is not trying to figure out how the world began. Even though the first words of Genesis are “In the beginning,” the book is really about how to live, not what was there at the beginning.

Scientists who criticize the role of religion ironically tend to have a sort of biblical literalism. They say the Bible is about how things work and how the world started, and so is science, and we just have better data. That’s really not true – I think moral questions and scientific questions are just different questions. You arrive at different answers, but that doesn’t necessarily mean you’re opposed to one another.

And the same mistake is made on the right. People who react to the theory of evolution the way some creationists do are making the same mistake. They take the implications of Darwinism to relate to issues that evolution doesn’t address. So it happens on both sides. I think it’s equally a mistake on both sides though. It seems to me our moral traditions and scientific method are not addressing the same questions.

Q: I don’t agree that this is a case of equal offenders on both sides. If you were to ask the majority of weekly churchgoing Christians or Republicans in Congress whether they agree with your account of Biblical literalism - that science and the Bible are not asking same questions, that religion is about how to live, not how the world began – I don’t think they’d agree with you.

Levin: Yeah, I’m not sure they’d agree with that either. Even so, I think what they make of the religious traditions that shape their lives suggests that they take these to be books of moral teaching and not books of scientific fact. Certainly there are biblical literalists among American Christians and some American Jews too. But it seems to me it doesn’t make sense for secular scientists to be biblical literalists when they think of what the right has to say to science, and what religion has to say about science.

Q: But you know, Coyne wouldn’t be using that interpretation if he didn’t feel his adversaries were starting from a viewpoint of biblical literalism.

Levin: But the question is, why does it matter? Why is it that both side are feeling defensive? It seems to me that on the merits neither has a grievance. It seems more mysterious to me that someone like [Coyne] would feel defensive about what some Christians have to say about evolution. There’s something telling about the desire to control the cultural story. I can see why cultural conservatives would want to do that, but it’s more interesting to me why secular scientists would want to do that.

Q: You said there’s a narrow range where the right has any problem with science. Where do you see those issues, and are there other issues where the left has problems?

Levin: I think for the right, the problems tend to be around human biotechnology. Not in the sense of studying the human animal but acting on the human animal. Science tends to think of itself as a way of knowing, and it is, but it’s also a way of doing. And when what’s done is to human beings, I think the right gets worried. Not only with life issues, but also when we begin to address selves to juncture of generations, engineering our descendants, picking out beginnings of life. Those issues matter for conservatives, and when science enters that realm it becomes controversial.

Increasingly lot of problems between science and left will be in environmentalism. Environmentalism is built on an understanding of nature that’s very different from a scientific understanding. Science begins from an understanding of nature as a moderately hostile force, best understood as a whole made of parts. Modern ecology begins from a benevolent view of nature, that the best humans can do is stand out of way, and it understands nature as a single whole. This begins as a philosophical issue but I think it becomes a practical issue. Science is the moving force behind a lot of what most troubles environmentalists – industrial capitalism, nuclear energy, etc. I think we see hints of what’s coming from Europe, where the Greens are not generally the pro-science party.

Q: Looking back on the Bush administration, do you think there’s been any misperception about how the administration handled science? read more

Most scientists hate getting drawn into political debates, but in the last decade the two spheres have overlapped more than ever. Stem-cell research and global warming are just the most visible cases; when presidential candidates are routinely asked whether they believe evolution is true, you know the subject has reached a new level of urgency.

The Obama administration intends to “make scientific decisions based on facts, not ideology.” But the injection of ideology and values into science is sometimes inevitable. Facts alone can’t tell a scientist whether it’s right to do a given experiment in genetic manipulation, for example. The deeper problem is when ideology leads people to ignore facts and succumb to a brand of relativism, and a despair in science’s basic ability to discover objective truth. This is the most dangerous kind of “war on science,” whether it comes from the right or the left.

Recently I talked with evolutionary biologist Jerry Coyne and Bush health policy adviser Yuval Levin about how science and ideology might interact in the post-Bush era. Jerry comes at the issue from the left and Yuval from the right, but I think it’s fair to say that they both have observed a popular suspicion of science that crosses party lines. And each author has a new book out that speaks to the subject - Jerry’s “Why Evolution Is True” and Yuval’s “Imagining the Future: Science and American Democracy.”

I’ll publish my talks with them in installments, starting today with a portion of the Coyne interview.

Q: You argued recently in The New Republic that it’s impossible to accept the facts of evolution and still be a true theist. Do you think it’s possible to accept modern biology and still be a true conservative?

Coyne: It depends. Insofar as the Republican party wants intelligent design to be part of science, insofar as they don’t think global warming is a serious threat or is caused by humans, I think that’s inconsistent because the evidence is there. You can claim as they do that there’s no evidence that global warming is real, but this stuff is directly contradicted by the evidence.

On the other hand, when you talk about issues like stem cells and abortion, I don’t know how much of that is conditioned by scientific knowledge. If you take the view that a fertilized egg is a human being, then abortion is wrong, and there’s nothing science can tell you that will change your mind. If you say a fetus only becomes a human being when it becomes conscious, and that’s a scientific question, then if you think first trimester babies aren’t sentient, it might change your mind about abortion. But I don’t think people’s moral judgments are informed by science that way.

Q: Has your scientific training and study affected your political views?

Coyne: To some extent, but only indirectly. I’ve always been a bit of a left-winger. Any candidate who’s anti-science, I kind of write off. Since that’s mostly Republicans, it’s made me maybe even more left wing than I had been before.

I think learning science can sometimes affect people’s views on politics. Clearly some conservatives have broken ranks on certain issues because they learned more about the science. Writers like George Will and Charles Krauthammer embraced evolution and denigrated creationists and the intelligent design people. They did that because they learned about evolution, but not everyone is going to change their minds when they learn the facts. It’s a subset of people whose minds are open that you’re aiming for.

Q: In some ways global warming is a stranger case. At least with abortion or creationism there’s some biblical basis for people who reject the science. But it’s not like you can find a biblical reason for rejecting the evidence on global warming.

Coyne: Well, yes you can. I’ve found that almost all creationists reject global warming. They believe that humans have stewardship of the planet, and whatever we do with the planet is OK. This brings on the rapture. If you look at the blogs of any of these intelligent design people, you find constant claims that global warming is just a big hoax. They don’t say it explicitly, but I think it’s the same reason why Ann Coulter thinks we can do anything we want to the environment. Because we were given stewardship, and we can bloody well wreck it if we want.

Q: Do you think one ideology is more susceptible than others to rejecting evidence?

Coyne: In the sense that Republicanism is more allied with religious views than left-wing politics is, I think being right-wing tends to lead to the rejection of science more than people on the left. There really isn’t a Democratic war on science. Granted, there are people like Jenny McCarthy and Jim Carrey who argue against vaccines, but I don’t think in this country at least the left wing is especially associated with rejection of scientific findings. I mean, most left-wingers are not anti-vaccine.

Q: But on issues like genetically modified foods and nuclear power, there are a whole set of less rigorous ways of looking at those things that are more associated with the left wing.

Coyne: Actually I didn’t think of those. But you know, we’re going to have genetically modified foods and we’re going to have nuclear power. I don’t think the left is going to block those things from happening. In terms of issues that are dire, that have real potential to hurt us, I think the most anti-scientific spirit is coming from the right.