Thursday, September 13, 2012


On Saturday I went to a friend's wedding.  It's the 6th wedding I've been to in the last 5 years.  It was a small, intimate, outdoor wedding of family and close friends.  Though the forecast threatened scattered thunderstorms, the weather couldn't have been more perfect.

I sat (as I usually do) next to friends I knew in undergrad - some of them married, many of us single.  My friend sitting next to me remarked, "Every time I come to a wedding, I feel like I have to re-examine the course of my life."  And I sympathize with him 100%.  It seems like friend after friend has been getting married, and where am I?  Where are the rest of us?  Even if it's not entirely true, it feels as though we're lagging behind in "life progress."  It's rather unsettling at times.  I'm so far from marriage that I can't even see it in the distant horizon.

At least my other friends (married couple) spoke the truth that as we get older, our dating pool only increases (formula: minimum age of dating partner = 1/2 your age + 7).
The following day I met up with another friend (also married) on my way back from the wedding.  We chatted for a while on politics and catching up and all that.  He always relished my medical stories, especially the gory ones, haha.  His wife was a trooper too with my descriptions.

After a while when it was time for me to go, he gave me the location of his brother's grave, the same brother I had considered one of my closest (and longest) friends.  It felt strange driving to his grave.  I found it rather easily.

There I stood on the road, looking between two small stone walls along rows of graves.  The sun was bright, the sky blue, and the trees and grass green.  At the far end stood a statue of Martin Luther.  And there I saw his sign, a temporary placement for his headstone not yet finished.  Standing at the foot of his grave, I could see it was a recent-ish burial as the grass had not fully grown in the spot.  I had brought no gifts, no tokens.  I saw a single black feather and placed that under the sign.

And I began to say my last words.  It was weird, talking to no one but the breeze.  I wasn't even sure of what to say, my ramblings barely coherent even to myself.  And then I teared up as I admitted that I was bi, something I never got around to telling him while he was still alive.  The words choked, stuck in my throat as I said, "I know I never told you, but I thought you should know . . . I'm bi, probably more gay than straight but I'm working on figuring it out.  I know you would've been okay with it, you would've helped me figure it out in your own way, but there's no way to know now, eh?"

It was awkward, but what does that say?  What does that mean?  That even now, even talking to no one but the air, those words would be so damn hard to say?  I suppose I really haven't changed too much since the beginning of this blog.  I don't see an endpoint.

Having too much time makes idle thoughts wander, too much time to re-examine and yet still do nothing.

Wednesday, September 5, 2012

Treatise on a Cultural Truth

I wish to begin a discourse, a treatise, on a cultural truth.  That what we believe is true, correct, and accurate may not hold true across all peoples.  Given the same data and knowledge, we may reach very different conclusions - each with its own merits.  Warning: this post is rather long.

Early last week, the American Academy of Pediatrics (AAP) revised their position on infant male circumcision, stating:
"New scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure, but the benefits are not great enough to recommend routine circumcision for all newborn boys."
It is a shift from the AAP's neutral stance that had been reaffirmed since 1999.  The statement was revised by a committee that had reviewed the medical literature on the subject for the past decade.  This is in stark contrast to a German court in Cologne that essentially banned non-medically indicated circumcision, and you can read my thoughts in my post here.  To me this contrast highlights one of the age-old questions: "What is truth?"  Is truth objective or subjective?  Is it an immutable reality or something malleable to our perspectives?

The BBC News wrote a nicely balanced article, Circumcision, the ultimate parenting dilemma, comparing and contrasting how the US and Europe have approached this topic, looking at the same medical literature, and coming to polar conclusions.  Whereas the AAP has move more "pro-circumcision," the Royal Dutch Medical Association maintains its neutrality (if not slightly "anti-circumcision") stance.  At the end of the day, despite the science and the medicine, it would appear that the decision is decided upon a cultural truth.

Around the same time as the AAP's new guidelines, Dr. Tobian et al. - the same Dr. Tobian of Johns Hopkins who conducted one of the African trials that linked circumcision status to lower HIV infection rate - released an article titled: "Costs and Effectiveness of Neonatal Male Circumcision."  Instantly news stations ate up that press release, with news titles such as:

All worded rather strongly with words such as "will go up" or "will spike," suggesting an objective immutable truth to the study.  So what did the study report?  It says that if the US infant male circumcision rate continues to fall and fell to 10% (the approximate rate in Europe), the following could occur:

Lifetime health care costs per man: increase by $407
Lifetime health care costs per woman: increase by $43
Net expenditure for the US health care system per year: increase by $505 million, reflecting an increase of $313 per male circumcision not done
Net expenditure for the US health care system over 10 years: increase by over $4.4 billion

Lifetime prevalence of HIV for men: increase by 12.2%
Lifetime prevalence of HPV for men: increase by 29.1%
Lifetime prevalence of HSV-2 for men: increase by 19.8%
Lifetime prevalence of Infant urinary tract infections (UTIs) for men: increase by 211.8%

Lifetime prevalence of bacterial vaginosis for women: increase by 51.2%
Lifetime prevalence of trichomoniasis for women: increase by 51.2%
Lifetime prevalence of HPV for women: 12.9-18.3%

Those are big numbers, fighting numbers.  But they are potentially misleading numbers.  First of all the calculations based off of prevalence is, in my opinion, disingenuous.  Prevalence is the total number of people in the population with the disease at a given time.  The incidence rate is the number of new people contracting the disease within a time period.  The prevalence for a disease such as HIV, HPV (genital warts or cervical/anal cancer), or HSV-2 (herpes) will always be higher than the incidence rate.  Why?  Because people are living longer with those diseases, and they're considered "chronic," so the prevalence will always increase even if the incidence rate falls.

Second, the study fails to compare/contrast incidence rates between the US and Europe.  It instead falls on relying on data from the African trails on HIV and other sexually transmitted infections (STIs).  When Tobian was interviewed and asked about comparing the US to Europe, the article states:
"It is too difficult a comparison because "we have very different racial and socioeconomic backgrounds and different transmission dynamics," he said."
Wait a second there.  Tobian et al. used data from Africa, where racial and socioeconomic backgrounds and transmission dynamics are clearly more different compared to the US than Europe compared to the US.  Didn't he just invalidate his study, in some sense?  So what is the comparison between the US and Europe?

Europe (overall): 143 cases per 100,000 people (2000) to 332 cases per 100,000 people (2009)
US: 405.3 cases per 100,000 people (2009) to 426 cases per 100,000 people (2010)

Europe (overall): 16.8 cases per 100,000 people (2000) to 11.7 cases per 100,000 people (2009)
US: 98.1 cases per 100,000 people (2009) to 100.8 cases per 100,000 people (2010)

Europe (overall): 6.6 cases per 100,000 (2004) to 7.8 cases per 100,000 (2010)
US: 16.3 cases per 100,000 (2010) - CDC's website wasn't too user-friendly for finding info

HPV and herpes aren't tracked as closely and are difficult to track because of a latent asymptomatic phase.  But the US CDC cases seem to be overall steadily trending up, though herpes appears to actually have had a steep decline in the past 2-3 years.

As you can see, the US has higher incidence rates of all STIs, including HIV, compared to Europe.  At first glance, most of the STI rates in the US are either stable or slowly trending up at a rather consistent pace since the 1960s or so.  As infant male circumcision rates have decreased since the 1980s, one would expect to see a quicker pace of increase starting in about 1995-2000 or so (when the first cohort of more uncircumcised males reached age 15 or so).

It's true that Tobian et al.'s study is true utilizing the data he used.  But with additional data, different data, I reached a different truth.  What I see is that:
  1. the rates of STIs in Europe (on the whole, individual countries vary) are lower than in the US - and we should figure out why before resorting to cutting off a part of the human body.
  2. the velocity of increase in rates of STIs in the US aren't speeding up as the years progress, which should theoretically correspond to a decrease in infant male circumcision rates over the last 30-40 years if Tobian's assertion is correct.
  3. despite an estimated 211.8% increase in male UTIs in Tobian et al.'s study, the rate of UTIs in baby boys is still at about 1% or less (a lower rate than for females at any age).
  4. despite an estimated increase in HPV among both men and women in Tobian et al.'s study, there is now a vaccine for HPV that he likely didn't factor in (a vaccine, might I add, that has been recently FDA-approved for use in men as well).
So we must sometimes evaluate what we deem as "truth."  Even if we look at the same object we may still see it differently.  Culture can shape our truths and to evaluate our truths we must sometimes not evaluate the data, the science, the medicine, but rather the culture with which those truths are framed.  Below are some well-written challenges against the culture truth of infant male circumcision in the US:

Tuesday, September 4, 2012

The First Lady with Grace

I just got done watching the first night of the 2012 National Democratic Convention.  I was floored by Michelle Obama's speech bringing the first night to a close.  I'm also rather floored that it's already posted in its entirety on YouTube for you all to replay.

I believe it connected with many Americans in a very personal way.  It highlighted the struggles to improve one's station in life and that though it may not be realized in one's own life, it can happen through one's children or one's children's children.  It's not dissimilar to the story of my own family, immigrating from Hong Kong in search of a better life.  How my mom's family lived together in one apartment and I was cared for by all family members when I was born.  How my parents, grandparents, and uncles began on food stamps.  How my family worked its butt off to allow me, my brothers, and my cousins to be where we are today.

She tactfully touched upon all the social issues that President Obama has in some way championed - women's rights, healthcare reform, gay rights and marriage, and support for veterans.  She humanized him in a way that only she would be able to do.  She gracefully didn't lampoon the Republicans, something very refreshing to see.  It's easy to see why she's the most popular woman in the US.

I do agree with the news commentator on the TV - the Democrats have the social issues in hand, lock and step, but they need to refocus a good portion of the remaining nights of the Convention on the economic issues.  True, the economy has recovered and is growing, albeit slowly.  But they still need to bring that to the forefront.