In Medias Res, Part III

It’s almost three in the morning, and I’m driving toward Alice’s apartment. Part of me was tired over the adventure from a few hours ago, but the other side of me wanted to make sure that Alice got home safely. I assumed she was home because she was nowhere to be found when I went back to get my car after helping Tom out with the cowboys. However, as I was driving, I began wondering if I was wrong.

Nightlife in Juarez is weird. There are certain areas that are bustling with activity, especially those close enough for Americans to cross over and spend their dollars. The rest of the town is generally quiet… At least it was that way when I lived there. Since then, the escalation from the federal government in their war on drug cartels meant that several cartels fought, killed and took over Juarez as a prime gateway for transporting drugs into the United States. As soon as one cartel took over, another one would come along and stir things up.

Not so when I was living there. Yes, there was plenty of drug-related violence, but one cartel owned the city, and they made sure to also take their cut from the tourism industry. As I told the soldier, if he had gotten hurt, many people would have been made to pay the price of scaring away Americans. So, I was not worried about Alice’s safety, per se. I was worried I’d never see her again if she thought I had ditched her.

I mean, I did ditch her, but it was for a good reason. Also, I was back at my car no more than an hour after I stepped out of the nightclub. Did she really leave that quickly? As I looked at the outside of her apartment and saw all the lights were off, I wondered if she had gone home early or if she never went home. Three thirty in the morning was way too late for me to go knocking on the door, or to call her.

It’s 1990, and I’m riding my bicycle in the empty streets of Aldama at three thirty in the morning on a summer night. I had three whole months off from school back then, and I made sure to enjoy all of them by staying with dad up in the desert mountains. Because there was absolutely nothing that I had to do on any given day, I stayed up late and woke up just before noon. It was very rare that I woke up any earlier than 8am, and that was only when we were going on some trip with the family.

As I’m riding through town, enjoying how quiet everything is, a truck pulls up behind me. It is the local cop and his one partner. They turn on the blue and red lights and drive up next to me. They ask me what I’m doing up so late at night. Before I can explain to them that I’m just out enjoying the coolness of the desert night — and the incredible stillness of a whole town being asleep — they tell me to go home. “I’m sorry, but is there a curfew?” I reply. The cop driving the truck just stares at me.
“You’re Francisca’s son, aren’t you?” he asks. I nod. He smiles. “Go home. Tell her the fruit doesn’t fall far from the tree.”

It’s the early 1970s, and mom is in middle school. She stands up in the middle of the classroom while the teacher is out of the room, and she begins delivering a monologue. It’s her way of getting out all the thoughts in her head, I guess. A few years later, she is told that she is to stay home and take care of my grandmother, just like all the youngest daughters do. She is having none of it, so she goes to my grandfather and has a chat with him about her ambitions. He gives her money for school. A few years after that, I’m sitting in a baby carrier next to her while she’s taking courses on the law. That, or one of her friends is taking care of me while mom is in class. A couple more years, and mom is a lawyer, someone who is very good at delivering arguments and defending her point of view. I learn from her all I can in that regard, sometimes to my detriment.

As I’m walking away from Alice’s apartment building and back to my car, a police car pulls up. They turn on their lights and step out of the car, one of them shining his flashlight in my face. Instinctively, I raise my hands away from my body and look at the ground. “Hello,” one of them says.
“Hello,” I respond.
“What are you doing out here tonight?” the second one asks. I start wondering how much of my story they’ll want to hear. How much would they believe?
“I’m checking in on a friend,” I reply. “She was out late with me, and I lost track of her. So, I came to see if she was home yet.” They both look at each other then approach me. They ask me for my ID and I very slowly pull out my wallet. They ask me where my friend lives, and I tell them her apartment number. They look over at the building and see that all the lights are off, though one of them turns on on a higher floor from Alice’s. I see a person looking out the window.

Two years before, one of my little cousins (a toddler at the time) picks up the phone and dials 911. “Daddy is gone,” he cries. The operator keeps him on the line while she contacts a nearby patrol car. “I miss my daddy,” he says. While this is happening, my aunt is in the backyard, hanging clothes to dry. Me? I’m in one of the bedrooms, sleeping off a long night. My cousin left her little boy with my aunt — her mother — and we’re the only three in the room.

In my slumber, I hear a couple of cars drive up close to the house. This startles me because the street is usually very quiet, and the cars really made a lot of noise. Suddenly, someone knocks at the door. When they knock a second time, I get out of the bed and walk to the front door. Then I hear a third, very loud knock. When I opened the door, two police officers were standing about five meters from the door, pointing their guns at the door. It took a second for me to process the image.

“Come out, slowly,” the first cop said. I slowly raised my hands beside me and opened the screen door, then I stepped out. “Turn around and walk backward toward me,” he said. I did. When he told me to stop, I felt him grab my hands and slap on the handcuffs. “Is anyone else in the house?”
“Yes, my aunt and my little cousin,” I said.
“And no one else?”
“No one else,” I said just as my aunt came out the door.

My aunt explains to them that it was just us three in the house as two other officers who had just arrived join the second cop and walk into the house. One of them then comes out with my little cousin in his arms. “This little guy called 911,” they explain to us. “He was looking for his daddy.” As everyone nervously laughs, I kind of smile at the cop and then signal that I’m still handcuffed. “Oh, right,” he says, and then he takes them off.

In some other universe, I’m laying dead at the doorway. I’m sure.

As I look at Alice’s apartment along with the two cops, one of them turns around and walks off talking to his radio. He’s running my name through their database back at headquarters. They won’t find anything. I don’t even have an outstanding ticket, and I still don’t to this day. As he comes back and informs his partner that I’m “clean,” Alice pulls up with friends in a car, slowly stopping a few yards away. “And there she is,” I say.

An hour later, Alice and I are sitting on the sidewalk. She’s chewing gum loudly, and leaning her head against my shoulder, looking up at the sky. You can hardly see any stars because of the light pollution around us. “So you just decided to chase them and help that guy, huh?”
“Yeah, I know. I know. It was stupid.”
“Heroic, though. You’re quite the boy scout.”
“Stupid boy scout,” I tell her.

We sit there for a few more minutes before I tell her that I have to go. She kisses me on the cheek, and I’m on my way. After that, I didn’t see Alice as much as before. We kind of just drifted away, and I didn’t blame her. I left her behind in a dangerous city when I went chasing the group that was chasing the soldier. I could have gotten hurt, and she would not have known what happened. This pattern repeats itself every two to three years with other relationships until 2006.

I never saw Alice after moving out of El Paso.

It’s three in the morning on a night in August 2006, and I’m leaving the apartment of a certain young woman. There is a ticket on my windshield because I parked in a spot that gets cleaned overnight. It was for $50, but it was worth hanging out with her and watching Eddie Izzard while laughing and getting to know each other. By eleven that same morning, I’m across the street from her apartment, paying the ticket. A couple of days later, we’re out on another date, and then another… And then another.

Two weeks later, we’re on a couple of swings at a playground at a nearby park. “So you’re almost done?” she asks.
“Yeah, I just have to work on my capstone project.”
“And then what?”
“I don’t know,” I reply. I look up at the clear blue sky and take a deep breath then let it out. “Save the world, I guess?”
She smiles and says, “Then it’s time to get going…”

We got going.

The Pandemics You Can Try to Stop

In mid-April 2009, I noticed that the influenza season in Mexico had not ended the way it should. I contacted friends and acquaintances in Mexico City and other parts of the country to ask them what they were seeing. Epidemiologist colleagues told me that they had noticed the same thing. A season that should have been trending down was not doing so, and local hospitals and clinics were being overrun by people with respiratory symptoms.

That night, I emailed my fiancee (now my wife) and told her that I had a bad feeling about what was going on. I told her that it made no sense for Mexico to still be seeing their season being so prolonged. The US season was winding down, though. I remember writing to her that I hoped I was wrong.

After that whole thing was done and over with in 2010 (because it swung around and hit us twice in 2009), I wondered if there was something that we could have done to stop it. By “we,” I mean us in public health. At the time, I was just a freshman epidemiologist with a couple of years of experience. In ten years time, I would be a doctor of public health, and we would be facing another pandemic… The next pandemic.

Can pandemics be stopped? In one word: Yes. But it is very complicated. For example, the HIV/AIDS pandemic could have been stopped if enough resources had been put into place the minute it was identified as a sexually-transmitted infection. HIV was infecting the “undesirables,” though, and enough leaders (religious and political) were calling it a godsend to get rid of said undesirables. It was a punishment from above, not the continuation of a zoonosis that had started decades earlier.

Respiratory infections are a whole other animal, though, especially the ones with relatively (RELATIVELY) low fatality rates. Those with higher rates, like Ebola, kill the hosts before the infection is spread too widely. (Global travel is challenging that, however.) Those that infect you, incubate, and then attack but leave you well enough to have you go to school or work have the ability to really cause disruptions.

I mean, look out the window right now if you’re March 2020.

Bacterial pandemics, like the ones that cholera has caused, are mostly under control by our ability to deploy control measures (clean water and vaccines) and antibiotics. But we’re also entering a sort of “post-antibiotic” era where bacteria are evolving faster than we can make antibiotics against them. So future bacterial pandemics will also require control measures that are not pharmaceutical in nature.

What we can do — and we should do at the end of this pandemic — is have a foolproof, well-researched, practiced yearly, top-of-the-line pandemic preparedness plan that spans the entire spectrum of everything we know has happened and could happen. From what a person will do in their everyday life to what small businesses will do when left with no workers and no employees, to what big groups and organizations will do to keep the disease from spreading. We can’t go blind into the next one — like we did into this one — because the next one could be the big one.

Then there are the epidemics and pandemics of non-communicable diseases, like obesity, diabetes and opioid use/abuse. Those are going to be super-difficult to figure out, perhaps more difficult than infectious disease. This is because we are social animals who’ve managed to separate into tribes and social strata. If something is happening to “them” and not “us,” and it will stay “over there” and not come “here,” we kind of look the other way.

Here’s an example… In Philadelphia, like in other cities in the United States, there is an epidemic of opioid use and opioid overdoses going on. Many of the people using and abusing opioids are using heroin, an injected opioid. (You can also smoke it, by the way.) When people inject heroin and other drugs, their risk for blood borne infections skyrockets. They share needles or trade drugs for sex (that is performed unsafely), and they get infections with Hepatitis B, Hepatitis C and HIV.

Look at what is happening in Minnesota.

Look at what happened in Indiana, that bastion of public health.

No doubt, Philadelphia is lining up to be the next epicenter of both overdose and blood born infections… If it isn’t already. To counter this, city health officials and health leaders have proposed a safe injection site. In a safe injection site, the user goes in, gets a clean needle and a place to rest. They get medical supervision while they use their drug of choice. Should something go sideways, they get immediate medical attention.

But drug addiction — against all evidence — is thought by many to be something that happens to “them,” the “others,” the undesirables. It doesn’t happen to “us,” the clean people, the God-fearing people. And if something is to be done for “those poor people,” it better not be done in our back yard, or my neighborhood, or anywhere that could possibly make me think that help is happening at all.

On Monday, March 16, 2020, supporters and detractors of a safe injection site in Philadelphia came together to give their opinion on a bill that would ban such help for “those people.” As you can imagine, the discussion was lively, including some gems like:

“Why would we want to be the first to experiment on this?… “It makes no sense whatsoever. I’m full of compassion for [people suffering from drug addiction], but I’m more full of compassion for my residents and all the residents symbolized by these civic associations.”

There are no safe injection sites in the United States, but there are plenty in other parts of the world. Those other sites have shown success in reducing overdoses and in guiding users into recovery programs. On top of receiving clean needles and medical supervision, they also are referred to care, and many of them take it. Some place in the United States, a place where these programs are needed, is going to be the first place, the “experiment.”

But the comments did not stop there.

Capozzi’s sentiment was echoed in the testimony of South Philly resident Anthony Giordano, who represented a community group called Stand Up South Philly and Take Our Streets Back.
“Safe injection sites are not safe,” he said. “Allowing people to consume illegal drugs of unknown composition in a so-called medical facility is beyond my comprehension. How is this safe? Helping people further harm themselves under the guise of a legitimate medical intervention just doesn’t make any sense.”

Some people tried to use science and reason:

“It amazes me that we’re sitting here talking about making a medical decision and we’re listening to public opinion,” she said. “We need to make this based on information like Dr. Farley suggested: medical consensus, meta-analyses and a medical opinion.”
Milas was unique among the four medical professionals because the opioid crisis had affected her a bit more personally. She had two sons die of opioid overdoses – one was 27 and other 31, she said.
“At the 100 legal supervised injection sites worldwide, there are no recorded deaths,” she testified. “Had my sons overdosed at a Safehouse-type facility, they would have had a 100 percent chance of survival.”
Roth piled on.
“The scientific evidence from peer-reviewed journals on these sites is clear,” she testified. “They reduce overdose mortality rates, HIV, environmental hepatitis risk, they improve access to health and social services, they help reduce substance use and help people enroll in treatment. Furthermore, they’ve helped improve community health and safety. In neighborhoods where a [safe injection site] exists, there are actually reductions in public injection and improperly discarded syringes, reductions in drug-related crime, and the demand for ambulance services for opioid-related overdoses goes down.”

You can read the rest of the South Philly Review article to see how one of the legislators used a very flawed non-scientific “study” to support his claims that safe injection sites are absolute evil. That’s where scientific discourse in public policy has gone… To unsubstantiated and flawed opinion surveys.

As I’ve stated before, several times, public health in the United States and in much of the world is all about politics. You better pray that the right political party is in power, or the right people are in power, so that the decisions that need to be made are informed by evidence and science more than the “what ifs” of public opinion. This is Democracy getting in the way of things, unfortunately.

As we saw in Wuhan, China, when authorities there felt the need to shut down cities, they did so without any apparent issues. (There might have been issues, but we’ll be darned if we ever find out.) That’s an authoritarian government for you in a very collectivist society. Can you imagine trying to shut down even a small town here in the United States? With people with guns? And SUVs?

Good luck.

So, yeah, we might not be able to stop this pandemic, or the next one. After all this, I’m going to focus on having what I call “premier” surveillance systems and response plans. We’re going to learn a lot from this pandemic, and I plan to make it my life’s work (on top of all of my other work) to make sure we don’t forget about this time, next time.

Until next time… Thanks for your time.