Friday, 30 October 2020

To the victors go the spoils, to the losers go the votes?

Victory and concession speeches carry no legal weight.

A candidate can concede or declare victory at any point during the vote counting when the tally looks bad/good for them, but the actual winner is the person who has the most votes when the counting stops.

In recent elections, some Republicans have petulantly refused to concede. Roy Moore, for example, never conceded, but that made no difference to the fact that he lost.

Concession is a mark of civility and class, like calling the victor to congratulate him or her, thanking supporters, and speaking warmly of hope for bipartisanship. It is crass, petty, immature, and selfish for the loser not to concede gracefully. But Republicans think they have an entitlement to rule, and that no non-Republican winner is legitimate, even in a landslide.

As noted above, claims of victory or defeat have no legal significance, but they do have psychological significance. If the legitimate winner wrongly concedes, as Gore did in 2000, it has the effect of making any dispute about the results seem illegitimate to the public.

In the imminent 2020 election, a record number of ballots will still need to be counted after election night. Federal law gives states 35 days to count them, although some individual state laws mandate a shorter timeframe. Too many ballots will remain to be counted for us to know for certain who has won the presidential race and many down-ballot races on election night, unless the victory is by such a huge margin that it exceeds the number of ballots yet to be counted.

So, expect a harrowing election night, but do not expect to go to bed knowing the winner of most races. Nor should you expect many candidates of either party to concede that night. Do expect Trump to declare victory no matter what the vote tally shows on the night. This is tactical; his Orwellian strategy is to try to make people believe falsehoods by simply stating them repeatedly as if the mere repetition of lies makes them true.

It is anticipated that there will be a "red mirage" on election night, with more Republicans going to the polls on the day and more Democrats voting by mail, leading to a false sense of Republicans leading in many races until all the votes are counted.

Expect Republicans in general, and Trump in particular, to argue that the count should be stopped and mail-in ballots should not be counted. In anticipation of this, some Republican-controlled counties are setting aside mail-in ballots to count after Election Day with the expectation that they may not be counted at all.

If the red mirage does not occur, and Trump, and other Republican candidates, are behind in important races, expect them to abruptly change their tune and argue vociferously that every ballot must be counted and the election is not over until they are. Remember that one group of ballots not counted until after election night is military ballots, which skew heavily Republican.

The Republican stance on counting ballots will depend on how they are doing in their races, but either way they will pretend it is on principle. Both parties will find this risible, but, just like with the SCOTUS seat, Republicans do not care about hypocrisy when it benefits their side. Not a single Republican believed the argument that filling Ginsburg's seat was not hypocritical after their refusal to fill Scalia's because this time the same party controlled both the Senate and the White House, They simply did not care. They had power that they could use to benefit their own side, so they did.

Given the prevailing belief among Republicans that mail-in ballots will contain more votes for Democrats, they have been trying to slow down the mail so that ballots will not be received by Election Day. Some states require ballots to be postmarked by Election Day, but others require them to be received by Election Day. Alaska and Ohio have the most generous deadlines, accepting ballots up to 10 days after Election Day. By slowing their transit, the Republicans can prevent ballots not received by Election Day in states that require it from being counted. In response to the Republican mail tampering, some states have scrambled to change their laws to allow counting of ballots received after Election Day. These changes have been challenged in court by Republicans, with mixed results, depending upon whether the change was initiated by the state legislature or the state courts, and other factors. Another strike against the already appalling record of 2020 may be that it proves to be the first U.S. presidential election when mail tampering is such an effective voter suppression tactic that it changes the outcome.

The only guarantee of a Democratic victory is such a large majority of votes for Biden on Election Day that the uncounted ballots will not change the outcome. If that transpires, it is unlikely to prevent Trump from challenging the results. He, and the Republicans, can still harness electoral votes to override the popular vote.

How? Shockingly easily, as it turns out: All states but two give all of their electoral votes to the candidate who wins the popular vote in the state. (Nebraska and Maine divide them proportionally based on percentage of popular vote.) But they do not have to do this; the state legislature is at liberty to ignore the popular vote and give the state's electoral votes to the candidate of their choice. 

That sounds radical, but the legal barriers are surprisingly thin. The Constitution allows states to choose electors 'in such Manner as the Legislature thereof may direct'. All states currently have laws directing their legislatures to allocate electors based on the popular vote, but these laws can be changed. A state with a Republican-controlled legislature and a Republican governor (of which there are currently 21) can do it easily; if the governor is a Democrat, the legislature will have to have a sufficient number of Republicans to override the governor's veto. If a state has both a Republican governor and a Republican-controlled legislature, it is likely to be a red state in which the popular vote favours Trump anyway, but there are a few Republican-controlled battleground states that could go to Biden (e.g. Arizona, Florida, Georgia, Ohio, Texas).

If Trump is in need of electoral votes, states with Republican-controlled legislatures and Republican governors can simply ignore the state's popular vote and allocate all of their state's electoral votes to Trump. This manoeuvre could give Trump a second term even if he loses the popular vote by a wide margin, and even if he is unable to halt counting of mail-in ballots or otherwise invalidate legal Democratic votes.

Of the many nefarious schemes the Republicans are plotting to secure victory, this strikes me as the easiest and most likely for them to pursue unless the electoral vote is so close they they only need to stop the vote count in a few states to reach 270, in which case they have the federal courts in their pocket to enable them to do that.

Friday, 24 April 2020

As Higher Education Loses the War on Anti-Intellectualism and Greed, Aesthetics Are the Forgotten Casualty

When I was a high school senior choosing a college, one of my main criteria was aesthetics. I demanded a beautiful campus, with historic, ivy-covered buildings, with wood-framed chalkboards in the classrooms that hadn’t been replaced by ugly, modern whiteboards. I wanted formality, ideally academic robes, and the ability to live in a dormitory on a leafy, idyllic campus for all four years. I wanted to feel my place in a long line of scholars, going back to ancient Greece, soaking up knowledge from venerable library books that had served generations of learners. If Harry Potter had existed then, I would have said I wanted a university version of Hogwarts. Oxford or Cambridge clearly would have suited me best but, as an American, I sought out the most aesthetically-suitable of the New World options. Luckily, the U.S. does have a wide selection of historic colleges. But it might not have them for much longer. Higher education was already under threat in the United States before COVID-19, and it appears that the pandemic will serve as the final nail in the coffin, relegating the United States to the Third World status that its lack of an adequate social safety net has revealed it deserves.

Anti-intellectualism, manifested as a belief that your ignorance is as good as my knowledge, to paraphrase Asimov, has led to widespread denigration of the value of higher education. The Internet, potentially a way to equalise the dissemination of knowledge, has led to a devaluation of experts. “Why do I need to go to college when I have Google?” is the new excuse of the undereducated. Colleges are complicit in their own demise by offering not just individual courses online but entire online degree programs, up to and including doctoral level. Institutions saw online education as a way to increase revenue because online students don’t require campus facilities or staff, and courses can be taught by grossly underpaid adjuncts, who can be hired on a per-course basis, without the expense of benefits. A college can charge the same tuition for an online course as for the in-person version, but its costs are exponentially less.

The third fatal blow to higher education, after anti-intellectualism and online education, is the vocational attitude adopted by potential students and their parents in response to the outrageous costs of tuition and fees for a four-year undergraduate degree. A college education used to be the ticket to a white-collar job, and higher earnings than your high school-educated peers. But the 6-figure price tag of college, coupled with the lifelong indentured servitude of student loans, has driven students to think of themselves as customers, buying a degree that will lead to a job that pays enough to justify the expense of student loans. There is no intellectual curiosity, no learning for its own sake. Students go through the motions of taking classes, insistent that the money they’ve paid entitles them to passing grades in each course, and a degree, regardless of whether they have done any work or learned anything. They also require that degree to lead to a specific job. The result of this attitude is a drastic decline in the number of students majoring in the social sciences and humanities, and an increase in students choosing majors like nursing. When I went to college, I was told that what I majored in as an undergrad was largely irrelevant. The point was to receive a good liberal arts education that would imbue me with the writing, analytical, and critical thinking skills to embark on the career of my choice. Specialisation, I was told, should come in grad school. It’s impossible to imagine any high school senior being given that advice today.

This attitude of four years of college being an idyll of reading and intellectual discussions on a leafy campus harkens back to the days when higher education was the exclusive purview of the wealthy. Only those who did not need to make a living, who came from family money, had the leisure to study and learn. Indeed, no matter how intelligent you were, like poor Jude, you could not gain entry to a university in the UK unless you had the fortune to be born into the higher classes. I wasn’t; I was the child of a poor single mother, and female, both of which would have precluded my receiving any education at all in previous eras. 

So, I am not waxing nostalgic about a time when most people were excluded from university education. But there was a golden age in both Europe and the United States, after World War II, and the GI Bill, when higher education was opened to all, based on merit rather than money, sex, or class. That was a time when you could afford to go to college regardless of your background, and you could devote yourself to getting a liberal arts education rather than viewing higher education as vocational. Technical and vocational schools were for the non-college-bound, the electricians and hair dressers, a grey area between blue- and white-collar work that requires some training beyond high school. They serve as a modern replacement for apprenticeship.

Now, the pandemic has caused most colleges and universities in the United States to send students home to finish out the spring semester via online learning. Graduation ceremonies have been cancelled, and whether in-person learning will resume in the autumn is as yet undecided. Some high school seniors are choosing to take a gap year, attend school online or closer to home, or forego college altogether. Schools have been pressed to partially refund room and board money for the spring semester, and students are suing to recover a portion of their tuition, arguing that the hastily arranged online versions of their courses are not an equivalent learning experience. Federal aid has so far pumped $14 billion into schools that are haemorrhaging money, laying off staff and faculty, and facing potential closure, but it’s a drop in the proverbial bucket. Schools have requested $50 billion more,  just as an initial Band-Aid, with hundreds of billions more needed to keep them from closing if enrolment drops in the fall, as it is almost guaranteed to do.

That money will not be forthcoming from Congress so schools will close, and with their closure the traditional college experience will disappear forever. In a post-pandemic world, small colleges with quaint, picture-postcard campuses will have closed, and students will be stuck with dodgy online schools, community colleges, or big universities with ugly, modern buildings. The transfer of learning opportunities to new environments will deprive future students of the opportunity to spend four of their most formative years on the quad, learning purely for its own sake, enjoying an idyllic, transitional time between childhood and adulting, developing a moral compass, and a sense of their place in the history of learning. No online course can replicate having an engaging, intellectually-stimulating class in a historic building on a crisp autumn day, watching the leaves change outside the classroom windows. No more discussions spilling over into communal meals in the dining hall, followed by late night study sessions in the library, and deep conversations in the dormitory common rooms. These experiences are a vital part of the learning process; they cannot be replicated online nor in ugly, modern facilities.

I mourn the loss of the college campus and the traditional college experience. It's a vital part of growing up to be an intelligent, educated adult. I worry, from the perspective of historic preservation, what will happen to the campuses when so many schools close. But there isn't a damn thing I can do about it. The forces of anti-intellectualism and capitalist greed have won out over aesthetics and learning. Knowledge, as it turns out, isn't power. 

Tuesday, 31 March 2020

Post-Pandemic, Expect a Swift Return to Status Quo Ante

This pandemic should be a wake-up call to decrease economic inequality. Instead it will exacerbate it.

If every country had locked down sooner, the spread of the virus could have been arrested.

If the Chinese had recognised its pandemic potential sooner and prevented people from travelling abroad, it could have been contained within China.

If China had caught it even earlier, it might even have been contained within Hubei, the province where it originated.

If factory farms and consumption of wild animals had been eliminated after previous pandemics, we’d have fewer zoonotic viruses to fight.

If the virus hadn’t struck near the time of the Chinese New Year festivities, when Chinese emigrants travel home to celebrate then fly back to the countries into which they have immigrated (e.g. northern Italy), then the spread would have been slower, with more time for countries to react.

If governments at all levels had learned from previous pandemics to have a plan in place in anticipation of the (inevitable) next one, it could have been activated in a dispassionate, nonpartisan manner without time-consuming bickering about the appropriate response.

If supplies of PPE had been stockpiled against future need, demand would be less likely to exceed supply in a crisis.

If people practiced social distancing, with or without government guidance, the number of infections would be considerably less.

If tests weren’t withheld to keep infection numbers artificially low, we’d have a better estimate of actual cases.

If death certificates weren’t fudged with other causes of death to hide COVID-19 fatalities, we’d have a much more accurate tally of how many deaths are attributable to this virus.

If, if, if. As the human and economic toll mounts daily, we are justifiably wracked with self-recrimination for not doing more, sooner, to contain the virus. Will ‘we’, speaking broadly for humanity, both citizens and government officials, learn from our COVID-19 mistakes and act with more alacrity the next time a novel virus is suspected in a patient? I doubt it. I’m finding it hard to be optimistic. Rather than “buck stops here” mea culpas from elected officials, we are getting blame-shifting and denial. Rather than increasing international coordination and cooperation, we are seeing a free-for-all fight for PPE and medical equipment, and a refusal to accept aid by countries that need it, such as Iran and North Korea, based on pride and propaganda rather than public health considerations. Many countries are limiting testing for COVID-19 to keep numbers low. Federal officials in some countries, such as Brazil, Mexico, and the United States, have been locked in often vitriolic opposition to state and local officials over the question of whether to shut down businesses, with citizens caught in the middle, sometimes taking it upon themselves to self-isolate and expressing frustration and disgust with their political leaders.

This depressing pattern does not hold true for every country. Some affluent European and Asian countries, such as Denmark and South Korea, managed to take steps to save both lives and businesses. But they are outliers, with smaller, and more homogeneous, populations who have higher levels of trust in their governments. The delayed and mixed response of most of the world is disheartening. Even when national and subnational governments get their act together to enforce social distancing, people resist and defy directives that have been issued solely to protect them. Except for totalitarian governments who exert control over citizens to preserve their own power and enforce their ideology, governments are now making a trade-off between public health and the economy that has the potential to get them booted from power. Electorates reward incumbents in good times and punish them in bad times, regardless of their actual responsibility for economic conditions, which don’t usually correspond to election cycles in any case. A government who saves its citizens lives but sends the country into a recession is setting itself up for electoral vengeance, however undeserved.

What will the “if only” self-recriminations, electoral punishments, and economic fallout mean for the future? Ed Yong, in his March 25 piece for The Atlantic, opines:
“Veterans of past epidemics have long warned that American society is trapped in a cycle of panic and neglect. After every crisis—anthrax, SARS, flu, Ebola—attention is paid and investments are made. But after short periods of peacetime, memories fade and budgets dwindle. This trend transcends red and blue administrations. When a new normal sets in, the abnormal once again becomes unimaginable. But there is reason to think that COVID-19 might be a disaster that leads to more radical and lasting change.”
I don’t agree; once social distancing directives are removed, I predict a swift return to status quo ante.  That is an empirical prediction, not a normative wish. We should use this as a learning opportunity, to address global health, economic inequality, authoritarian regimes, lack of education, the idiocy of religious belief. Last year a troubling statistic went viral in the United States: 40% of Americans could not scrounge up $400 in an emergency. The support for pseudo-populists like Trump and Johnson and Bolsonaro around the world, and genuine populists like Bernie Sanders, the anti-immigrant sentiments, the rise in racism and sexism, are a direct result of growing economic inequality. We are returning to a feudal society of a wealthy 1% and a peasant population dependent upon the crumbs the rich deign to bestow in wages, benefits, a social safety net. There has been an undercurrent of rage that has been simmering for years as the middle class has shrunk and younger generations are unable to achieve the standard of living of their elders. Between the financial insecurity of the gig economy and never-ending student loan payments, hallmarks of adulthood like savings and home ownership are increasingly out of reach for even college graduates, hence the alarming statistic about nearly half the population being unable to find $400 in a pinch.

The most compelling lesson of this pandemic has nothing to do with viruses, public health, political leadership, or culture. There are fascinating and important lessons to be gleaned from all those facets but they pale in comparison to the simple fact that most of the world’s population, even in the wealthiest developed countries, still lives hand to mouth and is one paycheque away from not being able to pay current bills. Measures to delay rent and mortgage payments, prevent utilities from being disconnected, temporarily pause student loan payments, and halt evictions are only necessary because so many people are unable to survive for even a week without pay. The wealthy have tried their usual avocado toast blame game, but no-one is buying it this time. It’s impossible to deny that the reason so many people don’t have even a month’s cushion in savings is not because of too many lattes but because they—we, I should say, as I am part of this cohort—are not earning enough to save. It’s not self-indulgence stopping us from saving and investing; it’s a lack of jobs that pay a living wage.

If nothing else changes, post-COVID-19, this glaring problem should be addressed. Imagine the situation today if every individual and business had 6 months of savings to draw on. The damage to the economy, the need for taxpayer-funded relief packages, the failure of businesses and looming homelessness and crushing debt for so many Americans would disappear.

But it won’t. Nothing will change. The wealthy will turn this crisis to their advantage, squeezing even more money out of the poor in interest and penalties for every bill paid late. I am sure the credit card companies are salivating at the prospect of all the interest and penalties they will be able to charge.  Expect creditors to raise interest rates. Expect employers to lower wages, cut benefits, and not hire back much of their laid-off workforce, using the shutdown as an excuse to retool their businesses to lower overhead and increase profits. We were living in a world that catered to the very rich at the expense of everyone else. That world hasn’t changed because a few hundred thousand mostly elderly people have died of a virus. The rich will continue to get richer and the poor will get poorer. This pandemic should be a wake-up call to decrease economic inequality. Instead it will exacerbate it.

Monday, 30 March 2020

Another Battle Front in the War on Women

Childbirth has always been dangerous for both the women and babies involved. In the developed world, dangers from lack of medical care have been replaced by dangers from overly aggressive, unnecessary and harmful medical interventions. Every birth is a battle in the war between women and medical staff, and there can only be one winner: Either the woman and baby win or the medical staff wins. Women have only three defensive weapons to bring to their personal childbirth battles against medical staff:  1) Knowledge that the medical interventions being forced on them are unnecessary and unhealthy; 2) The word "NO!"; and, 3) a personal advocate, such as the baby's father or a doula.

That last defensive weapon is critical because a woman in labour is not in the ideal position to fight verbally, or physically if necessary, against intrusive medical staff who are determined to violate her bodily integrity and harm both her and her baby physically and psychologically.

The novel coronavirus pandemic prompted some hospitals in the United States to issue policies forbidding visitors—including birth partners. In practice this means women giving birth during the pandemic would be forced to give birth with only medical staff present, and new fathers would not get to meet their children until the mother and child's release from hospital.

To say I have been apoplectic with rage over this new policy is a gross understatement. My fury and frustration have been incandescent. Without someone on her side, a woman goes into battle with just two of those three defensive weapons, and the results will be catastrophic for both mothers and babies. A woman should not need a back-up to her birth plan and the word "NO!", but, in practice, a spouse or doula to reinforce the "NO!" is crucial to avoiding a cascading series of harmful interventions. (Which is not to say that all partners behave as advocates: Some side with medical staff and put additional pressure on their partners to acquiesce to harmful medical interventions.)
Medical staff undoubtedly reacted with glee to the prospect of having their victims even more at their mercy, but their cruel pleasure was short-lived in New York. I first found out about this barbaric policy a few days ago, a violation of both domestic and international human rights law, and specifically forbidden as a response to COVID-19 by the WHO, when Columbia-Presbyterian Hospital in NYC announced it and it trended on Twitter.
Today, I read that this cruel and harmful policy has been overruled by the state. According to this piece on NPR, "...earlier this month some New York hospitals told pregnant women they couldn't have any support person during childbirth. Within a week the state health department had prohibited that policy."
Thank goodness. Birthing women have a hard enough time battling medical staff without depriving them of one of their few weapons to protect their own health, and the health of their children.

Wednesday, 25 March 2020

Death-Defying Baking: Dark Chocolate Cranberry Cardamom Muffins

I love to bake but I need to reduce my sugar consumption for my health and longevity. To this end, I’ve embarked on a crusade to bake more healthfully. This post is part of my Death-Defying Baking series.
Once again, I’ve started with a recipe from Sally’s Baking Addiction. I love her vast collection of baking recipes; it's one of my first “go to” sites when I am looking for ideas for a particular ingredient (e.g. cranberries) or variations on a theme (e.g. zillions of different types of chocolate chip cookies).  Her recipes are meticulously tested, which gives me confidence to make healthy substitutions and expect good results: I know that I am starting with a well-designed recipe. I also find her photographs particularly mouth-watering.

During the holiday season I buy lots of cranberries but often don’t get around to using them all. Luckily, they keep for months in the fridge, which explains why I am still baking with fresh cranberries in March. I bookmarked this Cranberry Cardamom Spice Muffins recipe sometime in the fall, but just got around to baking them today for a COVID-19 isolation breakfast. Some of my variations here are made to healthy-up the recipe but others are based on personal preference and available ingredients.

1 and 3/4 cups (220g) all-purpose flour

SUBSTITUTION (health): I ONLY bake with whole wheat flour.

1 teaspoon baking soda
1 teaspoon baking powder
1 teaspoon cardamom

SUBSTITUTION (personal preference): I used 2 teaspoons for a stronger cardamom flavor.

1/2 teaspoon ground cinnamon

SUBSTITUTION (personal preference): Likewise, I used 1 teaspoon cinnamon for a spicier muffin.

1/2 teaspoon salt
1/2 cup (115g) unsalted butter, softened

SUBSTITUTION (health): I used 5 tablespoons butter and 3 tablespoons unsweetened apple sauce to lower the fat and calorie content, as well as add some moisture, which is needed when baking with whole wheat flour.

3/4 cup (150g) granulated sugar

SUBSTITUTION (health): I used ¼ cup granulated sugar. I found this more than enough and will use 1/8 cup next time I make these muffins.

2 large eggs, at room temperature
1/2 cup (120g) sour cream

SUBSTITUTION (health): I used nonfat yoghurt in lieu of sour cream. I do think they’d be delicious with sour cream and might indulge during the holiday season.

1 teaspoon pure vanilla extract
1/3 cup (80ml) milk

SUBSTITUTION (allergy): My partner is lactose intolerant so I used unsweetened soy milk. I do sometimes use raw milk in baking. I expect that your milky substance of choice would work in this recipe—cow, goat, almond, oat, etc.

zest of 1 orange

SUBSTITUTION (preference): I omitted the orange. Cranberry-orange is a classic flavour combination, but I don't like orange and chocolate together.

1/2 cup (63g) chopped walnuts

SUBSTITUTION (preference): I omitted the walnuts. With rare exceptions, I don't like nuts in baked goods.

1 and 1/2 cups (187g) fresh or frozen cranberries (do not thaw if using frozen)

ADDITION: 2 cups dark chocolate chips

The recipe calls for an orange or maple glaze, which I omitted both to reduce the sugar/calorie content and to keep the flavour focus on the cranberry/chocolate/spice combo.

I was intrigued by Sally’s claim that these muffin cups can be filled right to the top rather than the usual ¾ full because the method of baking at 425F for 5 minutes then turning the heat down to 350F will cause the muffins to rise straight up rather than spill over. I was concerned that my numerous substitutions might have changed the characteristics of the batter in ways that would preclude this supposed rise, but I decided to risk it and filled the muffin cups to the brim. My muffin trays seem to be larger than standard as I never get as many muffins as promised in a recipe. In this case, I got 8 1/2 rather than 12, which is fine as I’d rather have fewer, larger muffins.
They spread a wee bit—you can see the two at the bottom getting a bit amorous and not practicing proper social distancing. But I could not be more pleased with them. The kitchen, and the muffins themselves, smell wonderfully enticing, and the spice/cranberry/dark chocolate combination is heavenly. I put a lot of chocolate chips in, which makes every bite super chocolatey. The cranberry/chocolate combination is a favourite of mine.
It is not hyperbole to say that these are by far the most delicious muffins I have ever made.

Friday, 13 March 2020

Trump to cancel elections, declare martial law, zombie apocalypse, today at 3pm "Dumpster-Fireside Chat"

The market was rallying this morning until the Orange House announced that its current resident, Cheetolini, is planning to French kiss Sophie Grégoire Trudeau on live television at 3pm EDT to Prove to Wall Street that he has COVID-29 licked. After this announcement, the market immediately began to tank again.

Bets are currently waging as to whether His Massive Ineptitude will blame the global pandemic on Obama, "Sleepy Joe," or Hillary's emails. (My money's on the latter—who knows what was mouldering in those private servers.)

Thank goodness for closed captioning, because no sane person can bear to watch Trump's speeches with the sound on. Usually, it's steadier on the nerves to just wait and read the transcript afterward. By this point in Trump's reign, we've all gotten past our initial assumption that the transcriptionist must be drunk and adjusted to the staggering fact that, no, he really did say that.

Speaking of drinking, due to the urgent situation underlying today's vacuous blowharding, some of us will reluctantly tune-in live. To make Trump's mendacious, self-serving rambling more endurable, I propose a drinking game.

Drink each time Trump...

...praises himself for what a great job he is doing.
...blames Obama for his own administration's failure to prepare for a pandemic.
...explains that he doesn't want to have more Americans tested for COVID-19 because low numbers make him look better.
...gloats that the $1.5 trillion pumped into Wall Street yesterday is helping to stabilise and recover the markets, which is the only thing he cares about. to understand the science-y stuff better than anyone because his uncle taught at MIT, blah, blah.
...explains that the UK is exempted from the European travel ban because he has resorts there and he can make deals with Boorish Johnson because of Brexit that he can't make with those namby-pamby democratic socialist leaders in those other European countries that snigger at him behind his back, and they don't speak English in those other countries anyway.
...refers to the "do-nothing Democrats" in Congress without mentioning that it's the GOP that is preventing passage of COVID-19 relief legislation.
...blames Obama one more time for his own failings.
...whines that everything good that happens is 100% due only to him but nothing bad is ever his fault.
...frames COVID-19 as a "foreign" virus & claims that keeping them damn furriners out will prevent "real Americans," i.e., his base, from getting it. he won't be tested because he "feels great".
...says it's too bad that Trudeau's wife has the virus because she's not a bad looker for her age.
...blames Obama one more time.
...announces payroll tax cuts will fix everything. Bonus sip if he throws in elimination of capital gains tax.
...offers more financial relief to big businesses & wealthy individuals rather than working people who need it.
...declares a national emergency and says it means he can do anything he wants, but he always could anyway so he doesn't see the difference, and now say hello to your new Dicktator for Life.
...down the rest of your glass if he says elections will have to be postponed.
...if he cancels elections and declares martial law, finish the bottle.

Until then, enjoy your day buying toilet paper and shorting stocks.

P.S. Whoever coined the term "Dumpster-Fireside Chat" deserves a free bottle of their favourite tipple.  You won the Internet today.

Saturday, 4 May 2019

The Price of Hope

I received some disappointing fertility news last night.  The way I deal with things is to explain them to (mostly unwilling) people (who are trying valiantly to be polite) so, as my reluctant captive audience, you might want to pause here to get a drink and make yourself comfortable.

I’ll start with the general and move to the specific.

The first IVF (so-called “test tube” although conception actually takes place in a Petri dish, much more romantic) baby, Louise Brown, was born in Manchester in 1978.  The second was born in India, which, frankly, surprises me, as the last thing India needs is help increasing its population.  Oddly, the third was born in Glasgow and the fourth in Melbourne, which makes the British Empire IVF pioneers.  The sun never sets on British fertility?

The original purpose of IVF was to help couples in their 20s and 30s who could not conceive the old-fashioned way.  Brown’s mother had blocked tubes, and other early adopters of the procedure had low sperm count.  IVF was emphatically not established to address age-related infertility.  In fact, as its commercialisation spread (over 5 million IVF babies had been born worldwide by 2012), most clinics had a cut-off age of mid-30s.

But age at first birth has been rising, with women delaying motherhood to pursue higher education, careers, financial stability, and to find an appropriate partner.  Also, some women who had children young are remarrying and wanting to have a child with their new partner.  (There is much that could be said about the economic and relationship factors that push women to delay childbearing, not least a discussion of student loans, parental leave, cost of childcare, and the career penalty of the “mommy track”, but I’ll leave that for another post.)

IVF clinics are in the business of making money, and they make loads of it (get it, loads…never mind). A single IVF cycle can cost upwards of $25K in the U.S., and it’s typical for women to endure up to 7 cycles before getting pregnant or (more likely) giving up.  Clinics have responded to the demand for services by women in their 40s by raising their age limits.  But, since they rely on success rates to lure new clients, and IVF success over age 42 is unlikely, they face a conundrum:  Do they take people’s money, when they know the chances of a live birth are essentially zero, and lower their stats, or turn away potentially lucrative clients who will ignore the statistics in their desperation to have a baby? In some cases, regulators have stepped in, with some countries setting an age limit on IVF.  Insurance will not cover it over a certain age, usually somewhere between 39-42.  But the main solution clinics have found is the use of donor eggs (and, in cases where male infertility is a factor, or the woman is single or gay, donor embryos).

Age is no barrier when eggs from younger women are utilized.  Assuming she is otherwise healthy enough to sustain a pregnancy and give birth, an 80-year-old woman could bear a donor-egg child.  IVF success rates with OE (own egg) drop dramatically over age 35, and become essentially zero after age 42, but there is no decrease in success rates with DE (donor eggs).
For women who choose to use donor eggs, and who have no fertility issues besides egg quality, success is virtually guaranteed.  But some women don't want to use donor eggs.  These women are on the cutting edge of IVF, pushing doctors and clinics to use their own eggs despite the odds.  So far, success has been elusive.  Egg quality is the problem.

It’s ALL about the egg.

Whereas men are continually producing sperm (always a good excuse to get out of housework, “Sorry, honey, busy making sperm right now.  I can paint the garage or we can have a baby, your choice.”), a woman is born with all the eggs she will ever have.  Yes, it sounds somewhat ironic, that we are making all of our eggs when we ourselves are still foetuses.  Female fertility commences at puberty, when hormones stimulate the follicles in which those eggs reside to begin maturing.  Fertility declines as that reserve of eggs dies (follicular atresia) and some get used up via ovulation.  Of the 1-2 million eggs present at birth, about 90% will have died off by age 30. By age 50, most women are nearly out of eggs.
Why does it matter that so many die off?  We have plenty to spare:  Since a woman ovulates one egg per month for about 40 years, she uses less than 500 of that million-egg stash.  The issue is egg quality.  Even if a woman ovulates religiously every month into her 50s, her chances of a viable pregnancy decline rapidly after age 30 and precipitously after age 40.  The reason for this drastic decline in fertility is an increase in chromosomal abnormalities in the eggs.  In your 20s, one out of 10 eggs that you ovulate will be chromosomally abnormal.  In your 40s, all 10 will be abnormal.

These DNA hiccups don’t always prevent conception from occurring but, in the days following conception, as the aneuploid blastocyst divides, it is nonviable.  An aneuploid blastocyst either fails to implant or fails so soon after implantation that the woman gets her period as normal and has no idea that conception occurred.  This very early pregnancy failure happens in about 70% of all pregnancies, even in young women, but is usually invisible.  With the invention of super-sensitive home pregnancy tests that can detect the weakest rise in hCG, impatient women who are desperately hoping to conceive obsessively test early, get a positive result, and then are gutted when they get their period.  It's smart to wait until your period is late rather than test early and be disappointed by these extremely common early failures.  But most women whose biological clocks are ticking loudly and thus are desperate that this has to be the month don't have that kind of patience and take advantage of the new early tests only to be let down when their period arrives on schedule despite a positive pregnancy test.

Cruelly, some chromosomal abnormalities take longer to manifest.  The woman misses her period, celebrates a positive pregnancy test, perhaps even tells her partner or announces it to the world, and the early pregnancy progresses normally, but then the aneuploid (abnormal) embryo reaches a point in foetal development where it fails.  This causes a miscarriage usually within the first 5-12 weeks of pregnancy.  Later miscarriages, and stillbirths, are also caused by these chromosomal abnormalities. A 49-year-old woman who conceived naturally has a 99% chance of miscarriage in the first trimester.  That percentage goes down only slightly in the second, with the chances of stillbirth so high in the third that there is overall a less than 1% chance of a woman who conceived naturally at 49 having a live birth.

In some cases, the chromosomal abnormalities are not incompatible with life and are discovered via in utero testing.  So, the few women who don’t miscarry end up needing abortions when abnormalities are detected in utero.  (Some women choose not to get tested, or to carry to term even when tests have shown that their foetus is abnormal.  I find that unconscionable but that is a subject for another post.)

Conventional wisdom says that these abnormalities occur because the eggs are “old”.  But that’s a misleading view.  Men have the same problem:  Male fertility declines slightly in the 30s and dramatically in the 40s and 50s due to chromosomal abnormalities in sperm.  A miscarriage in a woman in her 40s is just as likely to be a result of an abnormality in her partner’s sperm as in her egg, unless he is considerably younger. Since sperm are made fresh every day, it isn’t the age of the sperm themselves that is the problem.  It is not known why abnormalities in both sperm and eggs increase with time but it’s the same with all the cells of our bodies, and may be due to environmental, lifestyle, nutrition, or other factors we haven’t discovered yet.  The point is errors in meiosis increase with age and, whilst they may not prevent conception, they prevent viable pregnancy.  If you get pregnant over 40, you are almost guaranteed to have a miscarriage, not a live baby, at the end of it.

IVF could change all that. In a normal cycle, one egg matures and is released at ovulation.  If it’s a dud, you have to wait a month for another go.  The IVF process involves hyper-stimulating the ovaries with drugs to mature multiple eggs at once, the more the merrier.  I don't want to do it; it’s gruelling, disruptive, and risky:  the woman must inject hormones into her abdomen daily, which have both unpleasant and potentially dangerous side effects, and endure repeated invasive and undignified procedures, including surgical retrieval of however many eggs she has succeeded in maturing.  (The male role in all this is to watch some porn and jerk off in a cup, but no-one said life was fair).

Once the eggs are fertilized in the aforementioned Petri dish (most labs play Ravel’s “Bolero”, but some have reported higher success rates with Prince), they can be genetically tested before implantation.  The more embryos you have to test, the higher the chance that one will be chromosomally normal (euploid).

So why are clinics steering women over 40 to egg donation?  Two reasons:

1)   It’s common in women over 40 for a retrieval of 10 eggs to result in 10 aneuploid embryos. It can take many exhausting and expensive IVF cycles to get even one euploid embryo, and then you have to factor in implantation success rates, which are quite low for all age groups.
2)   In order for the IVF drugs to stimulate multiple eggs to mature, a woman must have a reserve of eggs available.  Reproductive endocrinologists (REs) assess ovarian reserve in two ways:  By counting follicles during an ultrasound and by measuring the blood levels of a hormone called AMH (Anti-Müllerian Hormone—Attorney General Barr seems to produce an excess, but that’s another story…rimshot).  AMH is excreted by developing follicles.  It peaks at puberty and decreases until menopause, when there are no more developing follicles.  The desired level is 1.0-2.5.  Levels of 0.7-0.9 give you some chance, but levels below 0.6 are considered an indication that your ovaries are running out of eggs and have closed up shop.  At this AMH level, via ultrasound one can usually see them displaying little “retired, moved to The Algarve” signs.  Even the most aggressive IVF protocol won’t result in any mature eggs for retrieval in women with low AMH because there aren’t enough eggs left.

The pressure to use donor eggs is egregious.  Most REs refuse to treat any woman over 42 who wants to use her own eggs.  But that is changing.  A few years ago, one clinic in Illinois agreed to treat women up to age 45. Others have followed, with one infamous clinic in upstate NY treating women up to age 49.  Success rates have been low so far:  The oldest baby born to a woman using OE IVF was 47, a record achieved in 2018, beating the previous record of 45, set in 2014.  But success rates may be low in part because the number of women trying to use their own eggs is still low.  As more women delay childbearing, and more clinics become willing to let them try OE IVF, expect to see success rates rise.  Many women also go abroad, because foreign clinics are much less expensive and don’t care about success rates—they are eager to take desperate women’s money.  There is now a clinic in Cyprus that will do OE IVF up to age 50.  (They originally said 55 but the legal age limit is 47 and a crackdown made them lower it to 50.  They're allowed some wiggle room because of the money IVF tourism brings into the country.)

This is where we move from the general to the specific:  I want my own biological child, and I just turned 50 last Sunday.  I delayed trying to conceive until I turned 40, at which point the ticking of the biological clock trumped financial and relationship considerations.  I had one early miscarriage at 42 but no other conceptions (that I know of).  I don’t have the money for IVF but the existence of that clinic in Cyprus is tantalizing.  I realise they are peddling a fantasy: I am a social scientist; I understand statistics. But the desire for your own biological child pushes all realistic assessment of numbers from your mind.

A birthday is a time to assess where you are in life and make a plan for filling any gaps between where you are and where you want to be.  This includes one's health.  To that end, I've made appts for a variety of routine health screenings, including a fertility assessment.  There is only one RE in my (rural) area.  Luckily, he takes my insurance.  My last attempts to see an RE, at ages 42 and 46, went poorly when they flat-out refused to treat me based on my age alone.  I was a nervous wreck thinking this guy was going to laugh me out of his office. Yet, strangely, I also had a good feeling about him, and that was justified.  He listened to my story, my hopes about the clinic in Cyprus, and he didn’t waste my time belaboring statistics I already know or trying to convince me to go the DE route.  When he heard about my PSVT, he further impressed me by immediately referring me to a cardiologist he respects.  That’s not under his purview so he didn’t have to take an interest.

In the end we agreed to the following:  He would test my AMH levels that same day.  At my age, every month counts; you cannot waste even one cycle.  In two days, I would come back for a mid-cycle ultrasound.  IF my AMH was high enough and IF my ovarian reserve and everything else looked good, he’d take me on.  At this point, he leaned across the desk and declared that, if he did take me on, “it would make a full-court press look like a walk in the park”.  I liked his attitude but there is one thing I didn’t tell him:  If he were to initiate this aggressive egg priming protocol, I don’t have the money to go to Cyprus.  But perhaps I could freeze eggs for use years hence when I can afford it.

I initially thought the ultrasound went well:  The tech saw follicles, with a burst one indicating ovulation had occurred, and she said everything looked normal. But the RE had a totally different interpretation.  He saw only 3 total follicles (they like to see at least 10), at least two functional cysts (which are benign and common, occurring when the follicle that has ovulated reseals and fills with fluid; the problem is that a follicle can sometimes fill with fluid without releasing its egg first—the former type has no bearing on fertility, the latter type obviously does) and he found a birth defect known as a septate uterus, where a membrane that is supposed to disappear during foetal development still divides the uterus down the centre.  It is very common and often causes miscarriage; a woman usually cannot carry a pregnancy to term unless the membrane is cut—a procedure that would be routine in a younger woman planning to have children, but which has never been done in someone my age.  RE will likely be of the impression that I have no chance of pregnancy so no point in correcting the defect.  Since it's elective—there are no health implications; it is purely to restore fertility—I don't know if my insurance would cover it.

As for the AMH, late last night, after I was already in bed preparing to sleep, an email popped up from the lab:  My AMH results were in, and my level was an abysmal 0.3.  That is waaaaay below the minimum level for treatment.  I was shocked and disappointed.

But I am not giving up.  I have been reading about ways to improve AMH levels, and even induce the ovaries to make new eggs from stem cells.  I am going to propose that I try these methods for 4 months and re-test in Sept.  RE can’t say no to letting me re-test then, and maybe I’ll be in better financial shape.  But I can’t deny that this AMH lab result and ultrasound were a major disappointment.  I am NOT willing to forego having my own biological child; that is a crucial part of life.  I’ve been feeling as grim as our rainy weather today, and trying to keep my hope, and spirits, up.