Terms of Endearment

This nation is badly split.  The presidential election this cycle accurately reflects the acrimony and small-ness that pervades our political perceptions.  As we perseverate over minutiae, our country languishes in self-imposed malaise and our economy teeters on the brink of disaster.   What makes the hyperpartisanship worse is the fact that the country is split almost 50/50 on either side of the divide.

Does any of us really believe that this will change after the 2012 election?  It is unrealistic to think (just as it was in 2008) that we will magically rally around our president and our congress to tackle the major issues of our time.  Given the likely divided nature of our government, and the definitely divided nature of the electorate, the American public can look forward to more fiddling while Rome burns even under the term of the next president.

It is a common theme in presidential politics that first term presidents often “pivot” to the political center in order to buff their chances for re-election, while second-term presidents are “unleashed” from those concerns to return to their idealogical base.

However, Mr. Romney has made too many promises and sold too much of his political capital to the far right of his party to credibly govern as a compromising moderate if he wins.  During his first term, President Romney would need to burnish his credentials as a bona fide conservative in order to convince his base (who is luke warm on him currently) that he is not deserving of a primary challenge.  While President Romney would no doubt vanquish such a challenge, it would be the ultimate pyrrhic victory and likely fatally wound his re-election campaign.  Thus, shortly after election we can realistically expect a lurch to the right from President Romney, which would likely worsen gridlock (without a senate supermajority) and increase the shrill tones of partisan debate.

President Obama, for all of his soaring rhetoric, has not shown a tremendous aptitude for bipartisan leadership and unification of the electorate.  While there may be many reasons for this, it is safe to say that a fair portion of the blame can be laid at his own feet.  As an “unleashed” lame duck president, the right wing warns, he would be free to turn sharply to the left and lead as the unabashed liberal that he inclines to be.  This would also serve (with a Republican house) to worsen gridlock and partisanship.

Lest we get too depressed, there is a glimmer of hope in these scenarios, and it comes from the unlikeliest of sources–President Clinton.  In 2008, it was clear that President Bill Clinton was smarting from the rough and tumble primary contest between his wife Hillary and Mr. Obama.  He was scarce on the campaign trail, and reticent with his endorsements.  In 2012, however, President Clinton gave a tremendous speech at the Democrat’s convention, and has been full-throated in his endorsement of the current president.  It is widely assumed that he is playing nice within the party to help ease Hillary’s (unopposed?) march to the Democratic nomination in 2016.  It is conceivable, and even likely, that in exchange for the badly needed enthusiastic endorsement, President Obama has agreed to throw the full weight of his personality, and his office, behind Hillary’s presumed run in 2016.

President Clinton’s endorsement of Obama has held real value in this cycle.  And in return, President Obama will need to give Hillary something of real value back.  In a very real sense, then, he will not be able to lead as the unleashed liberal that he is, taunting Republicans with brinksmanship at every turn.  Such a term would be considered a failure, and a failed President’s endorsement and party would hold no value.  In that situation all he could deliver to Hillary was his base, a consituency she arguably is more comfortable with than he is.  He will be forced, for her sake and due to promises made, to govern and lead through unification and compromise, in order to win over the middle ground of American politics, the independent voter.

There is good reason to believe that Mr. Romney’s first term would be reminiscent of an “unleashed” second-term president, whereas Mr. Obama’s second term would be more reminiscent of an accountable first-term president.  Given the choice, I prefer a president who feels accountable and motivated to move to the middle any day.

Pander Express

The 2012 Presidential campaign has been marred by intensely vicious, personal attacks.  Many of these are totally unfair and unbecoming of those men seeking to become leaders of the free world.  Unfounded attacks on a person’s “American-ness”, his wealth, his faith, his place of birth, or the color of his skin have no place in our current debate.  One attack, however, is particularly stinging because of its truth… That of Mr. Romney’s “flip-flopping” on key issues.

Mr. Romney’s waffling positions on social issues are famous by now, from his support for abortion rights (and his charitable contributions to Planned Parenthood) to his vehemently pro-life stance.  Likewise, his support for gay marriage has shifted to a vehement opposition.  His shifting positions on policy are also gaining more and more attention.  As governor of Massachusetts, he advocated and argued for an individual health care insurance mandate, one he now argues is unconstitutional.  At various times, he has come out both for and against a path to citizenship for illegal immigrants.

To many, these shifting policy stands disqualify Mr. Romney for the presidency.  In my view, they represent an asset which may uniquely qualify him for the job.

The Presidency of the United States, as it is conceived and expected, requires almost superhuman capabilities.  The President, after all, is not a king nor a dictator imposing his whims or his views on the people.  He is an elected executive who ideally represents a “first among equals” among citizens; meant solely to provide checks and balances to the legislature, and to speed along the beaureaucratic process.  Importantly, the president is elected to represent the people.  Not just the people of his home district (like a congressman), or the people of his state (like a senator), or the people of his party (like a chairperson) but the entire citizenry of the United States–equally responsible for considering the welfare of the coalminer in West Virginia, the Sierra Club member in California, and yes, the casino magnate in Las Vegas.

We rightfully demand principled leadership from our most prominent representative.  However, we do not often reflect upon what principles we are demanding.  Principled leadership is extremely important–when it comes to the principles which we all share.   Defense against common enemies, shared prosperity, freedom and liberty, and many others explicit and tacitly implied in the constitution.  If Mr. Romney is elected, and is pressured to pursue a militantly pro-life agenda (just using this issue as an example), he is doing a disservice to a large segment of his own constituents who are equally vehemently pro-choice; and thus not doing his job to represent the American people as a whole.  He was not elected to be the President of the Republican Party, after all, but to be the President of the United States of America (even of those who didn’t vote for him).

Many of the issues a president must confront deal with less constitutionally clear decisions. In these cases,  flexibility, an open mind, and the ability to see all sides of an issue are paramount.  Misplaced rigidity leads to a hyperpartisan atmosphere, disenfranchisement, gridlock, resentment, and eventually political instability.  On those issues where legitimate disagreement exists (and it always will) regarding an interpretation of our core values (eg: does abortion violate a right to life, or does banning it violate a right to freedom?), a president must have the ability to carefully weigh all opinions and all listen to all parties, and only then reach a conclusion which he will be responsible for communicating to his constituents.

A candidate who has spent his life cultivating and defending a single world view on social or economic issues will have a considerably harder time considering the rights, welfare, and arguments of all of his constituents than one who has spent time on both sides of an issue.  Mr. Romney’s colorful history, to me, means that he has carefully considered all sides of an issue, and at various times in his life convinced himself of the merits of each side of an argument.  It means that he recognizes that a single approach is not appropriate in every situation, and that complex issues have complex answers.  Even if it just represents politically expedient pandering, it belies the understanding that his constituency has diverse and disparate interests.

There are many reasons I may not vote for Mr. Romney, but his flip-flopping will not be one of them.

A Dark Night

On July 20th, shortly after midnight, a 44 year old neuroscientist suffered a massive heart attack while driving down the freeway.  His car spun out of control, killing 12 innocent bystanders and wounding scores of others.

This didn’t actually happen (that I know of).  But I hope for the reader to take a moment and reflect on how they reacted to the above paragraph, and compare it to the paragraph below:

On July 20th, shortly after midnight, a 24 year old neuroscientist opened fire in a crowded theater.  Twelve people were killed, and scores of others were injured.

A very different reaction to that news, I would think.  Unfortunately, however, the second event did occur, and many innocent lives were lost as a result.

The reaction to the first paragraph is usually a feeling of remorse, and a reflection on the fragility and randomness of life and death; accompanied by a feeling of sympathy for all the victims (including the driver).  However, feelings about the second paragraph are more often going to be dominated by anger, blame, and sympathies for the victims (exclusive of the shooter).  Therein lies a major key to understanding this human tragedy.

In our society, mental and psychiatric illness is not treated in the same vein (no pun intended),or with the same degree of respect, as physical illness.  Despite countless years of research indicating the physiologic basis for psychiatric disease, the basic feeling remains that somehow the person suffering from the illness, whether it be depression, psychosis, neurosis, or any other manifestation, is to blame to some degree.

Gun control advocates have been quick to blame lax gun laws for the shooting, and they have been anxious to use this shooting to restart a national discussion about gun control.  I don’t disagree with them, or with the premise that our gun control laws are too lax in this country.  Unfortunately, while they are addressing an important issue, they are missing the true root of the problem.  The fact is that this man suffered from a severe psychiatric illness which hijacked his actions.  And the sad fact is that even if guns were illegal, his illness would have demanded of him that he either find a way to obtain them, or use whatever weapons were at his disposal (such as tear gas and explosives–which he did use) to wreak the havoc that he did.

Assuming news reports are correct, the man, James Holmes, considered himself to be the “Joker” from the second Batman film–a character who sees himself charged with a mission to expose society’s ills through the institution of anarchy.  The shooter’s methods, like the Joker’s, were deliberate, highly organized, and intelligent.  I am not a psychiatrist, but these characteristics are highly consistent with psychosis, likely schizophrenia.  It is unclear whether this was ever even diagnosed, much less treated.  In fact, when the suspect’s mother was called, her first words were “you have the right person.”  This intimates that the family was potentially aware of these tendencies, even if they were in denial.

I would contend that Mr. Holmes’ psychiatric disease was allowed to progress to this homicidal conclusion precisely due to our inability as a society to deal with it as a true medical illness.  The taboos associated with psychiatric disease of all variants are so strong and pervasive that patients are often unwilling to seek treatment, families remain in denial, and proper precautions and treatment are not undertaken.  Imagine the reaction among his peer circle or his employers if he told them he was taking medications to control schizophrenia, and compare that to the reaction they would have if he told them he was taking high blood pressure medication.  These social mores are a strong disincentive to seek treatment; and a lack of treatment is what leads so many psychiatric patients to end up at the end stage of their disease–gravely disabled, a danger to themselves, or a danger to others.  The end stage manifestations then reinforce the social taboo, and the vicious cycle continues.

What happened in Colorado is inexcusable, and I am not suggesting a lack of culpability on the part of the shooter by any means.  However, if we are to use this tragedy as a springboard to a social discussion, let’s make sure that we at least have the correct discussion.   I believe that as a society, we should grieve for all the victims of this heinous, preventable strategy, including for the young man whose brain was hijacked by a relentless disease.

Ramadan Mubarak!

It has been a long time since I posted in this space, life seems once again to have gotten in the way of artistic expression (such as it is).  Now that Ramadan is on the horizon (quite literally), life promises to get only busier, and inspiration less frequent.  Last year, I was asked by my good friend and prominent blogger Aziz Poonawala (of City of Brass fame) to write a little about fasting during Ramadan.  The result was a humble essay which nonetheless summarizes many of my thoughts regarding the fast.  I have reproduced it here for my own readers.

Why do I Fast?

Every year around this time, as I begin preparations for Ramadaan in my personal and professional lives, I am asked that perennial question: “Why do you fast?” I am asked this by colleagus, friends, peers, and even myself. Of course, fasting is only one of the many manifestations of the rituals of Ramadaan, but as the most dramatic, it often attracts the most attention. Having observed the Ramadaan fast for twenty five consecutive years, I have answered this question every year multiple times. Each year, however, I find my answer to be slightly different than the year before, perhaps a testament to my changing attitudes, maturity, and station in life.

Having asked and answered this question many times myself, I have also heard a myriad of different answers. On the one hand, there have been complicated discussions on how the fast serves as a nexus between body and soul, an intensely physical act of the body which is meant to affect the health of the soul. On the other hand, there is the simple “because it says so in the Quran”. There was even once an interesting analysis on the importance of periodic depletion of hepatic glycogen stores. However, none of these answers can encompass all aspects of the fast. Just like every facet of a diamond reflects a different color leading to its brilliance and beauty, so too does every facet of the fast play an important role in understanding its importance.

Over the years of asking and answering the question, certain themes have emerged which serve to illustrate the importance of the fast in terms and ideas which are universal and easily understood regardless of culture, education, or religious affiliation.

A real, true, feeling of accomplishment.

The month of Shaaban (the month before Ramadaan), usually passes in a fog. Ramadaan looms in the near future and is coming forever closer. Thirty days of fasting and prayer, during the Los Angeles summer at that– it seems impossible. When I describe it to my friends, it seems impossible even to me. When I lie in bed at night, it seems impossible. As I make my preparations, it seems impossible. And it may prove to be this year, but I doubt it. After all, I have been doing this for 25 years consecutively and it has not been impossible yet. Somehow, one day at a time, I make it through. When Eid comes, I reflect upon the last month and inevitably wonder how I could have done it–it immediately seems impossible again. A challenge of this magnitude, requiring this degree of discipline and sacrifice, and met consistently by most of the community makes other wordly challenges pale in comparison. What can really seem more difficult than the fasts of Ramadaan? With that feeling on Eid, there is a real confidence that I can accomplish whatever I set my mind to. That my success at a task is only limited by the priority I give it.

The priority I give it.

Those people who can fast easily try to tell me that fasting does not affect their daily lives. That they can go on and do anything they would do if they were not fasting. Some even try to convince me that they can accomplish more, because they feel lighter, or have more time. I hope that’s true for them… But it is surely not true for me. During my Ramadaan fast, I have to constantly make choices. I have a limited amount of energy and strength, and I have to continually evaluate my every action to make sure it is something worth my energy expenditure. Or, is it so important that it is worth missing a fast to accomplish? The fast of Ramadaan forces me to prioritize each and every one of my actions with respect to each other, and with respect to the fast itself.

One of my passions is training in the Martial Arts, a week without a training session and I feel a true sense that I am missing something. And yet, is it more important to me than my faith? On any regular day, riding the endorphin high of a great workout, I might wonder. But Ramadaan crystallizes the answer that was within me all along, as I realize that missing a day of fasting just so I can train is incomprehensible. Most of us in the Western world are faced with a very real decision during Ramadaan about how much time to take off from work/school. And the answer is different for each individual. But within that answer lies each individual’s personal priorities, laid bare for them to reflect upon… and isn’t that one of the major advantages of Ramadaan–reflection?

Reflection.

What is it about the hungry state that makes me more pensive? Perhaps, denied of the energy I normally possess, and forced to budget my strength continuously, I turn inwards. The power of reflection is a potent side effect of the Ramadaan fast, if not one of its main intended effects. With every hunger pang or dry swallow, I am reminded that I am Muslim. Not only that I am Muslim, but that I afford this part of my identity a very high priority in my life, whether I normally realize it or not. It seems that the fast serves to throw one’s internal spiritual landscape into sharp relief, to be examined with painful veracity.

Fasting makes me realize that I believe in a hereafter, in a world view greater than Earthly pleasures. Mankind rules this earth. Uses resources freely, hunts to extinction, and dominates his environment and all living things. That is a simple fact. But who will control such a creature? And how? By reminding him continually that we don’t need all of the resources that we use. We don’t need to eat quite as much as we do, or hunt until there is no more. That the hunger pangs we feel for 1/12th of our lives are felt by others for their whole lives. That the world is not our pleasure palace, to spend our days doing whatever feels good at the time and moving on. This constraint on our basic bodily function, self imposed, reminds us continually that it is not all about the “here” and the “now”. Just as the confidence imbued by Ramadaan carries throughout the year, so too does this basic humility.

What’s the purpose of the fast? Perhaps it is meant to be different for everyone, like a Rorschach ink test for the soul. And perhaps it is meant to change over time, as one’s outlook on their faith and their place in it changes. But what is definitely true is that the Ramadan fast holds the potential for spiritual growth for everyone, regardless of age, culture, or level of education. And it also helps deplete hepatic glycogen stores.

 

Of Crime and Punishment

It’s playoff time in the NBA. A time when I force my family to forsake primetime television for professional basketball.  A time when I am continually forced to ponder one of the deeper questions in life… Why does the last three minutes of a basketball game take half an hour?

The answer to anything more than a casual basketball fan is clear.  The culprit is the intentional foul.  To those less familiar, this technique is when the trailing team will intentionally foul the other team in an effort to force them to “work for their points” by hitting foul shots.  By percentages as well as anecdotes, this strategy can work by forcing more of the game to take place with the clock stopped (lengthening the game, much to my wife’s chagrin), as well as putting the onus on the leading team to make foul shots.

There is a deeper question here, however.  One that we often ignore, perhaps because it is just too hard to answer.  Merriam-Webster defines a foul as “constituting an infringement of rules in a game or sport.”  That is clearly the case in basketball, where impeding an opposing players ability to move in an unimpeded fashion or to take a shot (or to sometimes even remain standing) is universally considered an infringement of the rules.

It becomes clear then, that in the almost universally popular sport of basketball, players are encouraged to break the rules of the game on a regular basis simply because the punishment they endure is more advantageous to them on the whole than following the rules of the game.

Would this action be allowed anywhere else in society?  Would we condone a homeless man partaking in a violent crime, simply to get free room and board (albeit in a jail)?  How about the man with a severe illness who robbed a bank so that he might go to jail and get taxpayer funded healthcare?

Are rules and laws in society at large only applicable to those for whom following them is advantageous?  If so, by analogy of the NBA, it should be perfectly acceptable to tell a child to rob a bank, because even if he/she gets caught, they will only spend a few years in jail, but the potential upside is tremendous.  If rules are only meant to be followed when they are to our advantage, they cease being laws and become merely guidelines.

There are many examples of sports mirroring life, and bringing out the best in us through healthy competition and fair play.  But a society, such as the NBA, where rule-breaking is universally condoned when it is advantageous to the offender sends the wrong message to our children about acceptable behavior in society as a whole.  The NBA seriously needs to consider rule changes to make the punishment fit the crime, and to make playing by the rules advantageous to all parties.  (My humble suggestion, a shooting foul on a missed basket should be worth three free throws)

NOTE: This is not meant to be a “crotchety old man” essay (though lately I feel more and more like one).  Rather, a serious look at the moral and ethical implications of the concept of an intentional foul.  I would welcome any and all feedback to these rhetorical questions from basketball fans and non-fans alike.

Open House, Open Mind

LA Masjid

Our new masjid… Just part of the Mohammedi Center Complex

Friday, May 5th 2012 was a red letter day for the Dawoodi Bohra Community of Los Angeles–my religious community.  Our new masjid (mosque), under planning and construction for over a decade, had finally been finished.  On Friday, we hosted multiple civic, interfaith, and community leaders to visit with a reception, tour, and a lunch.  After that program, we opened up the masjid complex for the entire local community and neighbors by way of an open house, and guided tours.

To understand the significance of this event, consider this: I am forty years old and have been a Muslim all of my life.  This will be the first masjid I have ever belonged to as a member.

The event was also important in that it was out of the ordinary for the Bohra community.  We tend, for better or for worse (and I feel, mostly for worse), to be a tremendously private and introverted community.  The upside to this is that we do not concern ourselves about what others do or say about us, manifesting a communal self confidence that belies our small numbers and minority opinions.  The downside of this is that we are also unconcerned with spreading the  goings-on within our community to the outside world.  I am not talking about proselytizing, I am talking about simple neighborly sharing.  While we have nothing to hide, it becomes the natural perception that we do.   And there is little more frightening in America than a Muslim with something to hide.  This event went a long way towards changing that introverted attitude within our community as a whole, and our leadership in particular.

Time will be the only true arbiter of whether opening up our community to outside scrutiny was truly a beneficial decision.  After all, increased visibility can be a double edged sword.  But if the outpouring of support and positive media coverage we received are any indication, the favorable ramifications promise to be manifold.

From a personal perspective, this was a vitally important day as well.  As a physician, I live largely in the public eye; interacting with a large swathe of the local population from all occupations, socioeconomic classes, creeds, cultures, and races.  I live locally, and as such my personal lives and professional lives often intertwine (ie: hypertension advice in the bread aisle at Pavilions).  As my mosque is also local, it was inevitable that my religious life (a large component of my personal life) would eventually intersect with my professional life.  I was long dreading that day, however, and working hard to avoid it.  Perhaps I was partly motivated by insecurity over my clothing and customs; but mostly I was pessimistic about the non-Muslim population’s ability to accept Muslims as anything other than crazy nut-job terrorists as their default opinion.

The experience I had in this regard pleasantly surprised me.  Multiple people from my professional life, including patients, hospital administrators, colleagues, referring doctors, and sales representatives attended our function.  In interacting with them, though dressed in my traditional Muslim outfit, I was able to easily summon the professional confidence that I project in any other situation.  Far from the embarrassment I predicted I would feel, I felt comfortable and able to be taken seriously and treated with respect.

Likewise, the implicit distrust and default skepticism which I thought would greet us in the countenance of our visitors never materialized.  Their support for our community was clearly genuine, and not just the thin veneer of politeness I expected.  Their joy at our successful accomplishment, their welcoming of us as part of the local community, and their willingness to learn about Muslims and Bohras with a truly open mind was evident.  Obviously, there is a clear selection bias at work, as those who harbor fear or resentment of us were unlikely to attend our event.  But the number of people who did attend, and who were genuinely encouraging clearly indicated that my previous pessimism was at least over-rated (though unfortunately probably not totally unfounded).

Last Friday represented a “coming out party” for our community as a whole; as well as for me as an individual.  Both were long overdue.  In a sense nothing concrete has changed, however.  Those who hate us or fear us still will, this event did not involve them by their own choice.  Those predisposed to an open mind may have developed a positive attitude towards us.  I am not planning to start going to work wearing my traditional topi and kurta or otherwise advertising my personal beliefs.  The only thing that has palpably evolved is perceptions– ours, theirs, and mine.  Perhaps that means everything has changed after all.

Notes from the Heart…

Having just returned from the American College of Cardiology Sessions in Chicago, my mind is swimming in the latest and greatest in cardiac care and treatment.  I arrive at my place of work armed and ready to apply these principles to caring for my patients.  What I learned, however, surprised even me.

As an interventional cardiologist, I firmly believe in the power of simple interventions, such as balloons and stents which I use routinely, to impact the length and quality of life.  But, in the end, everyone knows that these therapies close the barn doors after the horses have left.  They are helpful, but if you need them, then in many ways you have waited too long.

What impressed me most was the emphasis in the cardiology community on prevention, and some of the new and impressive research that is looking at non-medical interventions.  Here are some of the latest and greatest news, in layman’s terms:

  • Meat is Murder? Much has been made of the recent paper in Archives of Internal Medicine on red meat consumption being linked to early mortality.  While impressive, it still remains one article.  At the ACC however, a host of supportive data was presented which bolsters this paper, and transforms it from an interesting single study to a major cog in a big wheel of diet modification.  While I am most definitely NOT ready to advocate a vegan lifestyle, I think a universal recommendation opting for greater incorporation  of plant products into our diets with fewer meats is absolutely appropriate at this point.  I was impressed not just with the breadth of research, but of the quality and scientific rigor which went into many recent studies in this field–something that had previously been sorely lacking.
  • Size Does Matter.  A major boost for obesity surgery at this meeting was the study looking at its effects on diabetes.  While it was well known that bariatric surgery (particularly the gastric bypass) could improve the state of control of cardiac risk factors, this study compared it to medications, and it came out better.  This is no surprise, really.  By treating the underlying cause (truncal obesity) of insulin resistance, you will achieve better results than by masking or compensating for the insulin resistance that causes Type II diabetes.
  • Blood pressure drugs got you down? Not to worry, for too much longer anyway.  A simple, catheter based treatment called “renal denervation” which affects the various complex neural pathway causing hypertension has shown very promising results at treating hypertension with minimal side effects.  Its use as a routine treatment is still years off, but look for a fast-track approval process for patients with very severe high blood pressure beginning sometime in 2013.
  • Stents are not the work of the devil.  Over the past five years, oversimplified analysis of the COURAGE trial had led many to feel that coronary stenting had no role in the management of blocked coronary arteries causing chest pain.  A recent major study (FAME II) was stopped early, however, because stents showed so much benefit.  The difference? In the second study, the operator had to objectively prove a stent was necessary first.
  • Neither are surgeons.  As interventional cardiologists such as myself take over everything from clogged arteries to aortic valve replacement, many prematurely mourned the death of the field of cardiac surgery.  Not so.  Recent registry data showed that in many patients good old bypass surgery led to better outcomes than even the newest stents.  In addition, newer questions have been raised about the outcomes from minimally invasive (catheter based) aortic valve replacement.  These need to be answered before rapid, widespread adoption of this procedure.
  • Don’t believe the hype: I have received countless phone calls already this week asking for the newest cholesterol medication which promises to be a “wonder drug.”  This is truly shocking to me, because usually when I want to start cholesterol medication, I am met with a lot of resistance.  To top it off, the newest drug is an injectable medication studied in only a small fraction of the patients that the other therapies have been studied in.  This medication may indeed have an eventual role in management of severely high cholesterol, but its rapid demand reeks of pharmaceutical company influence in everything from clinical trial design and presentation, to the timing and tone of press releases.  High cholesterol is a big money industry, and let’s get something straight: these companies are only interested in selling you their product.  If you happen to get better while using it, well that’s OK too.

Medicine continues to change on an almost daily basis, and cardiology changes faster than most other fields.  These are but a few of the new and exciting perspectives that I gained at the annual American College Conference.  And I’m sure by next year, they’ll all be wrong again.

Good Grief

Moslem Tov?

Recently, I had the opportunity to attend a bar mitzvah ceremony at a conservative temple here in Los Angeles.  I am well known to many in the congregation due to my profession and I was greeted with warmth and acceptance, despite my Muslim faith.  Although this was not my first temple service, it was the first I attended that fell on Shabbat.  As such, it was the first time I participated in the full religious ritual.  The result was a transformative experience in many ways.

The similarities were eerie, almost like practicing Islam in another dimension.  The sermon was basically about a favorite Muslim topic–tawhid (but as it related to Moses and Aaron, a different subject for a different time).  The head coverings, the segregation of men and women (though not as strict), and the bowing during prayer all evoked images of Muslim services.  Since we share a common heritage, it will come as no surprise to those versed in history or theology that our services have so much in common.

At first, one thing I found a little surprising was the emphasis on holocaust remembrance.  While I am reasonably familiar with the inhuman atrocities committed during the holocaust, I was initially taken aback by the emphasis placed on the holocaust during the services.  After all, my thoughts went, this happened seventy years ago in a far away land, and most of the younger people in the room had never actually met a victim.  Did they really need to perseverate on it so much?

Three words  from my wife caused perspective to crash down upon me, however, as she whispered to me “It’s their Karbala”.

Karbala, of course, refers to the infamous massacre at Karbala, Iraq perpetrated 1400 years ago on Husain ibn Ali, grandson of the Prophet Mohammed (SA).  It is commemorated regularly to this day by Shi’as (such as myself), especially during the Islamic month of Muharram.  It is mentioned at almost every Shi’a service, and often evokes almost uncontrollable expressions of grief, even today.

The power of grief to unite and galvanize a community is second to none.  The massacre of Karbala and the holocaust share this trait in common.  Both are grotesque acts of violence, willfully perpetrated on innocents.  Both of these events are used to unite, and indeed define, their respective communities.  Most historians consider the massacre at Karbala to be the coalescent moment of the Shia movement, which had actually begun a generation earlier.  Similarly, while the modern Zionist movement was in existence long before World War II, the holocaust served to coalesce the movement into a definable and concrete entity.  Even the events of 9/11 can be understood in a similar fashion, as they served to unite the country like very few times in our history. Unfortunately, along with the patriotism, they also awoke the xenophobia which long lived under the surface of the American psyche.

Grief is the ultimate expression of love.  Without love, there can be no grief.  And thus expressions of grief help us to realize the love we harbor inside ourselves.  The grief that we feel serves a true barometer of our internal value for the lost, a barometer immune even from self-delusion.  In this way, grief serves as a true reflection of our soul.  To grieve with someone is thus to share a special bond with them, a bond between the souls.  In this way, shared grief can unite a community like no other single experience.

The holocaust is a trauma on the Jewish experience which will never, and should never, heal.  Much like the effect of Karbala on the Shi’as, the holocaust unites the Jewish people, and even defines them in a very real sense.  Thus, it will very likely be remembered and commemorated 1400 years hence, much as Karbala is today.  The critical observer will find many differences between these events, however.  They would be correct in doing so.  But I would endeavour to focus on the similarities instead, as collective grief is one of the common bonds of humanity which unite us.  With my wife’s simple but profound sentence at that moment, I was privileged to share in that grief; and at least for a moment I became one with my Abrahamic brothers.

 


Calling a Spade a Spade

Recently, a US soldier in Afghanistan left his base at about 3 AM.  He walked about half a mile to a nearby village, entered three different homes, and shot dead at least 16 Afghani civilians (at least twelve of whom were women and children).  In the first home, where eleven of the victims were located, he gathered the bodies to burn them.  He then returned to base and turned himself in to authorities.  At the current time, his motives are unclear.  Much information about the killings and the killer has not yet been released.  What is known is that many of the victims were asleep at the time of the killings.

The US Government has issued a necessary but predictable statement of remorse, assuring that an investigation will soon be undertaken, and appropriate legal actions will be pursued (US soldiers in Afghanistan fall under US legal jurisdiction).  The question remains, exactly what crime was committed here?  Was this act part of the “fog of war” and thus representative of collateral damage?  Perhaps the shooter is not guilty by reason of insanity, due to PTSD and a possible history of previous brain trauma?  The killing may represent first degree murder (based on the premeditation inherent in walking a mile to the nearest town).  But, intriguingly, the news media has yet to use the word “terrorism”.

The first two, more lenient, possibilities also seem the least likely to be successful.  The shooter clearly had not been engaged actively by an enemy at the time of the shooting, and collateral damage can only be claimed if he had targeted a real or perceived enemy.  The insanity defense is very likely to be used and is already being used in the media, where all sorts of excuses (ranging from stress to alcohol to a bad marriage) are being floated for his actions.  It is interesting that these same excuses would be considered absolutely inadequate if the killings had occurred against an American town on American soil.  However, this strategy is unlikely to succeed legally and politically, as the shooter clearly knew what he did was wrong (he immediately turned himself over to authorities), and because the government will want to show swift and severe judgment in order to avoid unrest and backlash.

The question then becomes, is this  US soldier a terrorist?  Here is a person who has targeted innocent civilians and killed them in cold blood.  If his motivations were motivated by pure psychopathy then he is nothing more than a deranged cold blooded mass-murderer.   If, however, his motivations included any element of religious or political ideology, then his actions must be considered an act of terrorism.

When Major Nidal Hasan (also a member of the US Military) opened fire at Fort Hood, he was immediately branded a terrorist.  He had, after all, murdered innocents (sort of–members of the military industrial complex are considered reasonable targets by the Geneva Convention) and was motivated by political ideology.  But, when Joseph Stack flew his plane into the IRS building (sound familiar?), clearly motivated by a political ideology, he was branded a deranged anti-government crusader and some Americans even considered him a hero.  In fact, in an official statement “government officials were quick to rule out any involvement of terrorism in the incident.”

Let us hope that we have not devolved so much as a society as to believe that the definition of terrorism is inherently related to one’s own religion, or the nationality of the victims.  While this seems clearly to be the case with the news media,  the FBI official definition of terrorism includes no such reference:

“the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives” (28 C.F.R. Section 0.85)

While it is a major tenet of US law that the accused is innocent until proven guilty, it is a painful fact that if in fact our soldier was motivated by any religious or political objective then he has committed an act of terrorism.  If we are to maintain consistency with our rule of law, not to mention any semblance of credibility in the global community, then we must have the strength to call a spade a spade.

RELATED: The Daily Beast editorial board had a very interesting internal discussion on what they should call terrorism, related to the Joseph Stack incident.  They also had the courage to post it online in its entirety.  It is worth a read.

Be Careful What You Wish For

Rick Santorum has shown incredible perseverance so far in this GOP primary season.  Initially considered as a bit player, he has rocketed to national prominence on the strength of some strong primary and caucus wins, and now deserves at least legitimate discussion as a GOP nominee.  Anyone (including Mr. Santorum) who claims to have predicted his degree of relevancy this late in the race should seriously have their honesty questioned.  And yet, here he is.

It is true that Mr. Romney, his main rival and the current frontrunner, is a deeply flawed candidate.  His shifting stances on hot-button issues such as abortion and universal health care are well documented.  His wealth leads to a potentially very accurate and thus lethal charge of being “out of touch”.  And his recent campaign strategy of “vote for me, I’m inevitable anyway” reeks of defensiveness and pushiness at the same time.

Mr. Santorum, however, is arguably no better–and perhaps worse off.  He is a staunch conservative, but his views on most social issues steer far right of the majority of the American populace.  His economic credentials are questionable, as is his foreign policy experience.  His last foray into politics ended in an 18 point shellacking in his home state.

Perhaps a reason for his surprising success can be found in the contests so far.  I have neither the time nor the expertise of great political (and baseball statistician) Nate Silvers, but some trends are too clear to miss.  If one evaluates the states that hold primaries (as opposed to caucuses) and separates them according to open (anyone can vote) v. closed (only registered republicans can vote) primaries, we have the following results:

Date State Type of Primary State Results Santorum v. Romney National Polls Santorum v. Romney

10-Jan

New Hampshire Closed

-30

-9

21-Jan

South Carolina Open

-11

-16

31-Jan

Florida Closed

-33

-13

7-Feb

Missouri Open

30

-17

28-Feb

Arizona Closed

-20

2

28-Feb

Michigan Open

-3

2

6-Mar

Ohio Open

-1

-10

6-Mar

Oklahoma Closed

6

-10

6-Mar

Tennessee Open

9

-10

6-Mar

Vermont Open

-16

-10

(For the sake of simplicity, I have only compared Santorum and Romney and removed states where one or the other was not on the ballot, or that any major candidate claims as their home state.  National polls are from RCP polling data (average of polls) on the date of the primary).

In states with open primaries Santorum tends to outperform his national polling data significantly–in fact, by an average of 11.5 points.  In states with closed primaries, he tends to underperform compared to national polling by an average of 11.75 points.  That is over a 23 point swing!

Although this is not a complete analysis (accounting for regional differences, etc), the magnitude of the difference is clearly significant.  The difference in the type of primaries is entirely comprised of the ability of Democrats and Independents to vote.  It is not a stretch to surmise that Mr. Santorum and his extreme right wing views on social issues, his vitriol towards President Obama, and his radical  religious rhetoric does not embody significant crossover appeal.

It thus stands to consideration that the Democrats (and perhaps independents) are using the open primaries to help nominate Mr. Santorum.  In their eyes, this is a win-win situation–they either succeed in propping up a “straw-man”, who (at least in their estimation) is an easier candidate for Mr. Obama to beat in November, or they help deplete Mr. Romney’s war chest by using Mr. Santorum as a surrogate with which to attack the front runner.

A similar strategy was espoused by Rush Limbaugh in 2008 and dubbed “Operation Chaos” as he urged his listeners to participate in open primaries to drag out the Democratic nominating process, and it has been reborn this year by the Daily Kos, and dubbed “Operation Hilarity.”  The scary thing is, such tactics may actually work.

The Democrats who are doing this are playing a dangerous game.  By swinging for the fences, they are hoping for a home run–ie, President Obama walking to re-election against who they see is an inferior candidate.  But if they succeed in influencing the nomination, they will have helped nominate an extreme social conservative and religious radical, and given him the confidence that no race is out of reach.  At that point, all it would take is one damning picture or quote released at the right time to help create… President Santorum.  And then, perhaps, President Romney wouldn’t look so bad to these Democrats.

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