On a Christian Solution to the Syrian Refugee Crisis: Who is my neighbor?

“But the religious expert, seeking to justify himself, said to Jesus, “And who is my neighbor?”

This question, uttered 2000 years ago by a man wishing to know the limits of personal compassion, echoes throughout history as mankind tries to define who is worth loving and resounds loudly today in the public debate of the refugee crisis.  To this question, Christ has a ready reply in the parable of the Good Samaritan. 

As the story goes, a man was assaulted on a lonely road from Jerusalem to Jericho.  Two Jewish religious leaders give a wide berth of the man as they pass him by.  A Samaritan then sees the man bruised and bloodied and stops his journey.  Surely the questions of his own safety occur to the Samaritan, as there is no guarantee the person or people that assaulted the man are not still lurking in the shadows.  To help a stranger is to leave himself all the more vulnerable to attack.  And yet he picks the man up, takes him to an inn, and pays for the man's needs himself.  In the parable, Christ illustrates the neighbor as the man who crosses cultural boundaries, who sees his fellow man in need and, despite personal risk and financial loss, comes to his aid.  To his questioner Christ poses the question, “who was a neighbor to the man who was assaulted?” to which the religious expert rightfully answers, “the man who showed mercy to him.”

The answer to this question of who is our neighbor is important for us today.  Prior to asking it, the religious expert had correctly answered Jesus that the second most important commanded is to “Love your neighbor as yourself”. So for those of us who follow Christ, contained in this interchange is both the command to love, the definition of who to love, and a demonstration of what it is to love. 

UNHCR 2015.  International refugees and internally displaced 

people by year.

To what degree can we apply these principals to the Syrian refugee crisis? The United Nations High Commissioner for Refugees estimates there are over 60 million refugees in the world today, either seeking refuge internationally or as internally displaced people.  Not since WWII, and arguably in the history of the world, has the number been higher.  Half of these people are children.  Taken together, these people would be the 24^th largest country on the planet.  Their original countries are broken, so they are wanderers on the road, existing in a space between national borders and legal status.  Their needs are the fundamental needs for all humans: shelter, nourishment, medical care and a place to call home.  They are an entire nation of the man found assaulted on the road.

Yet there is potential peril to ourselves if we help.  If we take in Syrian refugees, the argument goes, then who knows if we are letting in ISIS.  Are we leaving ourselves vulnerable to attack? Will we be the next Paris? Is there the potential for something worse than Paris? There are many questions and few answer to such objections.  Yes the potential for harm exists, no we cannot guarantee against unintended consequences if we allow these people in.  History and human psychology would suggest xenophobia far outpaces actual risks of xenophilia, but nonetheless risk remains. Like the Samaritan, as we stop and gaze at the assaulted millions, the risk of personal involvement weighs heavily on us.

Furthermore there are financial considerations.  What does an influx of thousands or millions of displaced people do to an economy? What about jobs? I find it hard to believe that our economy is at the point of a zero sum game, where one more person in means one other person out, and yet it seems incredible that there is room for everyone.  As more people come in, the economic stretch will be gradual, and those first affected will be the poor on the fringe. If 10,000 refugees mean 1,000 American families are displaced from jobs, what is our moral responsibility to those families? What about the already burgeoning costs of medical care, education, and social welfare? I can conceive there is a balance where at some critical number of new people, the scales will tip toward economic disaster, where more people will end up hurting than if we had never allowed anyone entrance in the first place.  Like the Samaritan, we will certainly feel our wallets lighten and our resources stretched by the moral obligation to provide for those we have taken responsibility for.

What conclusions can we draw from the above discussion? Is this a Good Samaritan moment where we help every person we encounter on the road? Or are the complexities such that we are justified denying refuge to those seeking it? The answer, as almost all answers in the real world, lies in a balance somewhere between the extremes.  For Christians, the command to love is overwhelming.  “Loving our neighbor as ourselves” is the second greatest commandment, subordinate to and proceeding from the greatest command to “love the Lord your God with all your heart, soul, mind and strength.” Christ’s answer to who is our neighbor is the man on the road in need of help.  Personal and financial perils are inherent in this command and acceptable risks to take, as Christ himself demonstrated on the cross. We are no greater than our master.  Yet we are also not called to be destructive with our love.  After this experience, I doubt the Samaritan did then give up everything and committed his life to roaming the roads, looking for hurting people to help.  There was also a limit to Christ’s healing ministry, he did not heal every person in every place he went.  He also spent time alone, praying and resting, valuable time than could have been spent helping the poor.  As Christians, we are called to selfless love, but we are not called to self-destruction. 

How do we strike such a balance with Syrian refugees? This balance does not give us an exact answer, but it certainly gives us the criteria by which we should approach an answer.  The correct answer is a selfless but not self-destructive one.  The answer that shows we love our neighbor as ourselves, and that accepts a certain amount of risk.  An answer that shows we are not first preoccupied with our own wellbeing, but rather the wellbeing of our fellow man.  However, It is also is an answer that accepts the complexities of the potential for harm in well-intentioned actions. 

With this discussion in mind, I will attempt a concrete solution to the problem.  I think the Christian response is to let Syrians in.  We need to be thoughtful about the amount we take and perhaps take some steps to verify the identity of the individuals, but we should open our doors to a decent number of them. We should encourage both our European partners and American continental neighbors to do the same, so no one is burdened with too many.  Then we should stay vigilant, having a good way of accounting for these individuals through appropriate identification mechanisms, perhaps tracking bank accounts and financial transactions, living situations, etc.  We should be strict in the law, with felony offenses resulting in removal from the country. We should also commit to social services commiserate with their humanity, such as basic housing, food assistance, education and job training and medical care all delivered with the goal of self-sufficiency within a few years time. 

We also need to address the supply of refugees from Syria, which means increase the military response to ISIS in an intelligent manner as well as a work with our multinational coalition to end the war in Syria.  Of course, this recommendation makes the situation sound simple when it is actually ludicrously complex and such an answer may be year away or may end in the dissolution of the state or worse, who knows.  But it needs to be higher on our priority list as a nation or else the humanitarian catastrophe will continue to degenerate and the Middle East itself will be at risk of explosion.  

Moreover, we need to pray.  Pray for the refugees, for a just solution to this madness. Pray for the disaster that is Syria, for peace and an end to the war. But also we need to pray for ISIS, for both the individuals’ salvation and the organization’s destruction.  An enemy is still an image-bearer of God, made in his likeness even if the eternal light in him seems long snuffed out. 

Lastly, this needs to elevate other matters of compassion in our minds.  Syria is all the rage right now, but what about the Latin American refugee children or refugees from other nations? What about the homeless American veterans? What about our actual neighbors next door with cancer, with broken homes, with selfish pride, with mental illness? Ultimately, this is a question of a Christian’s response to the evil and suffering of this world.  Christ’s answer to the problem of evil is a call to selfless, risky, sacrificial, but-not-self-destructive Love. 

“And we, seeking to justify ourselves, say to Jesus, ‘And who is my neighbor?’”

To which Christ responds, “Everyone.”

On Combination Chemotherapy: Hope through Death

The following is an essay limited to 500 words and answering the prompt, "What new medical intervention in the last 50 years had the greatest impact on pediatric medicine?": 

Leukemia is form of liquid death.  First described in 1845 after a patient died from a “suppuration of blood”, any such ghostly white appearance of the humors portended certain death. Slowly, doctors learned the true depravity of the disease: it was the blood, the ‘life of the flesh’, which attacked the body.

In the early 1960s, leukemia remained uniformly fatal.  Surgery had made progress against solid tumors and radiation oncologists had treated lymphomas, but both were impotent against the amorphous liquid cancer.  In humanity’s great battle against cancer, leukemia was the victor.  However, the first glimmer of hope arose from the ashes of one of humanity’s greatest battles, World War I.   As nitrogen mustard gas crept across the killing fields of Europe, researchers noticed it depleted the leukocytes of its victims. Thus began intensive research into chemotherapeutic agents, poisons that could kill cancer faster than they could kill the body.  Researchers discovered many types of chemotherapy, but none with enough killing power to completely eradicate leukemic cells.  After decades of research and war, doctors won several fights, but leukemia consistently won the battle and claimed its victim. 

Doctors Emil Frei and Emil Freireich of  the National Cancer Institute realized no single chemotherapeutic agent possessed enough power to eradicate the leukemic cells from the body.   So the duo proposed a clinical trial of a four drug combined regimen: vincristine, amethopterin, mercaptopurine, and prednisone.  VAMP, as it would come to be called, was a wildly controversial idea.  No one had administered so many poisons to a person before.  Even worse, the trial was for children, leukemia’s favorite target. Despite the opposition, Drs. Frei and Freireich maintained that the body had to be pushed to its limit, to the door of death itself, to push leukemia into the abyss.

In 1962 the trial commenced and the infusions started.  As the drugs dripped slowly into the children’s veins, their little bodies began to shrivel.  Leukocyte counts plummeted, as did the body’s ability to fight infections.  Some children experienced days of fever-induced delirium, others spent nights retching in the bathroom.  Drs. Frei and Freireich could only sit at the bedside, hold a hand, and wait.  Slowly, the miraculous began to happen.  The shriveled bodies plumped up, their energy returned, their infections subsided.  Laughter soon bounced off the walls of the oncology unit as the trial participants became children again.  Even more awe-inspiring, the cancer cells were gone from the blood and the first true remissions had been achieved!

The VAMP trials proved that cure was possible, and the work of Drs. Frei and Freireich inspired generations of doctors to continue research on combination chemotherapy.  The results of this effort are stunning: from 100% mortality 50 years ago, a child’s chance of surviving leukemia in certain circumstances is now greater than 95%.  From its dark beginnings as a weapon of war to its ascendant triumph as a lifesaving cure, the story of combination chemotherapy is a beautiful reminder that even in the darkest times, hope lives. 

On Vaccines 3: Fear as Fission

Author's Note: I request you remember the ground rules for this post: I am taking it as a given that vaccines are effective and safe. If you would like to dispute this fact, then please review this obnoxiously hyperlinked sentence.

Part 1: Hear no Measles, See no Measles, Think no Measles
Part 2: Risky Feelings

In this series, I am attempting to answer the question, “What keeps people from vaccinating their children?”  We are discussing vaccination behavior as a balance between the perceived risks and benefits of the choice.  In the first post of the series we discussed how we perceive benefits.  In the previous post we discussed the cognitive mechanisms of risk assessment as related to the affect heuristic.  Here we shall continue the discussion of risk and finish by exploring its relationship to our humanity.    

Loss Aversion

            People dislike losses more than they like gains⁴.  Psychologists call this loss aversion.  Many studies have demonstrated this tendency.  When participants were asked how much they would have to win to participate in a coin toss where they would lose $50 if they called it wrongly, people set the average price around $100³.  That is, a participant had to win twice as much as she could lose to make it “worth her while.”  Loss of what you already own is much more painful than a gain is pleasurable.

Loss aversion affects more than financial gambles.  When a dad weighs the risks of vaccines, a prominent fact in his mind is that his child is healthy now.  Suppose he consents to give his son the MMR vaccine at 1 year of age, and then at 3 years he’s diagnosed with autism.  If dad convinces himself of a causal relationship between the two events, then the sense of loss he would feel from his complicity seems unbearable.  If he compares that potential loss of his child’s good health against the potential benefits of preventing vaccine-preventable diseases (VPDs), uncertain and far in the future as they are, then loss aversion can be the key factor in his decision.   

Regret

            Related to loss aversion, people prefer sins of omission (bad outcomes from inaction) compared to sins of commission (bad outcomes from action)⁴.  Consider two investors.  The first owns stock in company A but considers selling it to buying company B.  He decides not to buy, and later learns he would have gained $2,000 if he had purchased B.  The second owns stock in B and then sells it for stock in A.  He also learns he would have $2,000 had he not sold B.  Which investor regrets his decision more?  When asked this questions, 92% of respondents say the second³.  Regret is a powerful emotional manifestation of loss, and our minds feel more regret when our actions are the cause of a bad outcome. 

            Now consider again the dad who is already uncertain about vaccines and is weighing the risks.  He is the one who has to consent to the shot.  His action of consenting directly results in the vaccination of his child.  If his child develops autism and he believes vaccines were the cause, then he will profoundly regret giving his consent, as he believes he is part of the cause.  However, suppose he decides not to vaccinate.  This is the inactive option since his child is naturally unvaccinated.   If his child catches severe pneumococcal pneumonia, it is easy to imagine that he will more readily forgive himself for his inaction and experience less regret.  In the calculus of choice, regret is an important variable.

Reference Frames

Both loss aversion and regret depend on your frame of reference.  What is the default position against which losses and gains are compared? If asked who is happier, someone with $2000 who wins $500 or someone with $3000 who loses $500, the obvious answer is the first person, by a lot³.  If satisfaction only depended on money, then they should be equally satisfied as they have the same amount at the end of the transaction.  However, we see that the starting point matters; it determines whether a final state is a loss or a gain.  If a third person initially had $2000, was given $1000 briefly and then had $500 taken away, we intuitively see this person is less unhappy (and probably quite happy) compared to the second person above.  This third person, although briefly owning $3000, feels little ownership of it – her frame of reference is starting with $2000 and thus her final state is a net gain of $500.

             Applying this logic to vaccines, we can see that the above examples of loss aversion and regret depend on the reference frame of the unvaccinated child with his current state of health.  From here, perceived injury by a vaccine is viewed as a loss of health and prevention of a VPD is a gain.  Now imagine a society with a robust public health program that has swayed public opinion heavily in favor of vaccines.  Society as a whole views the state of being vaccinated as the default state, where a child’s health should be.  Now when a parent considers not vaccinating, that is an act of commission, as it is their choice (choosing not to) which caused the deviation from the reference state⁴.  Similarly, he will feel less regret if he believes his child suffers an injury from the vaccine.  He was merely doing his fatherly duty of maintaining the reference health state.  Unfortunately for many people, the vaccinated child is not their reference state and loss aversion and regret come to bear negatively on their decisions. 

Overestimating Small Probabilities

            In general, humans are terrible with statistics, especially with small probabilities.  Research consistently demonstrates that we overestimate the frequency of rare events.  One group of researchers showed that people consistently overestimate the percentage of death from rare causes⁷. This is particularly true when the events are vivid, as other researchers have shown that people judge death by tornado to be much more frequent than death due to boring, everyday asthma, even though asthma kills 20 times as many people³.  Consider the fear the 9/11 terrorist attacks caused compared to the fear people felt on that same day towards a common, yet much more dangerous, activity such as driving.   Granted, many factors contribute to the fear caused by terrorism, but among them is the fear that you will be the victim of an attack.  This fear is irrational compared to the risk we face everyday by getting into a car. 

            Similar to overestimation, we overweight the importance of small probabilities.  How much would you pay to increase your chance of wining $1000 from 0% to 5%?  What about to increase your chances from 5% to 10%? The latter bet is double the chance to win compared to the former, so would you pay twice as much? Studies demonstrate that you most likely would not; you would pay proportionally more to go from 0 to 5% than from 5 to 10%³.  There is substantial psychological benefit when a person moves from no possibility of winning to any possibility of winning, what researchers call the possibility effect.  There is proportionally less benefit when a person moves from a small chance of winning to a slightly less small chance, and people reflect this preference in the price they are willing to pay for such a gamble.

            Now adverse reactions (AR) to vaccines do happen. All of them are rare; the bad ones, such as severe allergic reactions, are exquisitely rare⁸. Note that the possibility unfortunately does exist.  Given the above discussion, we know that the undecided parent will see the AR rates as much more frequent than they truly are, particularly because they are so vivid.  For the same reason, he will also overweigh the specter of ARs in his risk calculation.

             

Availability Cascade

            We can use these observations about risk assessment to explore a powerful, culture-changing process that strongly influences our response to vaccines, the availability cascade (AC). Availability refers to the degree of familiarity we feel towards a topic.  We feel familiar towards things we’ve been more exposed to.  If a topic is more available in our minds, then we will tend to overestimate its frequency, feel like we know more about it than we actually do, and be more likely to use what we know to draw further conclusions³. 

An AC, as Kahneman defines it, is “a self-sustaining chain of events, which may start from media reports of a relatively minor event [author’s addition: or Twitter messages or Facebook statuses] and lead up to public panic and large-scale government action³”.  This is not a belly-flopping Corgi video that you laugh about at work the next day; this is a piece of news that changes your daily life.  This is a viral idea that becomes a plague. Broadly speaking, this happens when a story catches the attention of a subset of people who become concerned.  The media reports the concern as a news story itself, which reinforces the concern in more people. The cycle repeats until the issue gains so much momentum, it has to be addressed on a large scale.  I find it interesting that it’s called a cascade, which may evoke the gentle image of a waterfall in many people’s minds.  However, I don’t think image does the idea justice. I see the process as more powerful and chaotic, more akin to the violent cascade of radiation in nuclear fission.

            Let’s use MMR causing autism as an example.  In 1998, a researcher makes up a bunch of stuff, writes a paper, submits it to a respected medical journal and it gets published (and later retracted). This is, unfortunately, not too unusual an event. The news media prints an article about the paper.  A portion of the population that was already suspicious of vaccines hears about the article and starts to make a ruckus.  A pretty person with a loud voice lends her celebrity to their concerns.  The controversy between nerdy scientists with their pocket protectors and taped glasses who say vaccines are safe and the supermodel who just knows for certain that vaccines caused her child’s autism is too juicy for the news media to ignore.  So the coverage intensifies, adding undue legitimacy to the controversy.  The anti-vaccination arguments begin to bloom and spread like a mushroom cloud –“toxins!, mercury!, overwhelmed immune systems!, government cover-ups!”  With the force of a bomb, they impact parents at their deepest fear, the safety of their child.  There the radioactive ideas remain, sizzling with intense doubt.   This doubt ignites our risk assessment strategies.  The affect heuristic, loss aversion, fear of regret, overestimating and overweighting small probabilities all burn brightly in the concerned parent’s mind.  The process is repeated millions of times, in the minds of anyone who hears such arguments.  Governments, doctors and scientists respond with a slew of non-made-up studies which state that the MMR vaccine does not cause autism.  Unfortunately, the facts do not fix the fears because they do not survive the cognitive processes of risk assessment.  So the cascade continues, its explosions echoing through history, its shockwaves reverberating into the future.

The Facts do not fix the Fears

            If there is main point for healthcare providers it is this: facts are not communication.  Too often, doctors sit with patients and tell them the facts of their illness and how to treat it.  The patient returns 1 month later having done nothing the doctor suggested and we blame it on non-compliance.  Each fact a patient hears has to navigate the gauntlet of our cognitive machinery.  If we do not communicate with an appreciation for people’s loss aversion, heuristics and biases, or terribleness with probabilities, then we are not communicating with a human brain, we are speaking to ourselves.   The only way to do this is both unfortunately cliché and extremely powerful: listen.  By listening, we can identity the patient’s cognitive process and speak not only to their intellectual gaps, but also to their doubts and fears.

            If there is a main point for anybody with an opinion about vaccines it is this: we all use these same cognitive mechanisms, therefore we are all at risk of the same thinking errors.  By extension, we are all wrong about a lot of things a lot of the time. There are members of our species that came up with scientology, believe that Reptilian overlords run the government, and think the Twilight movies are actual artistic achievements, and now this species is debating the merits of vaccines.  It should surprise no one that there are people who conclude wrong things, nor should it surprise you when you are one of those people.  If we understand this, we can approach debates with humility, understanding we are not so different than our opponents. After all, it’s certain that one of your beliefs appears to someone as anti-vaccination beliefs appear to you.  Now don’t get me wrong, this is a serious issue, and we are ultimately debating over the health and safety of our kids.  But in order to convince someone why they are wrong we have to first understand why they are wrong.  We have to understand the quirky shenanigans of cognition and humbly acknowledge that no matter which side of the debate, we all have similar brains that are quite fallible and, therefore, quite human. 

References

1.         Smith PJ, Humiston SG, Marcuse EK, et al. Parental Delay or Refusal of Vaccine Doses, Childhood Vaccination Coverage at 24 Months of Age, and the Health Belief Model. Public Health Reports. 2011;126(Suppl 2):135-146.

2.         Rottenstreich Y, Hsee CK. Money, kisses, and electric shocks: On the affective psychology of risk. Psychological Science. 2001;12(3):185-190.

3.         Kahneman D. Thinking, fast and slow. Macmillan; 2011.

4.         Cappelen A, Mæstad O, Tungodden B. Demand for Childhood Vaccination – Insights from Behavioral Economics. Forum for Development Studies. 2010;37(3):349-364.

5.         Slovic P, Finucane ML, Peters E, MacGregor DG. Risk as analysis and risk as feelings: Some thoughts about affect, reason, risk, and rationality. Risk analysis. 2004;24(2):311-322.

6.         Finucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgments of risks and benefits. Journal of behavioral decision making. 2000;13(1):1-17.

7.         Lichtenstein S, Slovic P, Fischhoff B, Layman M, Combs B. Judged frequency of lethal events. Journal of experimental psychology: human learning and memory. 1978;4(6):551.

8.         Medicine Io. Adverse Effects of Vaccines: Evidence and Causality National Academies Press 2012.