Tuesday, November 4, 2014

Ripley Was Right: Ebola, Science, and the Precautionary Principle

In my previous post on the Ebola outbreak, I focused on how the treatment of Ebola patients highlights the shortcomings of private healthcare in the US, and the need for a comprehensive public system.  I also mentioned that American media coverage has been limited, as we might expect, to a spectrum running from Republican/Fox fear-mongering to Democratic/MSNBC ass-covering. I avoided, and had formed no opinion about, the question of how dangerous this strain of Ebola is, or of any question about what preventive measures are called for.

Since that post, the subsequent brouhahas about who should and shouldn’t be quarantined have only exacerbated the ridiculous media paradigm in which what’s really at stake in Ebola is Obama’s presidential reputation or Chris Christie’s presidential prospects or which party will win the mid-term elections. At the same time, a lot of evidence has become available regarding the lethality and transmissibility of the Ebola strain we are dealing with. In this post, I want to look at some of that evidence, teasing out the issues of scientific knowledge and ethico-political authority that are raised by the Ebola crisis, and which are confused by the impulse to read them through the lens of American liberal/conservative categories, with which they have nothing to do.


Superbug

How lethal and how transmissible is the current (Zaire) strain of the Ebola virus?

Here’s a two-minute clip of Dr. Michael Osterholm, head of the Center for Infectious Disease Research and Policy at the University of Minnesota, speaking at Johns Hopkins:

(2 minutes)

And here’s Peter Jahrling, chief scientist at the National Institute of Allergy and Infectious Diseases, who’s been studying hemorrhagic fevers for 25 years, and helped discover the Reston strain of Ebola, in an interview with Vox:
We are using tests now that [we] weren't using in the past, but there seems to be a belief that the virus load is higher in these patients [today] than what we have seen before. If true, that's a very different bug. …
JB (Vox): A higher viral load means this Ebola virus can spread faster and further? 
PJ: Yes. I have a field team in Monrovia. They are running [tests]. They are telling me that viral loads are coming up very quickly and really high, higher than they are used to seeing.
As Vox points out (using statistics that have already been surpassed), the current Ebola outbreak is “remarkable” because “the virus has spread to six countries in Africa plus America, and has already infected more than 13,000 people. It has killed nearly 5,000 people. That is more than six times the sum total of all previous outbreaks combined.” It has a 50-70% mortality rate.

In short, unprecedented lethality:




Catch As Catch Can

Regarding the transmissibility of the present Ebola strain, Lisa M. Brosseau and Rachael Jones, professors in the School of Public Health at the University of Illinois at Chicago, have written, in a report for the Center for Infectious Disease Research and Policy (that they have taken pains to say “does not represent the opinion of the University of Illinois at Chicago or any other organization”), that: “Being at first skeptical that Ebola virus could be an aerosol-transmissible disease, we are now persuaded by a review of experimental and epidemiologic data that this might be an important feature of disease transmission, particularly in healthcare settings.”

Echoing a point that Dr. Osterholm made in a New York Times op-ed in September, Brosseau and Jones point out that: “Zaire Ebola viruses have also been transmitted in the absence of direct contact among pigs and from pigs to non-human primates, which experienced lung involvement in infection. Persons with no known direct contact with Ebola virus disease patients or their bodily fluids have become infected.” Thus, they find ”scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients.”

Given all this, and given, as they point out, that this Ebola virus has “No proven pre- or post-exposure treatment modalities, a high case-fatality rate, [and] unclear modes of transmission,” Brosseau and Jones insist that the use of respiratory protection--for healthcare workers, at the least--is “compelled” by the well-established “precautionary principle—that any action designed to reduce risk should not await scientific certainty.”

Not only is Ebola incredibly lethal and potentially airborne, it can, according to a Lancet study reported in the New York Times in 2000 “infect without producing illness,” and can “persist in the blood of asymptomatic infected individuals for two weeks after they were first exposed to an infected individual.” In other words, “people can be carriers without showing symptoms.” One study done by the New England Journal of Medicine and the World Health Organization found that “nearly 13 percent of the time, those infected with Ebola exhibited no fever at all.”

Let’s have Dr. Bruce Beutler, who won the Nobel Prize for Medicine and Physiology in 2011, sum it up:
It may not be absolutely true that those without symptoms can’t transmit the disease…It could be people develop significant viremia [where viruses enter the bloodstream and gain access to the rest of the body], and become able to transmit the disease before they have a fever, even. People may have said that without symptoms you can’t transmit Ebola. I’m not sure about that being 100 percent true. There’s a lot of variation with viruses.


Know At All

Here’s the point: “Official” spokespersons are telling the public that things are scientifically certain that are not, and that they know, or should know, are not. They are saying that it’s scientifically certain the Ebola virus cannot be transmitted by any airborne means, when what is actually known scientifically is that the full range of the means of transmission is “unclear,” and transmission by aerosol particles is a real possibility. They are saying that it’s scientifically certain the Ebola virus cannot be transmitted by a person who does not have symptoms when it is known scientifically that asymptomatic persons can be carriers.

One can say only say that it’s the consensus of the “scientific community” that asymptomatic persons are non-infectious if one defines that “community” narrowly enough to exclude this or that Nobel Prize-winner, and defines what counts as a relevant “symptom” to exclude things like “fatigue.” Even then, one cannot claim that there is no countervailing scientific evidence, or scientific argument, or serious scientist, that points to another conclusion. One cannot, that is, claim certainty—there’s no “almost” in certainly—on that point.

Let’s consider for a moment the claim that a person without symptoms even if carrying the virus (that must be part of the claim), absolutely, positively, scientifically-certainly, cannot transmit the virus unless s/he has symptoms. OK, what’s a “symptom”? Dr. Craig Spencer, the New York City Ebola patient, who had gone through “enhanced screening” for the virus on arrival at JFK on Friday, October 17th, reported feeling “fatigued” on Tuesday, the 21st, but, since he had no fever, vomiting, or diarrhea, he spent the next two days riding the subways and an Uber car, eating at The Meatball Shop, strolling on the HighLine, and bowling. Only on Thursday, the 23rd did he run a fever and get quarantined.

So, was his Friday fatigue a “symptom” or not? The only scientifically-certain answer to that question is: We do not know. Now that he’s sick, we can say with scientific certainty that he was carrying the virus even though he had passed enhanced screening. We can also say with scientific certainty that we do not know what every infectivity-triggering “symptom” might be, or at what moment in the chain of possible “symptoms” his infectiousness was triggered. A half-hour after he became fatigued? Fifteen minutes before he spiked a fever? (100? 101? 102?) The moment he sneezed on the subway? 

What this incident tells us, with certainty, is that we do not know with any precision exactly when this carrier of the virus was or was not capable of passing it to someone else. In other words, the only thing we are scientifically certain about is our uncertainty. Sometimes, to paraphrase the great epistemologist Donald Rumsfeld, there are things we know we don’t know.

We do not know all the ways we may catch Ebola without having a dying patient bleed all over you. That—knowing and acknowledging one’s uncertainty—is a supremely scientific attitude. Pretending and insisting on certainty is not.  It’s often the case, as I think it is here, that the claim of scientific certainty in official discourse—even the discourse of some scientists—is not “scientific” but “ideological.” That is, it is not meant to communicate knowledge—which may be somewhat complicated, unclear in its policy implications, and demanding of further research; it is, rather, meant to encourage a psychological-political disposition—to calm people down, to give them the sense that the authorities are in control and there is not much to worry about. 

Such a calming impulse may be understandable, especially in a situation where the predominant “opposition” discourse is no less unscientific and ideological, seeking only to create the opposite psychological-political disposition—to scare the crap out of everyone in order to increase disaffection with the party currently in power. But it only perpetuates the situation in which important issues of science and health get instantly captured and obscured by the ridiculous framework of American two-party politics. It reinforces a patronizing political condescension, in which “inner circles” of elites and specialists withhold information and concerns, which they worry about amongst themselves, from the public that is most affected.  As Dr. Osterholm puts it: “What is not getting said publicly, despite briefings and discussions in the inner circles of the world’s public health agencies, is that we are in totally uncharted waters.”

Such patronizing, in fact, exacerbates the conditions for fear-mongering. It is the mistrust of the government—let’s call it the “public authority”—that creates the conditions for irrational fear, and such mistrust arises because the government is rightly suspected of not acting transparently in the public interest. Further dissembling, along with paternalistic, contradictory, and obviously phony reassurances (Why did those CDC personnel wear respirators when they boarded a plane to get an asymptomatic passenger? Why are military personnel being quarantined?) only exacerbate the mistrust. Scary or not, telling the truth about risks and uncertainties, is a condition for thinking, and for making rational and effective decisions, about what is, after all, the health of the public. Sometimes it is not “irrational” to Be Afraid.


Free Radicals

Of course, the immediate question that arises in this context is: Quarantine or not?  Any policy answer to that question should be based on known uncertainty about when the virus is transmissible, not on ideologically-claimed certainty about lack of danger. It should be based on presenting the public with the range of possible scenarios, not patting the public on the head with a “What, me worry?” And, yes, it should be based on a rigorous consideration of the real public health risks, not on sympathy or admiration, however well-deserved, for this or that person.

I honor Dr. Craig Spencer and nurse Kaci Hickox. They have done the kind of personally-dangerous hardcore work in the service of humanity that puts most of us to shame. They deserve the respect and honor of all of us.  To them, it can be said without mental reservation: “Thank you for your service.” They are also human beings, capable of the same complex of contradictions and misperceptions that constitute any human subject.

Dr. Spencer went to Guinea and saved people’s lives. He then came back to New York and put people’s lives at risk. I am sure he did not think he was doing so.  I am sure he was enhanced-screened-for-sure, absolutely, positively certain, as a doctor, that he did not have Ebola, or he would not have gone for his sojourns through the city. He was wrong. According to a NY Post report (“disputed” but not quite denied by the NYC Health Department), Craig le flâneur also misled authorities into believing he had “self-quarantined” in his apartment, until the police checked his MetroCard, which revealed his movements around town. He’s a human being.

Nurse Kaci Hickox’s case has a few twists. She arrived at EWR from Sierra Leone with a fever—one of those relevant symptoms that she claimed was insignificant (like Dr. Spencer’s “fatigue”?). She was detained in isolation for three days, until she tested negative for the virus. (That’s a blood test, I presume. As I understand it, she has tested negative at least twice.) She then went home to Maine, where she has defied—in action, and now successfully in court—the Governor’s attempt to forcibly quarantine her.

It seems to me Kaci’s case involves two discrete moments and a few discrete questions. First, before any blood test: Is a fever a relevant symptom? If one says it is, then on what scientific basis can one object to isolating her? Because she’s a nice person, who just spent a month tending to the sick? Because she doesn’t think the thermometer was accurate? Because she just knows she doesn’t have the virus?

Once she tests negative, the question becomes: Does a negative blood test (or two) rule out Ebola infection?  I’m not clear on that. The fact that she had more than one seems to indicate that a negative test does not; on the other hand, her success in court may indicate that it does. At any rate, before getting a result, she had no scientific basis to presume, and insist that public authorities presume, a negative result. If the negative results do rule out Ebola, then of course no one has any scientific or political justification for restricting her in any way. If there’s still some ambiguity, then neither she nor we know if she has the virus or is infectious, and we are back at the basic ethico-political and legal question: What gives one the right to refuse a quarantine? 

The Nation may find it inspiring that scrappy thought-to-be-Democratic Kaci Hickox is “striking a blow” against inarguably arrogant and asinine Republican “bully” Chris Christie, but when Kaci insists: “I am completely healthy and with no symptoms. And if he knew anything about Ebola he would know that asymptomatic people are not infectious,” is that “he” the Governor of New Jersey or the Nobel Laureate in Medicine? Because, according to the latter, Kaci is wrong. Current scientific knowledge does not support a flat “asymptomatic people are not infectious.” And her case perfectly illustrates why scientific knowledge is not determined by the character—the complex of contradictions and misperceptions—of any human person.

Whatever the outcome of Kaci Hickox’s case, there is nothing scientifically astute or politically progressive about claiming that someone, no matter how wonderful a person s/he is, can diagnose him- or herself in advance, or take upon him- or herself the right/authority to answer those questions of public import. And, whoever is Governor or President or Nurse or Doctor, the idea that issues of quarantine and the refusal thereof, related to the outbreak of an incredibly lethal pathogen, should be seen in terms of a cage match between Fox News and The Nation, the idea that we have to line up, in bogus American terms, “left” and “right” on those issues, is scientifically ludicrous, politically ridiculous, and incredibly dangerous.

Scientifically, and therefore ethically and politically, quarantine policies are entirely justifiable, based as they are on the fundamental scientific precautionary principle and the fundamental political principle of the public interest. In this case, don’t forget, we’re talking about satisfying the precautionary principle with a quarantine of 21 days, not lifetime isolation.

Of course, any such policy must respect the rights of the quarantined, who are fully enfranchised citizens, not criminals. Any quarantine policy should be strictly limited in regard to time and conditions as defined by scientific criteria, and monitored by medical personnel, not the police. Those quarantined should, at public expense, be provided comfortable living conditions, meals, supplies, and full medical care, and indemnified against any job loss, demotion, or labor-related economic damages. That’s what a public healthcare system, designed to protect the public’s health would be prepared to do, and would do, without a cage match.

Don't want to discourage healthcare workers from going overseas to help where they are most needed? Encourage them! Pay them handsomely for it! If work like this—stopping an outbreak like this at its source—is important for the public health and the common good, which I think it is, then offer public funds to support and incentivize the people who have the skills and sense of social responsibility to do it, while making clear the possibilities of quarantine that may be inherent in such work.

It is worth noting that sending teams of doctors and medical workers, as Cuba is doing, seems to me of more direct benefit to public health concerns than sending in the 101st Airborne Division, as the US government is doing. Of course, in these United States, the armed forces are paid for—in advance, no questions; the cost of medical teams would be fiercely resisted.

Do you see the entirely different conversation that ensues? The lack of, and need for, this kind of public healthcare system, with these kinds of priorities, run by and for, and therefore with the trust of, the public is what we should be discussing—not  for whom the person quarantined voted in the last election, or which party will benefit most in the next. The national media, liberal and conservative, has us in the latter conversation because it prevents the former.

Indeed, does not this situation provide the irrefutable argument against Ayn-Randian libertarian fantasies based on an ethic of absolute individualism? Does not the threat of a globally active pathogen of unprecedented lethality and uncertain transmissibility prove, beyond doubt, the need for national public institutions with regulatory authority, up to and including the authority to impose personal constraints? Isn’t Ebola exactly what we need in order to say, with Norman Pollack: “Safeguarding the public’s health is NOT a trespass on civil liberties!“ Why don’t we say that a Dr. Spence or a Nurse Hickox has no more right to excuse him- or herself from the scientifically and ethically cogent precautionary principle with the Ebola virus than does Chevron with its fracking technology or Monsanto with its GMOs?

Do I hear: “Of course, in the abstract, the quarantine power is a legitimate exercise of public/state authority, but, but, but, in this case, right now, for someone like him/her (How much of it comes down to that?!), with all the fear it will evoke….”?  If you think a rapidly-spreading hemorrhagic fever virus that will eat your blood vessels from the inside out, killing 50-70% of the people it strikes, is not a public health threat that calls for quarantine policies—policies that no individual can overrule on the basis of his/her own diagnosis, his/her own desire for a bike ride or HighLine stroll, or his/her own honorable personal history of service (let alone some politician’s need to keep the people calm)—then please tell me: On the basis of scientific evidence, and consistent with the scientific precautionary principle, what public health threat would?


Science Friction

Underlying this debate is, I think, a confusion about science, about what constitutes scientific knowledges, about how such knowledges are produced within scientific practices, and about the role of  scientific “communities,” “consensus,” institutions and personnel in that process. (I think it’s important to recognize that nothing here is singular.)

Historically-developed, socially-constructed scientific disciplines produce explanations that help us understand how “reality”—or whatever part of that a particular discipline is looking at—works. These explanations may help us change that reality, or do something new with it.  Science—as a general term covering a web of different scientific discourses and practices—is a method for producing such explanations (which I also call “effective knowledges”). It differs from, and produces different kinds of explanations than, other methods. Thus, the adjective “scientific” refers to a kind of explanation.

In our society, a crucial difference in this regard is that between the scientific mode of explanation and the religious mode of explanation from which it historically diverged. For the modern secularist, science has replaced a process based on sacred texts, transcendent guiding voices, and revealed, essentialist, teleological narratives with a process based on a reciprocal interaction between empirical research, rational hypothesizing, and theory-building, without any essential precondition. The latter has been recognized as the more effective mode of explaining, and transforming what we can do with, “reality”—including the natural and the social world.  This is the sharp edge of the secularist critique of religion versus science. In this sense, science is basically secular epistemology.

The “theory-building” part is important. A scientific explanation of a discrete phenomenon is only complete when it’s embedded in a conceptual framework that ties it together with other explanations of other phenomena. A scientific theory is not “just” a theory, it is the effect and condition of producing scientific knowledges. Science is a process of “fact-finding” and theory-building, and the difference between “scientific” and “unscientific” is not a difference between “fact” and “theory,” but between two different modes of explanation, which give rise to two different kinds of theories and “facts.”

I find that liberal pundits often opportunistically confuse a difference between scientific explanations with a difference between a scientific and non-scientific explanation. 

To illustrate, let’s take the following:
  • Person A, working in a secular, scientific epistemology, a prominent accredited scientist speaking for a prestigious institution and claiming, with some reason, to represent the consensus of the scientific community, asserting that “We know with certainty that Ebola cannot be transmitted by an asymptomatic person,” and 

  • Person B, working in the same secular, scientific epistemology, a recognized accredited scientist speaking as such, and asserting, against the dominant consensus, that “Actually, we do not know whether Ebola can be transmitted by an asymptomatic person.” 

The disagreement here is stark. One is right, and the other wrong, because one (A) is asserting an absolute. (Of course, being wrong is not unscientific. Science proceeds through a series of mostly wrong answers.) Person B is certainly not standing in unscientific “theory” as opposed to Person A’s stance in scientific “fact.” If anything, Person A is in the more precarious position, since making an unsupported claim of absolute knowledge is a characteristically unscientific way of being wrong. They would both claim, and we should accept, that this disagreement is one within scientific practice, which may or may not be resolved therein.

It is definitely not resolved by pointing to the “consensus” of the “community.” That factor does merit consideration, when it can reliably be determined.  But the fact that A is the head of a government agency and gives press conferences with twenty prominent politicians and scientists standing behind him, does not mean that B is “in denial.” Can we count the number of times knowledges—you know, little things like the germ theory of disease—were produced outside of, and against, the determined opposition of, the established “scientific community” and its consensus? Is there anything less scientific than the appeal to authority?

In other words, if B is producing rational arguments and verifiable data, they should be considered part of a scientific inquiry, not straw-manned and dismissed as unscientific.

To elucidate further, let’s introduce person C, working within a religious epistemology based on revealed sacred texts, who asserts that: “God created everything all at once, as stated in the Bible,” and is countered by person B above, who asserts that “Evolution is a process of natural selection, as first outlined in the work of Darwin, and as elaborated in scientific practices since.”

This is not at all the same as the difference between person A or B above. A’s disagreement with B is one between two different scientific explanations, each based on empirical evidence and rational theory; B’s disagreement with C is a difference between two entirely different epistemological universes. To say that person B in the argument above is just like—as “unscientific” as—person C in the argument here is to make an elementary category error—to be, in fact, unscientific, in a fundamental sense.

Yet this is what liberal pundits constantly do regarding the Ebola issue (and others): Those who disagree with the conventional/consensus wisdom, scientific and otherwise, are just unscientific, fact-denying wingnuts who probably send their children on field trips to the creation museum. To see how false this pose of rigorous scientificity is, watch how these pundits treat a person C who speaks up to agree with the consensus, on the basis of his or her reading of a sacred text—Yes, we know this for certain about Ebola, because that’s the message of this passage…, or something like that. It’s unlikely such a person will be denounced as a wingnut, “in denial.”

The same liberal pundits are willing, rightly, to critique the scientific establishment and consensus on other issues—as in fracking and GMOs. It’s just some issues, usually those in which Obamabacan loyalty or Democratic Party electoral prospects are most at stake, that bring out an opportunistic fetishizing of the establishment and a sudden blindness to the political and economic pressures on particular scientists and scientific institutions.

The current flap over Ebola and quarantine demonstrates, again, that, even faced with a dangerous and unprecedented threat, it is virtually impossible to break out of silly, irrelevant partisan bickering, which causes many self-described liberals and progressives to confuse, while they claim to uphold, the paradigms of scientific rigor and public interest that can help us the most.

When it comes to a deadly infection and quarantine, we have a fine example of what can happen when a seemingly compassionate science official acts in defiance of an authority figure, who, seeming to be cold-hearted, is trying to enforce the scientific protocol that could actually save lives—the precautionary principle. We all know how it ends up. The science officer, it turns out, was motivated by something other than science or compassion, and Ripley was right:

(1:20)




______________________
Update (11/16/2014): Regarding the precautionary principle, you might want to take a look at the excellent working paper from the Extreme Risk Initiative at the NYU School of Engineering, "The Precautionary Principle (with Application to the Genetic Modification of Organisms)" [h/t Terry Steichen].  It's an academic, even technical, paper, focussed on GMOs, but its argument, including the following point about public skepticism vs. official assurance, is spot on in this context:
It has became popular to claim irrationality for GMO and other skepticism on the part of the general public—not realizing that there is in fact an "expert problem" and such skepticism is healthy and even necessary for survival. For instance, in The Rational Animal, the authors pathologize people for not accepting GMOs although "the World Health Organization has never found evidence of ill effects," a standard confusion of evidence of absence and absence of evidence. Such pathologizing is similar to behavioral researchers labeling hyperbolic discounting as "irrational" when in fact it is largely the researcher who has a very narrow model and richer models make the "irrationality" go away. 
These researchers fail to understand that humans may have precautionary principles against systemic risks, and can be skeptical of the untested consequences of policies for deeply rational reasons, even if they do not express such fears in academic format.

Related Post: The Irish Widow and the Liberian Fiancé: Ebola, CEO Disease, and the Public Good

Links










There are known knowns - Wikipedia, the free encyclopedia (“we know there are some things we do not know.”)

7 comments:

  1. I can't believe there are no comments on this post. It's one of the most substantial that I've recently encountered. Really deep thinking about not just Ebola and quarantine, but an excellent analysis of the precautionary principle and the scientific method. I'm still digesting it, after reading it several times.

    ReplyDelete
  2. Thanks, Terry. Glad you found this analysis so worthwhile. Pass it along, and we'll see if more comments follow.

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  3. I do have a question that came up in my discussions. Essentially, I was making the point that, given our current state of scientific uncertainty, the precautionary principle would guide us to require quarantine based merely on being potentially exposed to Ebola. A friend observed, however, that since the outbreak, we've had hundreds if not thousands of visitors from Ebola-stricken areas. To the best of our knowledge, none of them have turned out to actually be infected. So, would the concept of precautionary quarantine have created a huge problem/cost which, in hindsight, was unnecessary?

    ReplyDelete
  4. I have my own email subscriber groups (of over 100) and I did a Part 1 analysis of your thoughts (including a copy of your post and its url), and indicated I'd do at least one more on some of the other points you made. If you send me an email address for you, I'll forward this to you, FYI.

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  5. I am not sure exactly who needs to be quarantined. I don't mean to be evasive with that. My main concern was to show that the discussion was being channeled in ways that were not being honest and transparent about the criteria that we need to make such decisions. I don't think honesty, transparency, and dispassionate scientific thoroughness are preconditions for making such decisions. Decisions about a quarantine policy can't be takeh lightly, and I fear we're in a political atmosphere that makes such honesty and transparency unlikely. I'll say that, from what I've learned, it's my impression that we haven't needed a mass quarantine, and that the candidates most eligible for some kind of quarantine are those healthcare workers who have been in close contact with a lot of diseased people. That's unfortunate, but isn't it also, scientifically, obvious? The military isn't quarantining soldiers coming back from the hot zone because

    ReplyDelete
  6. Great post The Polemicist on Ebola!

    It's funny: We just created an amazing Infographic on "Ebola Virus. What Is It? Interesting Facts" because we found people were missing the essential facts about Ebola.

    Check it out: www.BioMedicalWasteSolutions.com/What-Is-Ebola/

    Let me know what you think:)

    ReplyDelete
  7. Very late to the party, but this is an excellent post. I note ebola is creeping into the news again, little by little.

    I learned a long time ago that MBA == dangerous idiot.

    ReplyDelete

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