Gonna go out on a limb

I was reading Chris Dierkes's piece about Obama's Notre Dame commencement speech over at Ordinary Gentlemen. He is, unsurprisingly, no more a fan of the Huffington Post than I am:

In the controversy around abortion, it is not hard for Obama to look fair-minded. Obama is helped in this by useful idiots from his left flank who write not particularly bright commentaries on his speech re: abortion like this one on the front page of the HuffingtonPost.

The link leads you to a not particularly bright commentary at the Huffington Post.

I try to avoid writing about the snake pit that is the abortion controversy in the United States. I am too ambivalent about my own pro-choice stance to question the sincere beliefs of others, and am loath to court undue controversy. But I am unable to contain my scorn at reading this:

A few minutes before President Obama's commencement speech at Notre Dame, the CNN anchor was intoning that he supports stem cell research and he supports abortion rights, and that he would not shrink from his positions on either. In fact, she said, he was going to use an email he had gotten on the subject of abortion as part of his remarks.

Good, I thought. It will be from the parent of the mentally retarded high school student who was gang raped, the doctor of an 11 year old incest victim, or possibly a woman with four kids already whose husband has just lost his job and medical benefits along with it.

Boy, was I wrong.

Friends, it would be much, much easier if everyone who sought an abortion were in straits as dire as those described above. I would love to tell you that, during my years working in New York, I was faced with young women consistently conflicted about their pregnancies, and who were aware of how profound a decision they were making when they opted for abortion. I wish it were not the case that many such young women truly did use abortion as a method of contraception, and that some (dare I say many?) of those young women did so blithely and with no apparent hesitation.

I would love to say those things. Those things are not true.

Abortion is a tremendously complex issue, and one about which I believe people of intelligence and integrity can honestly disagree. Indeed, I believe that both sides have compelling arguments in their favor. But if we're going to have this debate, then let us move away from the examples of women in extremis, and acknowledge that abortion occupies a much more muddy moral space. I will not make the cavalier young women I encountered stand-ins for women who seek abortion in general, but neither will I accept that they are outliers.

A BB across the bow of the USS Vincennes

I do not like Oprah.

I do not like her orgies of consumption. I do not like the whole brouhaha with James Frey, which appears to be never-ending. And I hated The Corrections.

More than all of that, however, I am appalled that a woman who has the fame and influence that Oprah enjoys would use it so terribly irresponsibly. In particular, I am appalled that she would give the ludicrous Jenny McCarthy a blog of her own under the "Oprah.com" banner (as well as, God help us, a show it seems).

I will leave it to my colleagues at Respectful Insolence and PalMD to go through her blog in more detail than I can stomach right now. If you read Bleakonomy with any regularity (may the Lord preserve you), you probably already know what I think of her and her boyfriend. (I think they are dangerous lunatics, in short.)

However, it is one thing for Ms. McCarthy to have her anti-scientific beliefs, and to expound upon them to her heart's content. It is, as they say, a free country. It is another thing entirely to provide a woman who apparently thinks her child's poop should be free of bacteria (hope you eat lots of Vitamin K-rich foods, kid) with a venue that will doubtless be read by a great many people, and which will be assumed to bear Oprah's stamp of approve as a result. People, for whatever reason, pay attention to Oprah, buy what she says, read what she reads, and (probably) voted how she told them to. The last thing this country needs is for her to be giving a ninny like Ms. McCarthy a wider audience.

Update: In trolling around the Web after writing this, I came across this post by the mother of a child with autism. Money quote (hat tip Liz Ditz):

We live in a culture where some people make critical health decisions for their children based on the opinions of self-proclaimed celebrity graduates from "The University of Google." I'm asking you to help right the balance, to ensure that science-based viewpoints counter earnest but misinformed sensationalism in the autism -- and parenting -- communities' information flows.

I know that some people will never vaccinate their kids, no matter the argument or evidence. Herd immunity will compensate and keep the rest of our kids healthy *if* enough other children get vaccinated. That is why it is so important to reach and talk to parents who are still formulating their immunization opinions, to educate ourselves with facts rather than furor, to have the confidence to spread the word about what we know and believe, to tear down the wall of harm that Jenny and co. have erected, and to shout it loud:

There is no proven link between autism and vaccinations! I believe it is my social responsibility to vaccinate my children!

Sita Sings the Blues; the review

The Better Half and I hosted one of our best friends this past weekend. We took a trip up to Waterville to have dinner at the sublime Freedom Cafe, and as luck would have it we had just received a recent mailing from Railroad Square Cinema about their current offerings. (A short digression -- the existence of those two establishments was a major reason I was able to survive the move from Manhattan to mid-Maine. May they stay in business forever.) I had heard nothing about Sita Sings the Blues, but was intrigued enough to suggest it to our friend, and the three of us decided to give it a shot.

It was fantastic, and utterly unlike anything I have ever seen at the theater before. A cunning, hilarious and poignant retelling of the Hindu epic the Ramayana, which tells of the marriage of Rama and Sita, Sita Sings the Blues also deals with the break-up of the film-maker (who did the vast majority of the work on the production herself) and her husband. In between expository segments (narrated by three droll shadow puppets) and dramatic re-enactments, Sita's travails are expressed through the songs of Annette Hanshaw (a 20s blues singer). The animation varies between sections, from crude line-drawings to brilliantly-colored celestial panorama, each of which contributes to the narrative in a unique and fascinating way.

The animator, Nina Paley, has made the entire work available for download, but if you can find a local screening, go see it. It is one of the most inventive things I have ever seen, and deserves to be enjoyed in the theater.

Have a nice time wandering in the wilderness!

Oh, poor James Dobson. Poor, poor James Dobson. It sounds like even Miss California USA can't cheer him up these days.

From U. S. News:

I want to tell you up front that we're not going to ask you to do anything, to make a phone call or to write a letter or anything.

There is nothing you can do at this time about what is taking place because there is simply no limit to what the left can do at this time. Anything they want, they get and so we can't stop them.

We tried with [Health and Human Services Secretary] Kathleen Sebelius and sent thousands of phone calls and emails to the Senate and they didn't pay any attention to it because they don't have to. And so what you can do is pray, pray for this great nation... As I see it, there is no other answer. There's no other answer, short term.

[snip]

I've been on the air for 32 years and I've never seen a time quite like this. It just illustrates what happens when we don't have what the Founding Fathers referred to as checks and balances, where the excesses of one party or one branch of government limit the reach of power hungry and self-serving people and keeps them form doing things that are harmful to the country. That's the way the system was designed. We have 2 major political parties in this country, not one. And bipartisanship is a media creation that's designed to promote one point of view instead of the debate that should occur. And that's why media doesn't talk about bipartisanship when conservatives are in power...

You can cry me a river, Dr. Dobson. I don't recall you mewling like a stranded kitten about checks and balances when your ilk had a strangle-hold on power for six years, so you can just sit back and ponder that your side lost. Because you're right that the country apparently is no longer interested in your particular brand of reactionary theocratic political demagoguery, and good riddance to it. You chose to tie your wagon to the political fortunes of a swaggering incompetent, so them's the breaks.

But what if the cater waiters mutiny?

Oh, goodie. It looks like New England really is going to be the epicenter for marriage equality in the United States. From the Times:

Gov. John Lynch of New Hampshire said Thursday that he would sign the state’s same-sex marriage bill if it was amended to further shield opponents from having to take part in ceremonies celebrating such unions.

Legislative leaders said they would allow the changes, all but ensuring that New Hampshire will become the sixth state where marriage between gay men or lesbians is legal.

I am happy about this for a variety of reasons. First of all, simply for the merits of having marriage equality in another state. But more selfishly, the more states that legalize same-sex marriage, the more fronts the anti-equality crowd will have to fight, thus diluting the power of their money and their organizing efforts. It's a lot harder to fight newly-minted gay marriage laws in four states than it was to fight in California alone, even if the latter is an extremely expensive media market. So, the more states make it legal, the less likely it is to be overturned in any one state (like Maine, my happy home).

The language Gov. Lynch wants added would make religious exemptions from performing same-sex marriages more explicit. To quote my friend Mary (yes, I'm name-dropping... sue me):

Mary Bonauto, civil rights project director for Gay and Lesbian Advocates and Defenders, a legal group in Boston, said Mr. Lynch’s proposed changes to the New Hampshire law were “not a big deal.”

“Current law essentially provides these protections,” Ms. Bonauto said. “If making it more explicit gives people some peace of mind, so be it.”

But what I particularly like is this, from the opposition:

“However the governor wishes to couch his decision on this,” Mr. Smith said, “the fact remains that by signing this bill, he will have broke his trust with New Hampshire voters after repeatedly stating that he opposes gay marriage. This amendment does nothing to protect the religious liberties of independent business owners, such as photographers and caterers, who in good conscience cannot perform their services for same-sex marriage ceremonies.”

I've said it before, and I'll say it again -- if you own a business, and are too determined to stick to your bigotry to accept my money, then I'm more than happy to give it to someone else. I don't really see the state of New Hampshire needing to force florists (a faction known to be hostile to gay men) to provide services for same-sex weddings. Sometimes the free market really does work all on its own.

The hegemony of daycare

I have only been a pediatrician in practice for a few years, so I am unable to comment with authority on the social trends that append to raising children. But there is a phenomenon I have noticed that I find utterly and completely baffling, and I wonder how long it has existed.

When did daycares get so bloody powerful? And paranoid, for that matter?

I cannot even begin to describe the cavalcade of frustrated and bemused parents that have been forced to schlep their patently healthy children in for evaluation because they have been directed to by their daycare providers. The parents know there is nothing wrong with their child, but are not allowed to return them to daycare until they get a note from a doctor stating that they are free of illness.

HIPAA prevents me from giving the details that would hammer my point home. Suffice it to say that there is no scrape too small or sniffle too insignificant to warrant a mandated visit. If one kid in the daycare has been diagnosed with something, any kid with a whisper of a hint of a related symptom needs to be seen pronto, which means mom or dad has to leave work, and then wait around my office until I can say that their little one is fine. Which they already knew.

Has it been ever thus? Is this new? Is this just a Maine thing? Because man, as much as I like being gainfully employed, it sure is a silly way of racking up healthcare costs.

Dept. of Overstatement

I happened upon a nifty little article at Slate about the limitations of medical studies, and how it is hard to extrapolate long-term benefits of various interventions from the short-term measures used in those studies. It's worth reading in its entirety, and the author makes it more accessible by likening the studies to (don't laugh) reality shows.

Paul Bataldan, who co-founded the Institute for Healthcare Improvement, once observed that "every system is perfectly designed to get the results it gets." Reality TV participants desperate for fame or love sing (and lip-sync) shortened, preselected songs or go on over-the-top dates in fabulous locations, followed by a team of camera operators. The ostensible goal—the one declared to the audience—is to identify the most talented recording artist or most compatible couple. But as Bataldan might observe, the shows are instead designed to win over television viewers, which is an altogether different (and possibly incompatible) goal.

The parallels to a major clinical drug trial are uncanny. In the federal Multimodal Treatment Study, hundreds of kids with ADHD, whose families were desperate enough to enroll them in a randomized study, entered a well-funded and highly supervised National Institute for Mental Health program complete with specialized therapy, regular evaluation by developmental experts, and careful drug prescription—a setup that's about as realistic as a date on The Bachelor. Within that very unusual, closely monitored environment, as reported in 1999, stimulant medications caused modest improvement after about a year. In response, use of these products surged nationwide, and Ritalin and its peers became household brands. But in March, the researchers described what happened after the lights went out. In their subsequent years in the real world, the drug-treated kids ultimately ended up no better off than the others.

Epidemiologists call this the problem of "surrogate endpoints," and it's no surprise to fans of reality television. Garnering the greatest number of text-messaging votes after a brief performance doesn't always mean you'll be a successful pop star; winning the final rose after an on-air courtship doesn't mean you'll have a happy marriage; and getting higher scores on a simple rating scale of attention-deficit symptoms doesn't mean you'll later succeed in school. In medicine, this problem happens all the time.

Few drug-trial studies have the time or money to study the actual health outcomes that people care about, such as whether the middle-aged man avoids a heart attack after a few decades, the hyperactive first-grader holds down a good job someday, or the menopausal woman remains free from a hip fracture when she's elderly. Waiting for these events would stifle any meaningful innovation, so doctors pick surrogate endpoints, which they hope serve as short-term checkpoints. Thus drugs trials for the preceding examples may just decide to measure the middle-aged man's cholesterol level, the youngster's symptom checklist for hyperactivity, and the woman's bone density with a DEXA scan.

This is really quite a clever way of framing the discussion. What isn't clever, however, is the misleading things the article says about ADHD medication.

It starts with the link's headline at Slate's main page, which was what initially caught my eye. It read something along the lines of "Surprising New Evidence that Ritalin Doesn't Work." [Oh, poo. Since I started writing this post, Slate has reconfigured its links, and the initial link heading is gone. Perhaps you would be willing to take my word for it?] Suffice it to say, this is drastically overstating what the study found.

Then there was this, from the article itself:

Though it may seem a stretch, the lessons of reality TV can help us understand why, for example, many parents recently were told—with the suddenness of Jason Mesnick's dumping his fiancee Melissa Rycroft on the last Bachelor finale—that a large federal study contradicted its initial findings and concluded that drug treatment for attention deficit disorder had no benefit in children who were followed for six to eight years. These results put into question the widespread use of stimulants like Ritalin and Concerta, which were prescribed roughly 40 million times last year, and led to an acrimonious public debate among the study's co-authors. [emphasis mine]

What were the actual results?

Using reports from parents and teachers as well as self-reports from the children, now high school-aged, the researchers found that the youth’s functioning remained improved overall compared to their functioning at the beginning of the study, suggesting that available treatments can still be effective. However, they also found the following:

• The eight-year follow-up revealed no differences in symptoms or functioning among the youths assigned to the different treatment groups as children. This result suggests that the type or intensity of a one-year treatment for ADHD in childhood does not predict future functioning.
• Youths with ADHD still had significantly more academic and social problems compared with peers who did not have ADHD. They also had more conduct problems including run-ins with police, as well as more depression, and psychiatric hospitalizations.
• Some differences emerged among the youths with ADHD. For example, youths who had responded well to treatment and maintained their gains for two more years after the end of the trial tended to be functioning the best at eight years.
• A majority (61.5 percent) of the children who were medicated at the end of the 14-month trial had stopped taking medication by the eight-year follow-up, suggesting that medication treatment may lose appeal with families over time. The reasons for this decline are under investigation, but they nevertheless signal the need for alternative treatments.
• Children who were no longer taking medication at the eight-year follow-up were generally functioning as well as children who were still medicated, raising questions about whether medication treatment beyond two years continues to be beneficial or needed by all.

Friends, the very measured findings above are not the same as "had no benefit." It appears that the benefits may wane, that the medication will not correct the entirety of the problems experienced by children with ADHD (a complicated and multi-factorial diagnosis) and that compliance drops off over time. Also, children who initially respond better to treatment do better in the long run. No surprises to any of that.

I am no great fan of ADHD medication in this country, which I think is too readily prescribed for too many children with too many problems related to too many factors. I am not particularly keen to argue for their widespread use. But the article oversells itself by hyping an eye-catching finding that doesn't necessarily exist to the degree they imply.

Which is a shame. The article, which is otherwise excellent, didn't really need to be quite so sloppy, even if doing so meant more people were likely to read it.