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The Seeds of Doubt: Medicine and Uncertainty

Recently, I asked my students to talk about vaccination.  I think the medical establishment has succeeded in finally getting the word out that the anti-vaccine movement really has no scientific merit, and that their claims can be traced back to discredited research.  As a result, almost all of my students said they would vaccinate along the regular schedule.

The funny thing is, my partner and I wound up in a situation that – for social reasons – led us to seriously consider avoiding at least some vaccination during pregnancy.  It’s an illustrative incident of a wider problem with medicine and the messaging doctors engage in, and shows part of why the public was so willing to accept the anti-vaccine message.

We (I’m going to keep saying “we” here, because we were both involved in the decisions, etc., but of course I wasn’t carrying a baby) were a couple of months pregnant in 2012, when the anti-vaccine movement was just past its apex, but when there was still a lot of public concern about vaccination.  In fact, there was enough that people had been refusing whooping cough vaccinations for their children, and as a result, a bunch of newborns had died in the nursery at a couple of hospitals in California.

As a result of the deaths in the hospitals, the CDC recommended that all pregnant women receive the Tdap vacciene.  Before this time, it was not recommended that women receive this vaccine while pregnant, basically because no one really knew whether it would be harmful, and herd immunity had been protecting newborns from the diseases.  Weighing the relative risks of newborn deaths against the unknown but relatively unlikely chance of harm to pregnant women or developing fetuses, the doctors made the recommendation that all pregnant women get vaccinated in the third trimester.  All of this happened while my partner was in her first or second trimester.  So, while she was in the midst of her pregnancy, the recommendation went from “Definitely don’t vaccinate any pregnant women,” to “Definitely DO vaccinate all pregnant women.”

This recommendation is perfectly reasonable from a statistical perspective.  There is no evidence that the vaccine is harmful, and there is a relatively large risk of enormous tragedy resulting from a failure to protect newborns.  The recommendation probably is the only reasonable thing to do, given the risks and options.  For us, the trouble is with how this was presented to us.

My partner and I are unusual – we’re highly educated, with a background in statistics and scientific research, and access to journal databases that allow us to directly read research that most patients would probably rely on their doctors to read and interpret for them.  Moreover, because of our areas of expertise, we are particularly attuned to the problems in the scientific process, and the way that social context can influence the science that underlies medical recommendations and practices.  In other words, we have more reason than most to be leery of sudden changes in medical recommendations that are related to politically charged issues.

We may even have read this article summary, in which it’s noted that among 128 women who had been vaccinated during pregnancy, about 16% had spontaneously terminated (miscarried).  Despite this, the authors summarize their findings by saying that there is no evidence of “concerning patterns in maternal, infant, or fetal outcomes.”  That many spontaneous terminations seems like a lot, but only out of context.  That’s because in the full article, they describe this as being within the expected rate of spontaneous termination for pregnant women in general (about 15-20% of pregnancies spontaneously abort in the general population).  It’s possible we only read the summary, and so didn’t have the context to correctly interpret that percentage.

We had already read a lot about pregnancy and vaccination (we were definitely not anti-vaccine).  Like all people waiting in anticipation of delivering our child (especially our first), we harbored deep-seated anxiety about the possibility of something going wrong.  So, we went in to see our OB/GYN, and had an exchange that went something like this (I’m paraphrasing from memory, so the words aren’t perfectly right here, but I think they are pretty close):

OB/GYN: You’re going to get the Tdap.

Amanda: Yes, I wanted to ask about that, because I know that the recommendation used to be that pregnant women should not be given it, and now we’re supposed to get it, why is that?

OB/GYN: Because the CDC recommended it.

Amanda: Yes, but why did the recommendation change?

OB/GYN: There was an outbreak of whooping cough in a hospital in California, and 12 newborns died, so we need to protect them by giving them the antibodies through mom.

Amanda: Ok, so what I’m curious about is whether any research shows that this is safe for women and the developing babies, or-

OB/GYN: Vaccines aren’t dangerous.

Amanda: Ok, but is there any evidence of that or is it just assumed?

OB/GYN: So I bet you’ve been reading all kinds of research.  Vaccines are safe.

Amanda: I know that they are generally, but it’s just that no one really knows what introducing those viruses-

OB/GYN: Pertussis isn’t a virus.

Amanda: Ok…

OB/GYN: It won’t harm the baby.  Pregnant women can get chemotherapy during the third trimester, and it doesn’t hurt the baby.  The baby will be fine.

Amanda: Ok, but…

OB/GYN: The CDC recommends that you get the vaccine.  You’ll get the Tdap in your third trimester, and you’ll be fine.

The doctor’s tone was commanding, defensive, belittling, and condescending.  He really had no interest in listening to our specific concerns, explaining the process of medical decision making, why the CDC thought the risk to pregnant women was small, or what the relative risks actually were for pregnant women being vaccinated.

It was at this point that both Amanda and I decided that we couldn’t work with this doctor anymore, told him, “Ok, we’ll talk about it in a couple of months,” and then switched doctors to someone we absolutely loved.

Here is the thing: we ended up getting vaccinated.  Our new doctor was also pregnant, and she said she was getting the vaccine.  While this wasn’t evidence, it did build faith.  She also helped us to understand that the old recommendation was made because of the reasons outlined above: no one really knew what would happen, so why take any risk if the likelihood of a baby getting pertussis was essentially zero?  But, despite the fact that no one really knew what would happen, she said, there really wasn’t any reason to expect any dangerous side effects.  The vaccine had been given to non-pregnant people for a long time, and in the third trimester, it wasn’t likely that it would cause any change or difficulty in the baby.  She probably had read the study I mentioned above that found it to be safe for pregnant women and developing fetuses.

This exchange wasn’t very different in terms of the information that she delivered to us from the exchange we had with our first OB, but it it was strikingly different in tone.  She was willing to listen and explain rather than command.  She acknowledged the sudden change in recommendation might appear startling, but that really it represented only a slight shift in actual risk.  She spoke to us with respect rather than contempt.  This difference in the social level of the interaction was critical to her success in getting our cooperation for achieving the best medical outcomes.

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The Morality of Gamifying Prisons

Two video game developers talk about the implications of their game, Prison Architect.  

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February 4, 2014 · 12:01 pm

Paying College Athletes: A Student’s Perspective (Guest Post)

(Written by Kelsey Backus)

            One of my outspoken psychology professors has a particular line he likes to fall back on when things go wrong in the classroom. When the white board markers in the room are shot and there isn’t a working one to be found, my professor mumbles, “The football team must have needed more revenue, so we don’t get working markers today.” The class laughs and then gazes uncomfortably around the room, looking for an identifiable athlete.

            This particular professor makes it a point to say that he does not follow the university’s sporting teams and has a particularly strong disliking for the football team. It seems he is not the only professor who is frustrated with the focus of athletics over academics at American universities. Students’ opinions appear to be more varied, though, based on my personal conversations with friends.

            The biggest problem with our discussions is that many of the people participating in this discussion, from students to professors to college sports fans, don’t have the slightest idea as to how the economics of college sports work. Is each sport funded by its own tickets and merchandise sales? Are they funded by the tuition we pay every semester? By private donors? Does anyone outside the NCAA really know the answer to these questions or is it hidden under piles of dense legalese, not to be understood?

            Contrary to popular belief, only 23 of 228 athletics departments at NCAA Division 1 public schools were able to bring in enough money to cover their expenses in 2012. Of that group, only 7 did not receive some form of subsidy. The NCAA itself made $871.6 million for the year 2011-12. According to the NCAA, 96 percent is distributed directly to the Division 1 membership, to support championships, or to fund programs that benefit student athletes. The remaining 4 percent stays within the NCAA, covering admin costs, building operations, and salaries.  (http://www.ncaa.org/wps/wcm/connect/public/NCAA/Finances/index.html)

            Thanks to TV contracts and merchandise sales, these student athletes are becoming worth more and more. According to Ramongi Huma of the National College Players’ Association, the average Division 1 football player would be worth around $121,000 per year and the average basketball player closer to $265,000 (thanks to March Madness). So some of these student athletes are worth more to the NCAA and their university than the scholarship they are receiving, and, thanks to the demands of the sport on top of schooling, are unable to take on a job at the same time to make money that goes toward living expenses. There is no doubt that being a college athlete is demanding but what would paying them possibly do to the system as we know it?

            By paying a college athlete through means other than a scholarship, the student athlete becomes an employee. Employees are subject to contracts complete with salaries, worker’s compensation, cuts, and trades. Students could potentially be traded away to a university that doesn’t provide their intended major. How do you distribute this money fairly? The University of Texas takes in an abundance of money compared to that of South Dakota State University. Do these athletes receive the same paycheck or do they make money based on how well the name on the back of their jersey sells? Is it only football and men’s basketball that must break away into this system? Do the other sports continue on as they are? And what about Title IX? How on earth do we maintain equal funding of men’s and women’s sports in a system that so obviously favors men? Men’s basketball and football could potentially become separate entities to avoid issues with unequal funding by gender. In this case, the university no longer provides support for the students. The NCAA runs it all.

However, should this be the case, the university no longer benefits from these sports either. Sports programs, whether they are profitable or not, are good for universities. They provide talented students with an extracurricular activity and, for some, a way to pay for a college education that they otherwise wouldn’t have been able to receive. Alumni crowd into stadiums to watch their alma mater play, thinking fondly of the old days, and are willing to donate money to the university itself. Additionally, when a university has a good men’s basketball or football team, interest in the university by potential students increases due to the national attention the university receives. South Dakota State only recently gained national attention when the men’s basketball team made the NCAA tournament the last two years in a row. Certainly, the NCAA and its employees are not the only people who benefit from the money made in these two sports. The question then becomes whether or not the university can make up for this loss of revenue and marketing through their profitable sports teams.

            As my psychology professor likes to point out, it often feels as though academics come second on a university campus these days. Maybe sending “college” football and men’s basketball off to become their own entities wouldn’t be such a bad idea. Universities would find other ways to make money via research, invention, and land grant opportunities. Perhaps this is the way in which colleges can return to the way they were meant to be: institutions of higher learning. 

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Video Game Violence From the Perspective of a War Survivor

I’ve read accounts of video game violence as experienced by American soldiers before, but this perspective, from a survivor of the civil war in Burundi, is very different.

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July 22, 2013 · 9:42 pm

http://www.steveswink.com/articles/an-e3-teachable-moment/

Women get harassed.  Steve wants us all to work against it and he has some excellent reasons why.

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July 22, 2013 · 9:28 pm

Deterrence Doesn’t Work: Immigration Reform Idiocy

I was in my car, driving to work, and I heard a discussion on the radio between a number of “experts” (credentials unknown as I tuned in mid-broadcast) discussing immigration law reform.  I could tell that they were probably politicians or politically motivated business people not particularly informed experts or researchers because they only answered questions by turning things back to their talking points, even if they didn’t match the actual questions at all.

On of the voices made this (paraphrased) suggestion: “We need to make the punishments for employers who employ illegal immigrants so severe that no one will take the risk and employ illegals.  This will remove the incentive for people to immigrate, because they are coming here for jobs.”  Based on this, I suspect he may consult for the private prison industry.

Anyone who could make this argument with a straight face either doesn’t know what they’re talking about, is deluded, or is actively providing misinformation.

Deterrence doesn’t work as a general principle.

It is amazing to me that American criminal justice policy can be as riddled with evidence for the failure of deterrence to work as it is, and for there still to be an apparent public perception that increasing penalties will actually deter anyone from committing crime.  Because it worked so great with crack (deterrence probably had little to do with police enforcement and more to do with people seeing the destructive results of the crack trade on their friends and parents’ lives) and with drug crime in general (The War on Drugs costs nearly as much as a real war, and is just as pointless), murder (the death penalty doesn’t deter, so what possibly could?), and political dissidence (even in colonial America, there is evidence that dissidents PREFERRED to be punished).

Except in a few very specific cases and contexts, deterrence just doesn’t work.  Police are spread too thin (or CIS in this case) to actually catch enough people to make general deterrence work.  And in the case of specific deterrence, there definitely isn’t enough oversight to actually catch people every time they break the law.  This means that the very first step of deterrence, certainty of being caught, doesn’t exist, and can’t, even in a police state or occupied nation.

This is particularly the case when you’re considering things like illegal drug markets or employing illegal immigrants.  Both parties (the immigrants and the employers) stand to gain from maintaining secrecy.  Hell, people in SD do jobs off the tax books all the time for cash, because they don’t want to pay the federal income taxes (SD doesn’t have a state income tax, which is why they can’t pay for adequate public education).  The employers like this, and so do the workers.  Unless CIS is going to start dropping in on every small employer in the U.S., doing a bunch of stings or otherwise engaging in a massive undertaking, there is no one who will be reporting the presence of these immigrants.  Increasing penalties will not help this problem, it will make it worse by increasing the motivation that both employers and workers have to maintain secrecy.

But, unfortunately the discourse surrounding immigration has taken the same tone as that surrounding crime in the U.S.: “Things are bad, getting worse.  We have to get tougher and punish the evildoers, so that the good, innocent, real Americans can be safe and prosper.”  It’s exactly the same kind of rhetoric employed to justify prison expansion during the 1990’s and 2000’s, and could be just as destructive.

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More reading

It’s an old post, but a good one.

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June 24, 2013 · 10:23 am

Guest Post: Gun Violence in SD

This post was written by Kelsey Backus

 

Guns and the violence associated with them have passed in and out of the news and social media spotlight once again since the December 14th school massacre in Newtown, Connecticut. We’ve had our distractions since then, what with the bombing on the Boston Marathon, but even following that event, my newsfeed was full of my more conservative friends boasting things like, “Guns don’t kill people, whackjobs with bombs do.” Crazy statements that weren’t exactly logical but received multiple retweets and favorites anyway.

            Nothing about the aftermath of the Newtown massacre seemed logical to me. There was a public outcry for change and it appeared that gun control would finally win over the majority. Instead, the debate headed in the opposite direction. Many states passed laws that were pro-gun. South Dakota, for example, passed a law that would allow school employees to bring guns into classrooms. 

            Behind this new legislation are a few ideas that are common in right-wing ideology including cliché’s such as “guns don’t kill people—people kill people,” and  “more good guys with guns can stop rampaging bad guys,” or “carrying a gun for self-defense makes you safer,” just to name a few. The majority of evidence, however, points to the contrary. (Check out this article by Mother Jones for a brief examination of 10 Pro-Gun Myths: http://www.motherjones.com/politics/2013/01/pro-gun-myths-fact-check). I will review this evidence and propose that it is not just one factor that contributes to gun violence, but many. I am not alone in this argument. However, the abnormally low rate of firearm-related fatalities in South Dakota has not been explored in much detail. What sets South Dakota apart from Wyoming, a state that is demographically similar in terms of both population and geography, and has comparable legislation involving gun control?

            Check this out, as I was researching the topic I found this map put together by a group of researchers from Boston (the entire paper is available freely online here: http://archinte.jamanetwork.com/article.aspx?articleid=1661390). 

 Image

This map shows you that states with a higher legislative strength score typically have a lower gun mortality rate. Wyoming, indeed, fits this mold. South Dakota, on the other hand, has the lowest possible legislative strength score while maintaining a low gun mortality rate. Both states have incredibly high rates of gun ownership. Wyoming is first in the nation with 62.8% of households owning a gun while South Dakota is not far behind at fourth with 59.9%.

Simply owning a gun has been linked to higher rates of homicide, accidental death, and suicide. In 2010, 16,259 people were victims of homicide and 68% of those involved firearms. In that same year, 51% of 38,364 suicides were by firearms. According to the Firearm and Injury Center at Penn, it is estimated that for every two firearm deaths there are five nonfatal firearm injuries.  This results in medical costs of $112 million and $599 million, respectively, not including the work loss costs, estimated at $40.5 billion. Loss of life and financial costs are enormous burdens placed on this country by firearms.

In addition to strength of gun legislation and rates of gun ownership, other factors have been found to contribute to fatal gun violence. Contrary to popular belief, however, population density, mental illness, stress levels, substance abuse, and unemployment don’t appear to have anything to do with it. Gun violence is associated with hither levels of poverty and lower levels of college graduates and happiness. Though mental health itself does not appear to contribute to rates of gun violence, access to mental health resources and treatment and mental health utilization does. These factors keep the depression status and suicide rates low. It is here that South Dakota thrives. A 2007 report released by Mental Health America has South Dakota as the healthiest state in terms of depression status (http://www.nmha.org/files/Ranking_Americas_Mental_Health.pdf).

Now what do we do? Addressing this issue requires a multifaceted approach. The first of which would be to increase access to higher education. Through needs-based scholarships, children born into poverty may be able to attend college, therefore decreasing their chances of living in a life of poverty or committing suicide. Scholarships for students going into mental health fields would be especially important as this could eventually increase the mental health resources made available in the state. The small amount of post-secondary schools in Wyoming could present a problem. Increasing tuition reciprocity programs with other states would allow students from Wyoming to attend schools out-of-state for the same tuition that in-state students pay. This increases their options and their chances of getting in to a good institution. By decreasing firearm-related incidents, more money could be spent in these scholarship and other post-secondary education programs as money would not be spent on medical and work loss costs associated with firearm incidents.

            Finally, as Fleegler and colleagues discovered in their 2013 study of gun legislation and gun violence, increasing the strength of gun-related legislation through implementing background checks for all gun purchases, not just those from federally licensed dealers would be a step towards decreasing the prevalence of gun ownership. This would be the most important step toward reducing firearm-related homicides and suicides. However, to suggest that increasing the strength of gun legislation would be an automatic solution, especially in a state in which guns and hunting are a big part of life and state economy, would be a mistake. I suggest that we continue to examine the differences between South Dakota and Wyoming associated with gun-related fatalities in order to provide us with a more thorough solution in the future. The sooner a solution comes to pass and is accepted nation-wide, the sooner thousands and thousands of lives lost annually in firearm-related fatalities may be saved.

 

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Back from the MSS, I review The Book of Mormon

I had a good time at the MSS this year, despite losing my flash drive in transit and having to rebuild my presentation from memory.  My regression table didn’t make it in, but I was able to talk about the general findings.

The project I presented on was a part of my ongoing research into the details of parent-child relationships and romantic (dating/sex, cohabiting, and marriage) partner selection.  The rest of that session was good, too, covering topics related to aging in a variety of contexts.

I attended a few other sessions, a committee meeting, and a focus group about the quality of the conference.  It was a productive couple of days.  And, I ATE.  As per usual, my photography was sparse, but I did manage to snap these photos of a local beer:

Image(Hopothesis – appropriate to the conference, but not all that hoppy in actuality)

and the counter at Pinkberry

Image

which was delicious

I also saw The Book of Mormon:

Image

Musicals are always lost on me.

I experience musicals the way most people experience juggling: I admire the technical prowess, but it doesn’t really move me emotionally.  I laughed a couple of times, but I always felt like the overall sense of humor and the necessities of the form – staged musical comedy – were at odds.

I also have a more general complaint about South Park that also applies here.  They’re transgressive comedy works sometimes, but at some point it becomes difficult to tell where they’re trying to satirize, and where they’re just reproducing stereotypes because that’s a shortcut to shocking people, even when it goes against what seems to be the grain of their satire.

In The Book of Mormon, the point seems to be to satirize the image of the Mormons, whose public image is of a mainstream religion and a group of very happy and contented people.  The satire makes sense: the absurdity of the Mormon mythology reflects the absurdity of all religions, and that seems to be the general point of the play.

However, by the time the first act is over, the play has moved its setting to Uganda, which is portrayed as a village with dilapidated huts, in which “80% of us have AIDS,” even the doctor has “maggots in his scrotum,” and the local warlord insists that women have their clitorises removed because they terrify him.  Is this meant to satirize my (white and western) expectations of Uganda?  If so, the wink never really comes, and the satire fails to really undercut the stereotypes, and instead seems to present them essentially as fodder for comedy themselves.

As usual, the best part of the conference was seeing old friends, talking to colleagues and making new connections.  Looking forward to next year!

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TED: Big (empty) Ideas

The TED conference happened last week.  I’ve been a fan since I saw the Raspyni Brothers juggle (I was trying to learn to juggle during my first year of grad school).  I was as amazed as everyone else when I saw Johnny Lee (in an early example of the maker movement working its way into the mainstream) demonstrate his Wii remote hacks.  For my crazy-right-winger-disaster-preparing-friend at Desultory Salutations, I bought one of Michael Pritchard’s super water filter bottles.  As far as I know, he hasn’t filtered and consumed his own urine.  Not through the bottle anyway.

But TED can be up and down.  My concern is that the Big Idea journalists like the recently discredited Leherer and even real scientists with Big Idea books to promote like Dan Ariely will take over the conference.  Their talks usually have the characteristics of good TED talks: they come at issues from a new angle, and they have an optimistic faith in positivism accumulating knowledge and making a better and better future.  But what makes TED appealing to me isn’t just a Big Idea backed by poorly described and exaggerated scientific findings, it’s the small advances in science that shed light on the scientific process and are presented by real scientists or activists.  For instance, Sheila Patek describing the process of figuring out how shrimp strike their prey, Vilayanur Ramachandran describing advances in neurology, or (trigger warning for this video) Sunitha Krishnan talking about her work rescuing sexual slaves.

All of these talks eschew the Big Idea.  They stick to what their work demonstrates, and don’t feel the need to try to expand their message to some grand platitude.  I’d rather have to contemplate the implications of the work myself than to have a small “truth” expanded into a grand but empty Big Idea.  A later Ramachandran talk demonstrates this; you can see how uncomfortable he is trying to make a basic finding into a big idea when he tries to take the discovery of mirror neurons into the realm of the explanation for human civilization.  I also would have preferred him to stick to the science, and let the Big Ideas develop on their own.

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