Divisive Politics

This post is going to tackle Keith Olbermann.
The link is via onegoodmove.org, a blog that often posts great stuff.

Keith Olbermann. He speaks with such energy and such anger. I am so glad his perspective has found a home on cable news. But often I watch and wish he'd gone further, or see obvious connections I wish he'd make. This leaves me so frustrated. With this comment he describes many of the grievances I've had with McCain. But I wish he'd point out what only John Stewart has noted: that 911 happened in New York City. New York City is the America that Osama bin Laden chose to attack, so when Sarah Palin and the rest of McCain's friends say that small town rural America is "pro-America" and by implication that the rest of America is "anti-America" they come dangerously close to aligning themselves with the enemy. Osama bin Laden is a religious fundamentalist, extremist. I do not believe for a second that he didn't pick his target carefully. He chose to attack a city in America that stands for all of the things that Islamic fundamentalists oppose: liberalism, freedom of expression, freedom of association, hedonism, feminism, multiculturalism, sexuality, intellectualism, and capitalism. New York City stands for all these things, both here in America and to the rest of the world. The World Trade Center in particular. These are all things that threaten the power of Islam and the power of Osama bin Laden to exert their tyrannical control over the lives of their followers and to regulate the personal, professional, and intellectual aspects of their lives. The only difference is that the rest of the world sees New York City as the essence and the nexus of American culture. Clearly Sarah Palin and friends see it differently.

When Sarah Palin draws a line in America between what she sees as the excess, greed, and sin of the American metropolis and the "small town", "hard working", "religious" values of Main Street and calls that the real America she is committing an incredible trespass against us. Is she suggesting that we as a country abandon the principles that allow this melting pot to exist in favor of retreating to our churches? If so this is is the politics of surrender.

What scares me about the divisive politics of McCain and Palin is not merely the divisiveness but where they draw the line. I'm from a small town and I know that liberal values can be welcome there. I know that this line is artificial. After 911 we all had New York City in our hearts. You still see banners honoring the NYC fire department flying outside fire stations in places that couldn't be more different. The kinship we feel with New York City I believe is especially strong because in many ways we are all from there. So many of our ancestors came through there looking for the peace and liberalism and freedom and opportunity she offers. But the a fundamentalism also flourishes in America. A fundamentalism that is not far from that of our enemy. This fundamentalism exists in a Christian form here but it too seeks to control our thoughts, curtail our expression, and censor our sexuality. It too fears the foreign and the unknown. It fears education. And McCain and Palin are exploiting that fundamentalism.

I hope people are smart enough to know when their fears are being exploited. I hope people remember 911 happened in New York.

Off-label drugs

This article from slate.com is the subject of my first response.

This article is itself an explanation of an article that appeared in the journal Child and adolescent psychiatry and mental health. Both articles totally missed a much more important point. It's true even the most experienced child psychiatrists experiment every day when they proscribe medications to children. Each study has a population of 1 and tells us nothing conclusive about what the likely efficacy or side effects of the drug might be on the next child. The solution is not to monitor children more closely. The problem is not that children aren't being closely monitored. The problem is that research is not being done on children. It is extremely hard to get IRB approval to study medications in children. Children are not able to consent to participation in research they can only give "informed assent". Parents must consent for them and ethically this is still viewed as an imperfect solution. Institutional Review Boards (IRBs), which oversee medical research, are concerned about this as well as the obvious potential for serious side effects. The demands that an IRB will tend to make on investigators wishing to do research in children tend to be extremely high. Many researchers are unable to meet those demands or find them too dissuading to attempt research. Unfortunately it is children that pay the price for this. As a result of not sponsoring clinical trials in children every child is instead the subject of research. You have a situation where doctors might as well be guessing, and do not always guess appropriately.

Let me give you an example. When we first started doing transplant surgery patients were given extremely high doses of immunosuppressive drugs to prevent rejection. These drugs carry many serious side effects including decreased bone density, increase vulnerability to infection, skin changes, metabolic changes, aggressivity and other mental status changes. It wasn't until many years later when clinical trials proved that giving as little as one tenth of the old standard dose was just as effective in staving off rejection of new organs, and substantially improve side effects. When doctors guess, even with the best intentions and information, they do not always guess correctly, and the patients pay the price.

Retrospective follow-up studies, which ask people to report how much of a drug or food they ate for a given period of time, instead of clinical trials are one approach that can help. However they come with their own set of experimental problems. They can not truly be said to prove causation (ie: drug X alleviates headaches), but rather can only show association (use of drug X is associated with decreased incidence of headaches). This is a start but many of these studies done in other populations have proved inaccurate. Investigators must anticipate all confounding variables and adjust for them in their analysis and there are often factors that contribute to a finding that are not considered. This approach to studying psychoactive drugs in children could still start to give doctors clearer guidelines in the use of medications.

But ultimately I'd like to stress the need for increased openness to studying medications in children. It's risky, its problematic, but the alternative is so much worse.