Wednesday, November 24, 2010

Drugs, Sex, and Money

On Wednesday, we took Polly to the doctor for her eighteen month check-up. On the way there, I watched my speedometer closely and used cruise control on the highway because I was nervous, and I always drive too quickly when I’m nervous. Every trip to the doctor carries a bit of tension for me - there’s always the possibility that they’ll find something wrong – but this trip had some extra worry added to it. This was the first trip to a new doctor for us, and I wasn’t sure how it would go. You see, Ava and I have chosen to use a non-standard vaccination routine for Pip and Polly. This makes us less than ideal patients for many physicians, and it takes some work to find one that will work with us. I had spoken to this one on the phone a couple of weeks earlier about our choices. At the time, he was amenable to working with us, but I was still worried that once we were actually there, this willingness would come with some caveat or a lecture about how we were needlessly exposing our children to death or dismemberment.


The question of vaccinations is a tricky one. Prior to the mid-1990s, medical authorities recommended that children receive a diptheria, tetanus, and pertussis (DTaP) shot, a measles, mumps, and rubella (MMR) shot, and a polio vaccine. Since then, the number of vaccines recommended for children between the ages of 0 and 6 has more than doubled (see here for each year’s recommendations). That’s a lot of shots and a lot of foreign substances being pumped into little bodies. It makes me nervous, especially because we don’t really have any long-term data on what all these new vaccines will do. These vaccines can be tested for safety over relatively short time periods, but there are no long-running studies on how something like the early use of the Hepatitus B vaccine might relate to levels of cancer, Parkinson’s, Alzheimer’s or other diseases later in life. And now that so many vaccines are being pumped into kids all together it will be very difficult to untangle the mess if something does come up in another twenty years. Given this uncertainty and the historical experiences with drugs like Vioxx, Ava and I are hesitant to over-vaccinate our children, especially for things like Hep A and B which are diseases associated with drug use, high risk sex, and poor sanitation and ones like chickenpox (varicella) and flu for which the most significant harm is usually the loss of work hours for a parent.

Compounding our hesitation is the reality that vaccines are big business for drug companies. Getting a vaccine included on the list of recommended shots can generate a large chunk of relatively consistent money for the company that produces the vaccine. This gives drug companies plenty of incentive to get as many vaccines included on the list as possible. Where there is incentive, there is money. It seems hardly coincidental that the rise in the number of recommended vaccines corresponds relatively well with the explosion of big money politics over the last fifteen years. Money talks in many different arenas whether it’s spent on lobbying, marketing, clinical trials, or handouts.

The drug companies are also pushing these vaccines at the individual level as well. We got a reminder of this the first time we skipped a scheduled vaccine. About a week after our doctor’s visit we received a postcard in the mail from our insurer. The postcard helpfully suggested that we had missed one of the normal shots. At the bottom of the card was a disclosure statement. The postcard had been paid for by Wyeth Pharmaceuticals.

In thinking about this recently, I’ve come to realize that I don’t blame the individual drug companies for any of this. They exist in a profit driven system where survival is predicated on selling as much stuff as possible. A good company is going to use as many ways as it can to stay in business. It is unfair to demand that they act as some kind of public trust when their ultimate survival is not protected by the public. This doesn’t make me any less suspicious of their influence. It only acknowledges that this influence is a product of structural constraints, not individual avarice.


Our concerns about vaccines and the influences at work in their usage have made finding a doctor a challenge. In Cincinnati we got very lucky. After a bad experience with Pip’s first pediatrician, we went to the internet and tapped into the social network discussions around alternative vaccinations to find a doctor who would be willing to work with us. We were pointed to one who turned out to be better than we could ever have expected. His entire practice bespoke a certain skeptical distance from the normal business of medicine. First, all appointments were scheduled for thirty minutes. Second, he had no nurses so that entire half-hour was spent with him. He did all his own measurements. He administered all his own shots. Third, he had no drug company paraphernalia or hand-outs lying around his office. There were no posters on the walls, no pens with drug ads on them at the reception desk, and no freebie drugs stashed away in a drawer of the examining room. Fourth, he made careful distinctions between conditions that should be treated with drugs and ones like common ear infections or pink eye which given the right attention and a reasonable amount of time, the human body can take care of by itself. All of these things gave us confidence in him and made us very comfortable in following his advice when it came to vaccinations (his preference was to administer the older vaccines – DtaP, MMR – and hold off on the newer ones unless a specific reason suggested itself (i.e. rotovirus for kids in daycare)).

When we moved to Lexington we had to start all over again. Going back to the internet, we searched again through the local internet discussions. Not surprisingly, there were very few names that came up as possible candidates. But again we got lucky. There was a newer family physician in one of the outlying towns who was willing to work with families like ours. After calling him up and discussing our preferences with him, we made an appointment for 10 AM on Thursday.

We got there a few minutes early so that I could fill out the new patient paperwork that is always a part of the first visit with a new doctor. There was no one else in the waiting room so I let the kids wander around and check things out. The office was a new one with cream colored walls and benches upholstered in dark green leather. On the magazine rack were several current issues of popular weeklies like Sports Illustrated and Newsweek, a requisite copy of the children’s story of the Bible, and a book on the palliative properties of different foods. Pip and Polly picked through each of these in turn while I worked my way through the various forms. During that time another family came in with a little girl about Pip’s age. The two sized each other up from opposite corners of the room.

And then came a reminder that replacing our doctor in Cincinnati will be almost impossible.

As I was filling out the final form in the stack, another person walked in the door. I looked up long enough to see that it was a woman, tall and thin with thick blonde hair that hung down past her shoulders. She wore a fashionable camel hair coat and the pressed black pants and black heels of a well-paid professional. I did not see her face, but I imagine her makeup and jewelry matched her obviously expensive and well-tailored clothes. Now, the office in which we were seated was that of a family doctor in a smaller town in central Kentucky. Most of the vehicles in the parking lot were either small sedans or large pick-up trucks. The family sitting across from us in the waiting room was dressed in jeans and sweatshirts as was the receptionist behind the desk. None of us looked like this woman. Before she said a word, I decided that she was a drug rep. This guess was verified when she asked the receptionist if the doctor was in and whether the office needed any more of something that sounded like ‘hyproxin.’


In college I spent two semesters working in the engineering division of a medium-scale electronic components factory. About once a month, a salesperson would come in and spend the day in our office. I think his name was Harry. He would usually bring us lunch and a few trinkets to share and would spend the day making his way around the office to the different engineers. He would ask what they were working on and suggest, or give a demonstration of, products he had that might be useful. Harry was a doughy guy, short and slightly unkempt, but with a likeable smile that allowed you to blow him off if you needed to. Every once in a while someone would seek him out to ask about a particular component, but usually his mode of operation was to start a conversation and see if it would lead to something. In general, the longer he got to talk with an engineer, the more likely it was that he could find a sensor or motor or electrical component that the engineer could use.

After seeing this drug rep, I pondered what would have happened in that engineering office if she had come in instead of Harry. The fundamental pattern probably would not have been different, but the promise of face time with a woman from whom these men would normally get no more than a few seconds of attention is a powerful force. I imagine the amount of time she would have gotten with all of those male engineers would have been noticeably greater. And, as a result, she probably would have sold more stuff than Harry.

Like that engineering office, the medical profession is a male heavy arena. This leads me to believe that the same principles I know to be true in that engineering office are applicable to doctors, namely an attractive female salesperson is likely to get more time and more attention from a doctor than her position as a drug salesperson might merit. And as with the engineers, more time equals more possibilities for finding or convincing doctors that she has something that they ‘need.’ As I discussed above, the potential for that kind of influence is worrisome. It’s also a troubling reminder of how screwy our health care system is that the prescription drugs we buy are being pushed to doctors using methods very similar to those used to sell sports cars and beer.

When I mentioned all of this to Ava, she brought up another salient aspect of this situation. The drug rep has access to the doctor in ways that are difficult for a patient to discern and evaluate. There is a fundamental lack of transparency about these relationships that makes it impossible for a patient to make an informed judgment. We can’t know how drugs are being marketed to the doctors, what information the rep is providing, or what the doctor does with this information. There is essentially no way for the patient to parse the influences at work in the doctor’s decision-making process. The doctor may hand off all the drug rep interactions to a third party in the office in order to keep some distance from the sales pitch. The doctor may lap up every free meal and golf outing the drug rep can provide. We just can’t know. It’s another one of the pitfalls of our current system. We are forced to trust that our doctors have the time, patience, and self-awareness to filter through the wash of information provided by a drug rep. Such trust is difficult to justify. Human beings are just too susceptible to suggestion and impulse. And the drug reps spend plenty of money and effort to sway things their way (see this article from The Atlantic for some examples).


Despite all of this, I will go back to this doctor. For one thing, the appointment went fine. The doctor was friendly and comfortable talking about our options and choices. He was good with the kids and did not try to constrain Polly too much in the process of examining her. It was a straightforward and no-nonsense visit to the doctor. For another, we don’t have that much of a choice. If we want to do the vaccinations our way, this is our guy. We too have our structural constraints. We sacrifice one set of choices in order to exercise another.

Thursday, November 18, 2010

This week's entry can be found at the Daddy Dialectic blog. The front page is here. A direct link to the entry is here.

Thursday, November 11, 2010

The Challenges of Children's Literature

While living in Cincinnati, I used to walk Pip and Polly down to the library about once every two weeks or so to check out some books. It was always a treat to have a couple of new stories to mix in with our own collection of kid titles. Since moving to Lexington, we had not done the library trip quite as frequently, mostly because I didn’t have the identification paperwork necessary to get a library card.

Two weeks ago I finally finished the steps necessary to get a Kentucky driver’s license and with it, my very own library card. The first thing the kids and I did after the clerk placed the new driver’s license in my hand was to walk down the street from the county clerk’s office to the rounded, multi-story black granite building that houses the downtown library. Pip was the first one through the door, and he headed immediately up the stairs to the second floor where the children’s section is located. Polly followed close behind. Walking past the computers and their games for a moment they stood quietly looking at the long wall of shelves holding all the children’s books, trying to decide where they wanted to dig in.

For all our experience with libraries, the book selection process itself is still a real challenge. First off, there is the difficulty of physically handling the books. I usually start picking up books at a random point in the shelves and flip through a couple to see if anything catches my eye. Following my lead, Pip and Polly do the same thing. As such we can pull a pile of ten to twenty books off the shelves in a matter of seconds. Keeping this from getting completely out of control requires a good bit of juggling and redirection.

More significantly, children’s literature can be an insidious product. The idea of a ‘children’s book’ carries with it a certain expectation that the content is safe and sensitive to the impressionable nature of young children. While this assumption may be true relative to the content found in adult fiction, Ava and I have found plenty of stuff in children’s books that don’t align well with what we want to teach Polly and Pip.

So over time I have learned a few shorthand keys to help ease the process of selecting out the couple of books that will actually leave the building in our hands. I tend to look first for things we have enjoyed in the past – books that rhyme, books with animals doing silly things, books about how things work. Farm settings and counting books also tend to be reliable. I then look to see if a given book has any of the material we have idiosyncratically deemed to be hazardous for our children. This includes excessive violence, romantic love, overt nationalism/patriotism, hypermasculinized things like giant cartoon trucks or military themes, and hyperfeminized things like princesses or prissy girls. If I find any of these, I slip the book down on to a table for reshelving and grab another one.

This pick and filter process works well for most books, but there is one group that continually causes me fits. These are children’s books which take a story or idea that is familiar to parents and give it an innovative twist. In some cases this twist is a flip of the protagonist-antagonist binary such as turning the three little pigs and the big bad wolf into the three little wolves and the big bad pig. In other cases the hook is that the story begins from the point where a familiar fairy tale like the Frog Prince ends. I’ve also read another particularly clever book where familiar songs, ranging from Old Susannah to the Battle Hymn of the Republic, were used as the foundation for poems about science.

I find these kinds of books to be very entertaining. In many respects they remind me of the old Warner Brothers cartoons with Bugs Bunny, Daffy Duck, Yosemite Sam, etc. Those cartoons were great because they contained such a diverse range of possible amusements. You could get slap-stick comedy, sophisticated cultural critiques, and self-reflective experiments in artistic creation all within a five minute segment. As an adult this sort of subversive playfulness feels like being let in on an inside joke, one that pokes fun not so much at my children but at what I remember as the overly serious adults of my own childhood.

At the same time, as a family our experience with these books has been largely unpleasant. Either they are pitched too far towards adults for Pip (and very soon Polly) to enjoy them or I end up trying to explain the parental focused references that Pip picks up on but doesn’t have the context or background to understand. In both cases, sitting down with these books usually resulted in a mixture of confusion and frustration that did little to help Polly and Pip enjoy our time reading together.

Despite these problems, I kept bringing these books home with us, always hoping that the next one would not suffer from the same deficiencies as the others. It took Ava’s intervention and some tears from Pip to bring home to me the reality of what was going on. The production, marketing, and selling of children’s books is an industry like any other. To sell books, publishers target the people who actually purchase the books: adults. Sometimes this means creating something that kids want and subtly encouraging them to beg their parents for it. Other times this means creating something that parents think they kids would or should want. And sometimes, it means creating a product in the kid genre whose real audience is intended to be adults (e.g. Toy Story 3). I apparently have a soft spot for that third category and was making choices accordingly. In the process my own interests were overwhelming my evaluations of what Pip and Polly would find enjoyable.

I have since gotten much better at recognizing when such a breakdown in the selection process is taking place. All the same, the temptation is still there. This past visit I came across a book entitled “The Secret Life of Walter Kitty.” I picked it up and flipped through it because of the Walter Mitty reference. The book was about a cat who, like Walter Mitty, imagines himself taking part in a whole range of adventures while barely straying from his house. It was clever and amusing so I put it into our take home pile. Then I caught myself and took another look. The pictures were complicated. The text was disjointed and scattered around all over the page. I guess Pip and Polly will get used to this kind of presentation as they get older but for now it was definitely too much. I reluctantly put the book down on another table for the librarians to reshelve.

We came home from the library that morning with a book by Dr. Seuss, one called ‘Me and Robot,’ one about a big dog on a farm, and one where a boy imagines seeing a dragon floating in the clouds. Pip spent all afternoon with this last one. He is in the process of learning what it means to imagine things and was determined to work out what in the book was supposed to be real and what was supposed to be a product of the boy’s imagination. It’s a challenge, and we worked it through page by page. I still don’t know if it really makes sense to him, but at least it’s a project that he chose and one that he is learning from.

Thursday, November 4, 2010

Opportunistic educations

Last weekend we took Pip and Polly to the local horse track. While in most places this would represent a moment of questionable parental judgment, in Lexington, KY it is a common and popular thing to do. The racing and breeding of horses is a significant industry in central Kentucky. The areas outside the city limits, particularly to the north and east, are filled with the rolling treeless fields of green grass encircled by double-layered white or black wooden fences that are the signature landscape of a horse farm. The lodestone for all of these farms and the local industry more broadly is the racing and auction facility at Keeneland. Going to the races at Keeneland is a bit like going to a golf tournament at Augusta National. It is immaculately kept and intentionally old-fashioned. The grandstands are made of painted black steel that is framed with grey limestone – the bedrock of the area. The grounds are all trimmed with dark green hedges and lots of flowers. The track officials, mostly older men, all wear kelly green sports jackets and slightly rumpled pants that make them look like friendly uncles. The facades of the betting windows are made of stained wood and contain directions handpainted in a script from the 1940s. It is a place that attempts to transport you to another world, and it largely succeeds.

One of the programs that Keeneland runs during its fall and spring race meets is a Saturday morning breakfast where people can come and watch the horses train while scarfing down scrambled eggs, sausage, and biscuits with gravy. While the food is decent, the real draw of the program is being out there early in the morning and watching the horses run as the rising sun begins to burn away the pre-dawn mists. It’s thrilling to stand at the rail as a pair of jet black thoroughbreds come sprinting down the track toward you. You can hear their hooves clomping in the dirt and their breathing pulsing louder and louder as they get closer. Then they fly past so quickly, your eyes have a tough time keeping up. Fortunately, you will get another chance as a second pair and then a third and a fourth will following in short order.

That thrill of standing at the rail is as powerful for kids as it is for adults. As such, we, along with a couple hundred other families, dragged our kids out of bed before sunrise this past Saturday morning to go have breakfast with the horses. Once we got there, Pip and Polly dutifully ate their eggs and biscuits and then reveled in trolling around the collection area by the rail, alternately watching the horses and watching the other kids watching the horses. After a while, we decided to take a walk through the stables to see what else was happening, and during that walk Pip gave me another of his ongoing lessons about teaching, learning, and the education of a child.

Every week Pip, Polly, and I designate a letter and number to work on during the week. Last week these were ‘L’ and ’10.’ Some weeks when we have some extra time we also add a shape or a color to the agenda. Last week was one of those weeks so on Wednesday morning out came the shape-sorter box and its 12 accompanying blocks. Pip fished around in the box for about a minute and then came up with a parallelogram in hand. We traced the block on a piece of paper while talking about the two main properties of a parallelogram: 1) it has four sides and 2) the opposite side pairs must be parallel to one another. I showed him that in addition to the common parallelogram that he pulled out of the box, squares, rectangles, and diamonds also fit this definition. Then I pulled a trapezoid out of the box and asked him if this shape was a parallelogram. He hesitantly said no. Then I asked why it wasn’t. I did this as a little test, both to see if he really understood what I had been telling him and to see if he could take an additional mental step by looking at the trapezoid and pulling out the significant difference between it and a parallelogram.

His response was to turn his metallic blue eyes towards me with a wide, helpless stare that I have learned means “I am no longer interested in taking part in this game. Just tell me the answer so we both can move on.” But I wasn’t ready to accept this. He had not even made a guess yet, and I really wanted him to give it a try. So, I let him play for a few minutes then came back at him with the trapezoid. He again gave me that pleading, blue-eyed stare before getting up to play with something else. When I tried to come at him a third time, Pip finally refused to sit still at all and I had to concede that he was not going to even try to answer the question.

It was a moment of classic parental overreach on my part. Correctly answering this kind of question would mean that he understood the concept and that his mind is agile enough to think around this kind of idea when it comes at him from another angle. It would also, most importantly in retrospect, validate my own efforts to teach him something. In this, his success would be my success, his failure would be my failure. Somewhere I vaguely I heard the Sirens singing.

Fortunately, by the time we went to breakfast on Saturday, this trapezoid episode had slipped from my mind. As we made our way away from the collection area and walked along the gravel drive between the track and the stables we passed a Ford F150 with an unusual horse trailer attached to it. The trailer was white and had a large half door at its midpoint. Over the top of the door we could see a series of pulleys and arms and straps hanging down from the underside of the roof. Along the side of the trailer were printed the words “Equine Ambulance.” When Ava read this out loud, it immediately caught Pip’s attention. He is an avid observer of emergency vehicles and has developed a keen ear for the subtle variations in the sirens of the fire trucks, ambulances, and police cars that regularly go down one of the busy roads near our apartment. An ambulance for horses was something Pip had not considered before, and he spent a minute or two looking this one over. Then he turned to me and said, “Daddy, why doesn’t this ambulance have any flashing lights?”

It was one of those simple, perceptive questions that require a series of verbal gymnastics to answer in a way that is satisfactory to both parent and child. The full answer is that an equine ambulance doesn’t have lights or sirens because if a racehorse is so badly injured that it would need to be rushed to a hospital, it is usually put down – i.e. killed - right there at the track. But how do you explain to a four-year old that horses aren’t cared for in the same way as humans? We opted not to and instead decided that this ambulance was for getting a horse off the track and that a second ambulance – one with lights and sirens – would be used to take a horse to the necessary medical facility. Pip seemed satisfied with that.

It wasn’t until several minutes later as we were strolling past a big chestnut horse being hosed down by a groom that I realized what Pip had done with the equine ambulance: he looked it over, compared it to what he already knew, and began asking questions to determine what meaning could be found in the similarities and differences. It was exactly what I had wanted him to do earlier in the week with the trapezoid. Now at one level I know that he does this kind of mental work all the time. But with the trapezoid failure still relatively fresh in my head, Pip’s evaluation of the equine ambulance was a welcome reminder of what he is capable of. Once I recognized this, I immediately brought up the equine ambulance again in order to compliment Pip on asking such a good question and to talk through the thought process indicated by the question. Hopefully, by making him aware of what he did, it will make it easier for him to harness that process again in the future.

Pip’s assessment of the equine ambulance also reminded me that I had gone about the whole trapezoid question the wrong way. While I have written in a previous post about the ability of parents to act as opportunistic teachers, I still possess an inclination to approach teaching as a direct linear process whereby the initiation of an educational moment is my responsibility (and also my privilege). This is largely a question of power and control. By reserving for myself the power to initiate an educational moment, I maintain control over the process and can feed the illusion that my contribution to my children’s learning is greater than it really is. The opportunist model turns this structure on its head. It is driven by the explorations of the kids. They show interest in something, then I figure out how to talk about it. With this, teaching becomes much more of a post facto and ad hoc activity, one in which I try to contextualize for Pip or Polly what they saw or did instead of instructing them beforehand on what they should see or learn from a particular experience.

The main benefit of this model of education is that I can capitalize on something which has already piqued their interest instead of trying to generate enthusiasm in them for something which I think is important or interesting. The main challenge of this model is relinquishing control over the immediate direction of learning and the vague feeling of power that goes with that control. It also means that I constantly have to scramble to keep up with them - though I am finding that with practice I can often find a way to make most things about some preferred set of ideas or concepts. It just requires being prepared with a range of ideas and finding which one fits best with the current object of interest.

This model is not fool proof or necessarily more productive than the teacher directed model. But, as a parent interested in taking part in my children’s education, it does mean fewer battles over trapezoids. Ultimately, I also hope it means more interesting conversations with my kids as we stumble together through the forest of possibilities that is the world in which we live. I just need to get better at staying out of the way.