May 19th, 2005

Whether Weather

We've had thunderstorms the last couple of days. I timed a walk down to Pioneer Square, Elliott Bay Books and the central branch of Seattle Public Library correctly. Unfortunately, when R. met me after work, it was really pouring. Hardship of hardships, we went to Wild Ginger. Yum.

In a complete and utter lapse of judgment, I didn't eat enough yesterday (plus there was all that walking -- altho we did catch a bus up the hill going home) during the day and would up eating late in the evening, which made me restless all night long. And I may have eaten something I'm allergic to, because I kept scratching, too. Poor R.

I think I'm caught up on calories today. I stayed in and read while it on-and-off stormed today. _Freakonomics_ was excellent. I have, as a result, identified yet another missing piece that applies to assessing medical care in the US and efforts to improve it. As avid readers (ha! I couldn't remember -- I had to look several entries back and check) may recall, I pointed out the hidden costs of financing medical care (late fees, interest charges and bankruptcies on credit cards directly attributable to medical care being charged). This new bit is the lack of apparent communication between the people who use economics to study medical care, and the medical system as a whole. So, there are all these people in the medical system (doctors and such) who study whether a given technique or drug or whatever has a benefit. And there are some economists who study whether a given technique or drug is deployed too little, too much or just the right amount. People make policy decisions in health care based on both sets of studies. But while the economists pay attention to the medical studies, it is far from obvious that the medical folks pay attention to the economists (a lapse that, I might add, is being worked on furiously by the fine people at CECS at Dartmouth, notably Elliott Fisher, may he please write a book for the mass market some time soon). I am not in a position to prove this missing link by showing who cites who, but I bet a clever person could and it wouldn't take long if they had full access to MedLine and some fairly rudimentary programming skills.

The question here is, "Is more care better?" We know that it isn't when the patient in question is healthy (this is why whole body scans and a lot of medical tests are not a good thing to deploy on the population at large -- false positive rates that are acceptable in one group of people can start offing large numbers of people when they can wreak havoc in everyone). Specifically, it's a terrible idea in normal pregnancy and childbirth (and that's exactly where we see the cascade in full flower). But it turns out this is a problem that shows up everywhere in medical care in regions of the country where there's a lot of care (specialists and so forth) available -- with the predictable effects of increased mortality and morbidity.

When I'm in full on rant mode, I think that turning back the clock, or across the board cuts in health care would actually improve things. However, on balance, I know this is not true. Part of the solution will involved a better informed health care consumer (that would be us), but most of the solution relies on groups like CECS coming up with ways to reform from within. Go them.

In the meantime, I'm reading Meredith Small's book on kids (waiting for the infant book from the library), which is a readable survey of ethnographic research as it describes child raising around the world, written by a good anthropologist who is also a parent following her own kids' development avidly. I also read _Generation Extra Large_, which raised a fascinating series of questions about to what degree parenting can counter a bad environment/peer pressure in the specific context of obesity/fitness. The authors would have us believe that parents can have a lot of say, if only by not contributing to the problem.

_Freakonomics_, _Generation Extra Large_ and Small all assiduously point out where parenting doesn't seem to have much of an impact; they are all opposed to what they often refer to as obsessive parenting, mostly on the basis of inefficacy. Score three for sanity.

I'm also waiting for Wolf's _Misconceptions_ from the library, because I cannot bring myself to give that woman any money by paying for her book; she's just a little too much of a pain in the ass. Amazon has a _ton_ of reviews of that book, which make for a fascinating microcosm of response to writing-about-childbirth. I was particularly entranced to see that a lot of women who weren't immediately planning on having children (much less currently pregnant) were reading about the subject. I find that very encouraging. But another theme arises in a number of these reviews. People seem to think they've read a lot about the topic somewhere between the second and third book they've read (parts of). That's just not a scale I recognize. While I have not yet read Wolf's book, I did skim extensively (for those of you who don't know what I mean by this: cover matter in and out, first few pages, last few pages, sampled pages throughout. I've probably read about 20% of the book), and some reviewers noted what I did, and what Wolf herself acknowledged -- despite her increasing knowledge and politicization on this topic, she nevertheless chose a ritzy, fashionable male OB for her second birth. Her explanation at the point she acknowledged this discrepancy didn't strike me as particularly compelling (she may do a better job in the rest of the book I haven't read; this is my main reason for planning on reading the book). Yet numerous reviewers were ecstatic that she revealed the truth about the medical system without mentioning how bizarre it was that she persisted in NOT using that information to her own benefit. This I do not understand. At all. I recognize it, however. And _Freakonomics_, quoting Galbraith, in defining conventional wisdom, suggests what is actually going on here:

"We associate truth with convenience, with what most closely accords with self-interest and personal well-being or promises best to avoid awkward effort or unwelcome dislocation of life. We also find highly acceptable what contributes most to self-esteem...[Economic and social behavior] are complex, and to comprehend their character is mentally tiring. Therefore we adhere, as though to a raft, to those ideas which represent our understanding."

I'm now a little mystified by precisely how the way I think about the world fits under this definition. It isn't convenient, it requires a lot of effort and a fair amount of unwelcome dislocation. On the plus side, it does closely accord with self-interest. I like the complexity, and the mentally tiring is largely irrelevant, because my brain pretty much won't shut off no matter what I do, and I'd rather have it doing something productive than not. This does not feel like a complete answer. Perhaps my self-esteem is irrevocably tied up in understanding my world as completely as possible. Certainly my need for influence and agency are.

In loosely related commentary, I'm still trying to understand how people come up with pregnancy weight gain recommendations. It's quite clear that they continue to rise in the US, and that US guidelines tend to have a lot of influence in English-speaking countries. It's also clear that as actual weight gain in pregnancy has increasingly exceeded even the rising guidelines, the obvious expected bad outcomes (macrosomia, shoulder dystocia, etc.) have not only not increased in that group of women that gains more than encouaged, but have apparently decreased. C-sections have risen, but that's an artifact of management guidelines. People who try to understand why some women still have LBW babies run up against some weird stuff, like women who report greater intimacy with their husbands are slightly more likely to have an LBW baby, more important other things (like educational attainment, income, etc.) being equal. Makes me very suspicious of how people define intimacy. I think this is an area where we really have no idea what's going on.

I really like this whole area: thinking about the medical system, the way it treats healthy people (which it doesn't generally do outside of pregnancy, childbirth and childcare), how to assess the kind of job our health care system is doing compared to other ways of arranging things. The whole reproduction axis is also fascinating independent of third party participants. (And yes, I've ordered _Birth as an American Rite of Passage -- how could I not?) Those of you who have suffered through my ranting about relationship development (whether friendly, sexual, romantic, etc.) probably recognize the obscene enthusiasm I bring to investigating so wide-ranging and evocative a theme. This one is a lot harder, tho. The relationship stuff lent itself so well to a personal-self-help narrative. That organizing principle is hopelessly inadequate here, and I'm at a loss for a replacement, which leaves me stuck reviewing books and hoping for a bright idea.