It Occurs to My Mother that She Might Be Dead
By Jean Sprackland
This unsettling poem appeared in the Financial Times on 14 September 2013. It’s from Jean Sprackland’s new collection Sleeping Keys,
She’s been stripping beds, gathering sheets for the wash,
a thing she’s done each week since she was fifteen –
first during her mother’s illness
then in all the houses of her married life –
grasping the sheets and heaping them on the landing,
stirring the air with crumbs and flakes of dust.
I tell her don’t be silly of course she’s not dead
and she says But how would I know?
I suggest she pinch herself, which I’m sure will settle it,
but she says That’s for dreaming, not dead.
I don’t think there’s a test for dead. And turns
and goes on stacking dishes in the sink.
That must have been forty years ago. Now I wonder
whether my mother is still there, somewhere,
asking the same question. How would I know?
I remember the glint in her voice as she said it,
the icy terror that seized me. And now
I stand with my arms full of sheets, and suppose I’m alive.
Unconsummated affairs
Alexandra Leaving (click here) led me to two more Cavafy poems. Longings (1904) was included as a Poem on the Underground in 2005. Remember, body … (1916) is in a newish translation by Aliki Barnstone. Regretful but tranquil about what didn’t happen – rejoicing in what did.
Longings
Like the beautiful bodies of those who died before growing old,
sadly shut away in a sumptuous mausoleum,
roses by the head, jasmine at the feet—
so appear the longings that have passed
without being satisfied, not one of them granted
a night of sensual pleasure, or one of its radiant mornings.
By Constantin Cavafy (translated by Edmund Keeley & Philip Sherrard)
Remember, Body …
Body, remember not only how much you were loved,
not only the beds where you lay,
but also those desires for you,
shining clearly in eyes
and trembling in a voice—and some chance
obstacle thwarted them.
Now when everything is the past,
it almost looks as if you gave yourself
to those desires as well—how they shone—
remember—in the eyes that looked at you,
how they trembled for you in the voice—remember, body.
by C. P. Cavafy (translated by Aliki Barnstone)
“A certain take on loss”
Alexandra Leaving
Cohen recites verses 4 and 5.
Even though she sleeps upon your satin;
Even though she wakes you with a kiss.
Do not say the moment was imagined;
Do not stoop to strategies like this.
As someone long prepared for this to happen,
Go firmly to the window. drink it in.
Exquisite music. Alexandra laughing.
Your first commitments tangible again.
Reminds us of CP Cavafy’s poem The God forsakes Anthony
When suddenly, at midnight, you hear
an invisible procession going by
with exquisite music, voices,
don’t mourn your luck that’s failing now,
work gone wrong, your plans
all proving deceptive—don’t mourn them uselessly.
As one long prepared, and graced with courage,
say goodbye to her, the Alexandria that is leaving.
Above all, don’t fool yourself, don’t say
it was a dream, your ears deceived you:
don’t degrade yourself with empty hopes like these.
As one long prepared, and graced with courage,
as is right for you who proved worthy of this kind of city,
go firmly to the window
and listen with deep emotion, but not
with the whining, the pleas of a coward;
listen—your final delectation—to the voices,
to the exquisite music of that strange procession,
and say goodbye to her, to the Alexandria you are losing.
Then Sharon Robinson sings it (click here)
Causing Havoc
Concealed conflicts
The message of the movie Hot Flash Havoc (click here) is that millions of menopausal women are denied the benefits of hormone therapy (HT*) by regulators who misinterpreted the results of the Women’s Health Initiative (WHI) trials. The regulators’ unanimous advice is:
Take HT for symptoms only, in the lowest dose and for the shortest time possible, and never for health promotion
The film disputes the evidence for increased risks of breast cancer, heart attacks and strokes, and claims that HT may even reduce cardiovascular disease. The message seems to be that:
Women should demand HT for health promotion
The authority for these extraordinary claims comes from a long list of “experts”, (click here) mostly self-styled pundits, TV doctors, complementary therapists and the like, but including the following apparently reputable clinicians and scientists:
Dr Anita H Clayton, Professor of Psychiatry & Neurobehavioral Sciences at the University of Virginia
Dr Sheryl Kingsberg, Chief of Behavioral Medicine, and Associate Professor Departments of Reproductive Biology and Psychiatry, Case Western Reserve School of Medicine.
Dr James A Simon, Clinical Professor of Obstetrics & Gynecology at the George Washington University in Washington, D.C
Dr Leon Speroff, Professor of Obstetrics and Gynecology, Oregon Health & Science University School of Medicine.
Dr Wilf H Utian, Professor Emeritus of Reproductive Biology, Case Western Reserve School of Medicine.
The producers claim that the film was made without support from HT manufacturers, and none of the above experts mentioned any conflict of interest on the website.
However a brief search of the internet reveals:
Dr Clayton – consultant, speaker, research support from Boehringer-Ingelheim, Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer, Wyeth and Sanofi-Aventis (click here)
Dr Kingsberg – financial relationships with Novo Nordisk, and Pfizer (click here)
Dr Simon – consultant, speaker, on advisory boards of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Merck, Novo Nordisk, Roche, Schering-Plough, Solvay, and Wyeth (click here)
Dr Speroff – consultant and research support from Warner Chilcott, Organon, and Wyeth (click here). Dr Speroff is already on our name and shame list (click here)
Dr Utian – consultant or advisory board for Bayer, Bionovo, Merck, and Novogyne (click here)
All these companies sell HT. Wyeth alone lost over $1 billion a year in reduced HT sales in 2003, when the WHI trials showed that HT increased heart attacks, strokes and breast cancer. Viewers might be interested.
I guess it just slipped their minds.
Jim Thornton
*Hormone replacement therapy (HRT) changed to hormone therapy (HT) Jan 2016
Thinly sliced Danish
More BJOG salami
Last year we drew readers attention to a florid example of salami publication in BJOG (click here). A group of authors from Denmark had taken five papers over 56 pages, to report a single study of the relation between low to moderate maternal alcohol consumption in pregnancy and child development at five years. Each paper was based on the same sample of 1628 women, reported the same exposure variables, adjusted for slightly different but overlapping covariates, and reported slightly different but overlapping outcomes. All five papers concluded that there was no proven harm from low to moderate consumption, but that mothers should play safe and not drink at all. The BJOG added it’s own two slices of commentary which concluded the same thing.
In the latest issue of the same journal (click here or here skogerbo bjog 2013) the same group have added yet another eight page slice about the same population and exposure variables, another overlapping set of covariates and a new five year outcome, the Strengths and Difficulties Questionnaire (SDQ) and its various subscores. The findings were the same, namely:
“This study observed no consistent effects of low to moderate alcohol consumption or binge drinking in early pregnancy on offspring behaviour at the age of 5 years.”
BJOG then added yet another two slices of commentary (here and here) each with the same conclusion again.
Last time (click here) I noted that the authors had mentioned eight other five-year outcomes, and jokeingly wondered if we could expect eight more slices of salami! It looks like my fears were justified; this paper reports just one of those eight other outcomes! Seven to go!
To summarise; one study has now been sliced into six separate reports covering in total 64 pages of journal, and the journal has added four separate commentaries. Every single one of which says what everyone knew already, namely that low to moderate maternal alcohol consumption has not be proven harmful to the baby, but that to play safe mothers should abstain altogether!
This sort of nonsense is wasteful, and makes the literature difficult to interpret. The Committee on Publication Ethics (COPE) (click here) is quite specific that it is scientific misconduct: “splitting up papers by outcomes is not legitimate”. However, it is a rather mild form of misconduct, so referral of the authors to their university bosses seems rather harsh. Perhaps public shaming will have some effect.
If they do it again I’m going to tweet them round the world!
Jim Thornton
KEEPS disappear’n
Where have the KEEPS trial results gone?
The Kronos Early Estrogen Prevention Study (KEEPS) was an important investigator-led randomised trial funded by a charity, the Kronos Institute. The KEEPS researchers tested the controversial hypothesis that hormone therapy (HT*), started soon after the menopause, was cardioprotective. The trial was registered here. The primary endpoint, a surrogate for heart attacks and strokes, was the rate of change in carotid intimal medial thickness (CIMT) over the four years post-randomisation. 728 women were enrolled and the final four year data collected in May 2012. So far no publication, or electronic pre-publication has appeared.
This is a bit slow. The results were presented at the North American Menopause Society in October 2012. According to the abstract:
“The carotid ultrasound studies showed similar rates of progression of arterial wall thickness in all three treatment groups over the four years of study. These changes were generally small, limiting the statistical power to detect any differences among the groups.”
i.e. it appears the trial was negative. This would be important for those gynaecologists who encourage the taking of HT, some even in the absence of symptoms, in the early years after the menopause. But only if they can read the details.
The investigators have published many papers based on other bits of trial data (click here), as well as some randomised results based on a subset of 76 participants (click here)! But no results for the trial primary outcome in a peer reviewed journal.
The reason for concern is that some of the authors have potential conflicts of interest with HT manufacturers, and they’ve issued two press releases suggesting beneficial effects on other secondary outcomes and in trial subsets (here pr_100312_a and here pr_100312). These have been used by medical journalists e.g. here, here and here, and in many other publications, to imply that HT is beneficial for younger post menopausal women.
Surely independent academic researchers wouldn’t suppress the main trial results just because they failed to support their hypothesis! Would they?
Jim Thornton
*Hormone replacement therapy (HRT) changed to hormone therapy (HT) Jan 2016
Love is a Bourgeois Construct
By the Pet Shop Boys
Released today. This catchy new single (click here) samples from the minimalist Chasing Sheep is Best Left to Shepherds by the Michael Nyman Band (click here), itself based on something by Henry Purcell. For an analysis by Wayne Studer click here.
It’s the best PSB title for years, and the lyrics are wonderful. If you don’t know why, you’ve not been following ripe-tomato.org.
Love is a Bourgeois Construct
I’ve been taking my time for a long time
Putting my feet up a lot
Speaking English as a foreign language
any words that I haven’t forgot
I’ve been thinking how I can’t be bothered
to wash the dishes or remake the bed
What’s the point when I could doss instead?
I’ve been hanging out with various riff-raff
somewhere on the Goldhawk Road
I don’t think it’s gonna be much longer
’til I’m mugging up on the penal code
Love is a bourgeois construct
so I’ve given up on the bourgeoisie
Like all their aspirations, it’s a fantasy
When you walked out you did me a favour
you made me see reality
that love is a bourgeois construct
It’s a blatant fallacy
You won’t see me with a bunch of roses
promising fidelity
Love doesn’t mean a thing to me
Talking tough and feeling bitter
but better now it’s clear to me
that love is a bourgeois construct
so I’ve given up the bourgeoisie
While the bankers all get their bonuses
I’ll just get along with what I’ve got
Watching the weeds in the garden
Putting my feet up a lot
I’ll explore the outer limits of boredom
moaning periodically
Just a full-time, lonely layabout
that’s me
When you walked out you did me a favour
It’s absolutely clear to me
that love is a bourgeois construct
just like they said at university
I’ll be taking my time for a long time
with all the schadenfreude it’s cost
calculating what you’ve lost
Now I’m digging through my student paperbacks
Flicking through Karl Marx again
Searching for the soul of England
Drinking tea like Tony Benn
Love is just a bourgeois construct
so I’m giving up the bourgeoisie
until you come back to me
Talking tough and feeling bitter
but better now it’s clear to me
that love is a bourgeois construct
so I’ve given up the bourgeoisie
Chris Lowe & Neil Tennant
HIV transmission by circumcision in Nigeria
Study needs repeating
This paper, just published online in the Nigerian Journal of Clinical Practice, has an important message, albeit buried in the discussion section. Click here or here NigerJClinPract164521-6082483_165344 for the full paper.
The authors report 22 consecutive new cases of childhood HIV presenting to Amino Kano Teaching Hospital between June and August 2010. Such a study design was unlikely to achieve its stated aim of determining “the prevalence, clinical features and CD4 counts plus percentage and mortality rate of paediatric HIV in the region” but it inadvertently revealed how the children got infected. The following text appears in the discussion section.
“[…] HIV transmission occurred probably via group circumcision in five infected boys (22.7%). Their mothers had tested negative to HIV and none of them had received blood transfusion previously. Three of the five boys had circumcision performed at the same time by a local barber known as ‘Wanzami’ while the other two boys had theirs done in other groups.” Elsewhere one other boy is reported to have been infected by blood transfusion.
On the face of it this is earth shattering – a quarter of paediatric HIV transmitted by infected sharps, 23% by circumcision! The World Health Organisation (WHO) and most AIDS experts claim to believe that hardly any HIV is transmitted this way, and in many parts of Africa are running campaigns to encourage male circumcision. Here’s one from Uganda.
Of course the numbers are small, but apart from the play of chance there is no obvious reason why a hospital-based series should over-estimate the percentage infected by this route. It might under-estimate it, if customers of ‘Wanzami’ were less likely to seek modern medical care.
Imagine if this happened in California, or New York. There would be an outcry, and an immediate public health investigation.
Such investigations are not difficult. Doctors just need to take a family history and check the HIV status and subtype of the mothers of all newly infected children. Most, as expected, will be infected with the same subtype. But if any mothers are found to be uninfected, or to have a different subtype, their baby was not infected at birth. In those cases the places where the child was immunised, or underwent any other skin breaking procedures need an urgent review of their aseptic techniques, and a check of their books for other children infected at the same time. If they turn out to be transmitting HIV, they need closing down or retraining.
According to a recent paper (click here) few if any such investigations have been done in Africa. Let’s hope the organisations presently pushing circumcision in Africa, do them urgently. If it really is an important route for transmission, many lives would be saved.
Their campaigns would also need rethinking, but surely WHO, UNAIDS, and the Gates Foundation wouldn’t delay for fear of that happening? Would they?
Jim Thornton (Hat tip David Gisselquist)
Vanity videos
You Tube clips by Clinical Commissioning Groups (CCGs)
Just been invited to view An intro to NHS Leeds South and East CCG (click here), an information video about how CCGs buy NHS services on patients’ behalf. Seemed rather patronising, but public involvement is important, and the video wasn’t aimed at me, so maybe it’s OK. With this Twitter push from GPonline (click here) it’s had 956 views in a month.
“Great watch, all CCGs need one of these! @NHSLeedsSE: our fab animation that explains what a CCG is & what we do http://bit.ly/170J5ig“
It set me wondering how many CCGs are spending money this way, and whether anyone’s watching. Do all 212 CCGs “need one of these”? At least 16 already have one (table), of which Leeds S&E is by far the most watched.
They’re appearing thick and fast; seven in the last two months – perhaps the CCGs have all been told that a publicity video is a good idea – but their view numbers are tiny. Many You Tube patient information videos have upwards of 0.5 million views. For example a video about taking a child to hospital for surgery produced by Chesterfield Royal Hospital NHS Trust, (click here) has had 367,749 views in a year.
The CCG videos are all scripted, and mostly professionally made. Most consist of senior staff, patient and clinician interviews with voice overs. I’d be surprised if any cost less that £10K, even without counting CCG staff time.
If Leeds S&E keeps up the current view rate, that would work out at just under £1 per view over a full year, the others up to 50 times more. Commercial advertisers pay Google about 1p per view.
But it’s worse than that. These are just the general information videos. Searching You Tube for “CCG NHS” reveals 978 more! None with any more views than Leeds S&E CCG. Only 40 got over a hundred. Most are in single figures. They’re aimed at the public but no-one’s watching.
Not all are professionally produced. Many are single camera jobs of a talk, clips from a conference, or even committee discussions. Packed with jargon, undefined acronyms and, forgive me, no cliché or platitude left unsaid. Even the speaker’s mum would struggle to watch some.
CCGs need to inform the public, but unwatched You Tube videos are the wrong way to go about it. This should be an easy bit of NHS waste to stop.
Jim Thornton
Filling Station
By Elizabeth Bishop
The reassuring idea that someone loves us however greasy and oily we are, may or may not be true. But this poem makes it so.
For a recording of Bishop reading it click here. She begins:
“This one will have to be changed – as you see somehow, I don’t know how – at the end […].”
According to my big yellow New Yorker Book of Poems there were two changes in the version published in that magazine in 1955. Surprising replaced disturbing in verse 1 line 4, and verse 5 line 2 became Why, oh why, the table? But by the time the poem appeared in her collection Questions of Travel (1965), and in Complete Poems (2004), disturbing, and why the taboret were back. They are surely preferable. This is the text as Bishop read it, and as published in Complete Poems.
Filling Station
Oh, but it is dirty!
—this little filling station,
oil-soaked, oil-permeated
to a disturbing, over-all
black translucency.
Be careful with that match!
Father wears a dirty,
oil-soaked monkey suit
that cuts him under the arms,
and several quick and saucy
and greasy sons assist him
(it’s a family filling station),
all quite thoroughly dirty.
Do they live in the station?
It has a cement porch
behind the pumps, and on it
a set of crushed and grease-
impregnated wickerwork;
on the wicker sofa
a dirty dog, quite comfy.
Some comic books provide
the only note of color—
of certain color. They lie
upon a big dim doily
draping a taboret
(part of the set), beside
a big hirsute begonia.
Why the extraneous plant?
Why the taboret?
Why, oh why, the doily?
(Embroidered in daisy stitch
with marguerites, I think,
and heavy with gray crochet.)
Somebody embroidered the doily.
Somebody waters the plant,
or oils it, maybe. Somebody
arranges the rows of cans
so that they softly say:
ESSO—SO—SO—SO
to high-strung automobiles.
Somebody loves us all.
By Elizabeth Bishop
Ripe-tomato.org 