Archive for the 'Research freebies' Category

The informed shrug

May 1, 2018

In thinking ahead to CIMSA 2018, I have had to do a little soul-searching as a scientist. My first thought was, “holy ***! my deliverables aren’t ready yet, and it’s coming up fast!” My new thought is: “Whoa, dammit. Those deliverables won’t be ready any time soon. Why don’t you plan on going there to listen and learn?”

cart-horse

Because all I have is a desk review in progress: an incomplete annotated bibliography, a time-consuming search strategy, and some hunches that have yet to be substantiated. And when I finish, all I’ll have is one of dozens of new systematic reviews that get published EVERY DAY. Far more than these stakeholders have time to read and learn from. From the evidence landscape maps I glimpsed on the Africa Evidence 2018 website (which appears to have moved and left them behind, sadly), I gained a greater appreciation of the distance between the publication process and the implementation of evidence-informed decision-making in public health practice, and the potential for connectivity between these two fields of activity.

From a conference like CIMSA, I hope to learn more about how these decision-makers set their expectations for evidence reviews, what types of evidence they are looking for, how they hope to find it packaged, and how they go about sifting through the available evidence in their day-to-day routines.

One thing is for sure, I don’t want to be like the other guys. I don’t want my exhaustive efforts to synthesize the available evidence to end in an “informed shrug”. I see too many Cochrane reviews end like this: “Having reviewed 100 papers, we found 2 that were almost good enough to take seriously. Neither was conclusive. We hope that more research will be forthcoming in this area. Thank you.”

That’s not helpful. You don’t seriously expect me to believe that after reading 100 papers in a given discipline, you learned nothing useful that could inform the design of these wished-for additional studies, do you? Don’t just tell me they should’ve used blinding and randomized designs. Tell me what they thought they learned, too.

Use your best judgment – if they lied in the abstract about the effectiveness of the intervention, I don’t need you to repeat that sort of nonsense. But if they noticed contextual variables that were frustrating their implementation of the intervention and that may have contributed to its lack of effectiveness, by all means bring that data to light in your review! In other words, show me that you were actually paying attention when you read the papers, not just skipping to the results sections after glancing at the methods.

Hand-offs as “stand offs”

March 25, 2018

A friend of mine was ribbing me about our awkward hand-offs at work earlier this week and, by a slip of the tongue, referred to them as “stand-offs” – a fitting malapropism, I felt, so I took a moment to write it down as food for thought.

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I just finished a grim little paperback about machismo in the narco-banditry-dominated mountains of Mexico yesterday, and the last two chapters really took the wind out of my sails as a vicarious adventurer exploring the bleak corners of the obscure. One endorsement on the book’s cover promised “characters straight out of a Cormac McCarthy novel” – but the modern view of those historied mountains was a bit less romantic than a Western novel.

The awkward truth about the drug trade seems to be that it barely pays at all unless you’re really good at killing the competition and stealing their loot – an ugly portrait of the life choices of the hardscrabble growers and dealers hooked on the Mexican version of gangster rap, dreaming of bigger AKs, more terrified girlfriends, and the opportunity to snort a generation’s worth of savings in cocaine while getting most of one’s calories from booze.

I mention this because there were so many real-life Mexican stand-offs to be had in the writer’s journey documenting this wasteland of macho excess and drug-induced paranoia. The writer, in fact, had to be about as charming and disarming as anyone can be, just to keep casual encounters with strangers from escalating into life-or-death confrontations.

Perversely, his story taught me a lot about de-escalation, hospitality and charm. One of his cardinal rules was not to hurry your way into, or out of, conversation with anybody. Exchange pleasantries, keep it informal, play it by ear. Listen. Very carefully. For innuendo, uneasiness, mistrust, any sign of negativity. Always adapt instantly to signs of danger.

This was a journey made possible by the unflinching hospitality of strangers who could’ve been killed for extending their help if their guest had been mistaken for a DEA agent. A journey demonstrative of the extremes in resourcefulness, openness and presence of mind needed to simply put strangers at ease.

In the hospitality industry, hand-offs between customer service front line staff and actual, irritable customers are a lot more likely to escalate into stand-offs than hand-offs among staff members. But that Freudian slip touched on an underlying continuity between these two inflections of interpersonal micro-encounters.

Hand-offs can be defined as moments of workspace-time in which interpersonal encounters take on a tension along the following lines:

A tells B, ‘now it’s your problem, here’s what I’ve done so far’

B looks at A and thinks, ‘do I tell A what I really think, or just shrug?’

And that opportunity to give feedback, ask for clarification, comment on tone of voice, or what have you contains within it a microcosmic battlefield. The politics of the attention economy are the stakes. To ask A (or B) to listen to detailed instructions or respond to a line of second-guessing concerns is to attempt a coercion. Will it work? Will it have consequences? For whom?

I dwell on this because hand-offs are a leading cause of medical errors (intervention research in this area is promising). But these micro-encounters and the attendant micro-aggressions interwoven in the fabric of cooperation, tension, and collegial joking around are layered, fluid, subjective, dynamic – in a word, difficult to dissect.

What is called for on all sides, I think, and not just in the health services, is an ongoing commitment to work on having the presence of mind to be adroit, disarming, considerate, persuasive, and a good listener at all times – not only at work but even in our roles as customers, patients, friends, and in the home.

Machismo, inattentive and blustery, irrational and ingrained in our animal nature, is always going to try to get the upper hand when we’re not careful. But machismo is for dinosaurs and drug cartels and period films – this is not the material a better future is going to be made of. May it come to play a lesser role in our lives.

 

“Pervy blin narkomom”

August 14, 2016

This summer I tackled my first real history book – real in the sense of first-class scholarship drawing directly on primary sources. The topic was 1930s Soviet industrialization, and the author is Stephen Kotkin. I chose Magnetic Mountain: Stalinism as a Civilization, the second of his books on Magnitogorsk, a large planned Soviet-era industrial and mining town. His first book deals with its more recent history, and I may read that one too, or one of his other titles about Russian history in the transition and post-Communist eras.

His research questions, in studying primary sources, included these: What was Russian about Stalinism, what was inevitable (inherent in the project of governance under communism), and what was idiosyncratic about it? This book is especially interesting in light of Putin’s heavy-handed efforts to rehabilitate Stalin, which can best be understood as reactionary conservatism, an attempt to reverse the demoralizing effects hindsight had on the Russian people during the late Communist era of de-Stalinisation, when so many skeletons were taken out of the closets to be buried.

I was largely unprepared for what I learned from this book, having always associated Russian Communism with American Socialism and the progressive movement. Maybe I shouldn’t have taken the movie Reds at face value. Socialists and other progressives were persecuted violently under Stalinism, as were any officials who questioned the official line, not to speak of rank-and-file Party members. And I was completely surprised to learn that Party membership was far from universal in Communist Russia. Apparently the Communist Party itself was made up of a highly selective new ruling elite – membership was tightly restricted, and yet at times during the Party’s history, Party members were the first to feel the brunt of a violent purge.

Kotkin paints a vivid portrait of everyday life for both workers and officials under Stalin, and the picture of a society in turmoil is engrossing. He documents ordinary workers’ adoption of communist values in everyday life as well as their grumblings, some violently suppressed and others blithely noted in passing by the keepers of official records. One witnesses rapidly rising expectations in terms of standard of living, and a glaring gap between these utopian promises and the reality on the ground. The lightning-speed eradication of illiteracy in the early years of Communism is documented alongside the extreme cultural paucity of the radical censorship regime. Promises to meet every citizen’s material needs are juxtaposed with images of famine, sometimes episodic and sometimes prolonged, but never equally distributed across the population.

Magnitogorsk_steel_production_facility_1930s

It becomes difficult to see Stalinism as a civilization when it seems that everything we associate with civilization today was banned under Stalinism, with the notable exception of jazz (which was always considered suspiciously bourgeois, but never quite fell out of favor with the ruling elite). But Kotkin convincingly attributes a sense of ownership of the revolutionary project to the Russian people in this era, and a deep sense of popular commitment to the goals of rapid industrialization, however traumatic the pace.  As a sense-making project, the book is definitely a success.

Perhaps the most valuable lessons to be learned from this book are the lessons of the purges within the Communist Party – while the author barely describes the purges of non-Party members, which were in fact far more extensive. Very likely this bias reflects a bias within the official record, with far more evidence available from which to describe the Party purges vividly. Kotkin recognizes the “housekeeping” rationale of the iterative bloodbaths alongside the vicious cycle of recriminations and careerist incriminations fostered by Stalin’s murderous directive that the Party engage in “self-criticism”, a byword which survived as a tenet of Party ideology even into the Khrushchev thaw.

If there had been any “housekeeping” agenda at work in the purges, it was a desperate and double-dealing project from the outset. Take the example of an official “purged” for engaging in illegal trade with state resources in order to finance his mandated quota of services and goods provided. His motive was simple: he had orders to deliver, and no budget with which to work. And had he not found ways to meet his quota, very likely he would have been “purged” for nonperformance.

The vulnerability of the Communist elite can be explained by the redundancies built into the Russian government under Communism: there were two chains of command, the state pyramid and the Party pyramid. Every organ of the state thus operated under two chains of command, the ordinary one and the Party one, which was to serve as an ideological watchdog and which was liable for the successes and failures of its counterpart. Hence the redundant Party bosses could easily be painted as self-serving leeches on the system, if any flaw could be found in their performance.

The first to be purged were the ideological non-conformists, lumped indiscriminately under the banner of Trotskyists. Later purges associated their victims with the fascist threat from abroad, and accused officials lagging in industrial performance (or guilty of ruining their equipment in an overeager attempt to exceed its production capacity to meet official targets) of sabotage and espionage in one breath. Kotkin illuminates an enduring level of xenophobia and ignorance of the outside world that could explain how some officials were purged simply for having foreign-sounding names.

Yesterday I discovered an anecdote about Shostakovich and his Symphony No. 5 that illuminates the era of the Great Purge nicely. The symphony was written while the composer (living in Russia) had fallen into disfavor, in the late 1930s. His opera Lady Macbeth had been a great success until the day Stalin came to see it, but the composer was “white as a sheet” by the end of the performance. Stalin had laughed during an explicit sex scene and had later walked out. The next day Pravda carried a scathing editorial about the opera, and not until Symphony No. 5 brought the audience to their feet with tears in their eyes was Shostakovich restored in stature. You can judge for yourself what the symphony is about.

The Russian proverb I used as the title of this blog entry appears untranslated as an epigraph to Kotkin’s last chapter, and he says it is untranslatable. But I was able to find the source:

“‘How was that as a first try?’ asked Trotsky. [Vladimir] Mayakovsky answered with a devastating pun: ‘The first pancake falls like a People’s Commissar’ (pervy blin lyog narkomom), a play on the saying ‘the first pancake falls like a lump.’”

This and other gems make Kotkin’s description of the “little tactics of the habitat” under Stalinism a real page-turner, and I am looking forward to checking out more of his work. But for now I am chewing through Khrushchev’s memoirs, the first half of which are profoundly depressing in this context. Over and over again he shares anecdotes about directives from Stalin that he carried out against his own better judgment for fear of the consequences of gainsaying the boss. I’ve made it up to the point of Stalin’s death now, and I’m hoping the second half of the book will show up the author’s engaging personality more fully, out from under the shadow of pervasive sycophancy in an environment of totalitarianism.

The sense of the past

February 23, 2013

In the art of narrating history, few can compete with the Baron Corvo for flair. In a masterful attempt at rehabilitating the reputations of the Borgia clan, he juggles rationalizations on necessity for possible misdeeds right alongside exhaustive catalogs of exculpatory evidence, on the logic that redundancy is the secret to thoroughness.

Corvo was the pseudonym of Frederick William Rolfe, son of a piano manufacturer, dubbed “baron” by one Duchess Sforza Cesarini while living as an indigent freelance writer and tutor in Venice. His history of the Borgia pope’s career in nepotism would not necessarily be considered an authoritative one, but his diligence in shoehorning the available evidence into firm conclusions is not truly unusual.

Take C.V. Wedgewood’s assessment of Machiavelli’s legacy in The Sense of the Past (1960): “It has sometimes been said that the divorce of politics from ethics begins with Machiavelli. This was not true in practice; politics and ethics have been through a series of marriages and divorces since the beginning of recorded history. Machiavelli happened to live at a time and in a country where this divorce appeared to be absolute; his observations rested on this assumption.”

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“History is a nightmare from which I am trying to awake.”

Then Wedgewood corrects Machiavelli for his pretense of objectivity in the study of politics, arguing that in truth he favored flattering the politics of antiquity, and discounted most evidence he encountered of agreement between moral policies and pragmatism, out of “his natural taste for subtlety, and his admiration for cleverness and force” (exemplified in the personalities of contemporaries like Cesare Borgia).

You can find Corvo’s sense of humor in the voices of more circumspect historians. These are the masters of good poise, presenting compromised source material to a skeptical readership with good humor and not too many apologies for its questionable nature.

He updated in style the reputation of a political crime family as colorful as a Caravaggio, just in time to capture the Victorian era’s passing discomfiture with what a contemporary audience forgets to blush at.

Tip their mouths open to the sky. Turquoise, amber, the deep green with fluted handle, pitcher the size of two thumbs, tiny lip and graceful waist.

Here we place the smallest flower which could have lived invisibly in loose soil beside the road, sprig of succulent rosemary, bowing mint.

They grow deeper in the center of the table.

Here we entrust the small life, thread, fragment, breath. And it bends. It waits all day. …

But the child of Hebron sleeps with the thud of her brothers falling and the long sorrow of the color red.

THE SMALL VASES FROM HEBRON

Of course, if like an ambitious politician he is full of rhetorical intensity but “trained in the art of inexactitude,” the narrator’s blind spots will come at a price. Some significant omissions in our history conceal from us what we still need to learn about ourselves.