The Mote in Thy Sister’s Eye

We all live in different worlds, don’t we? I suppose that’s what makes travel so interesting: to see how widely dissimilar regions and disparate societies recognize and deal with comparable problems. How, for example, they might attempt to solve the ever-growing dilemma of urban pollution. The Chinese, remember, shut down many polluting factories for part of the Olympics they hosted. It was a short term fix, to be sure, but the effects were visibly evident.

Activists, or even cities in other countries have attempted different, longer term solutions with varying success. A common one seems to be restricting the amount of vehicles on the roads, whether by licence number, type of vehicle, or on certain days of the week. The success depends on whether or not it strikes a chord in the society but, probably more importantly, whether or not it is voluntary or officially mandated. And by whom…

There is always the possibility of unintended, unforeseen consequences however bold and thoughtful the concept. Consider the deceptively simple idea of ‘car-free Tuesdays’ in Iran: ‘[…] campaigners in Iran began marking “car-free Tuesdays” to encourage people to leave their cars at home in the hope of cutting down on pollution.’ The BBC article was reporting on a story in the Tehran Times, and I’ve included the link. ‘Tuesday was chosen because it is in the middle of Iranian week when traffic congestion is high and air pollution at peak.’

All well and good, even if unofficial and as yet unsanctioned, ‘the campaign was kicked off by Mohammad Bakhtiari, 25, who has majored in architecture and is a member of a local NGO with 1,000 members known as “the guardians of the environment of Arak city.’ It seemed like a good idea –it is a good idea- but there are issues… The idea was to encourage people to use alternate, less polluting forms of transportation –buses, or perhaps car-pooling, but especially bicycles to get around the city. Iran is a very conservatively run theocratic society, and women have long had to conform to various religiously mandated restrictions. And yet, ‘It had been understood women that [sic] could cycle as long as religious concerns were respected. But when asked recently, Iran’s Supreme Leader, Ali Khamenei, said women were not allowed to cycle in public or in the presence of strangers.’

Of course I’m not from Iran, nor do I even pretend to understand Islamic legal opinion, but I think that this fatwah –if such it is- involves a fair amount of cognitive dissonance even in a society that is used to seemingly arbitrary restrictions being imposed upon it. Presumably atmospheric pollution was not something anticipated in religious jurisprudence –it’s barely appreciated in civil law even today. A Fatwah, I’m given to understand however, is expected to break new ground –otherwise it might be considered simply a ruling –a considered opinion on the interpretation of existing writings. So I’m puzzled as to why, given the chance to become responsible caretakers of the Divine Creation which all religions purport to acknowledge, that the opportunity would not be seized and glorified. It might even go a long way towards mollifying some of the public antipathy about some of the more obviously capricious restrictions.

Just a thought, though… Why can’t women do their parts? If they adhere to religious codes of dress and conduct, aren’t they as much stewards as anybody else? Of course it’s now gone Twitter… And the social media campaign founder Masih Alinejad has said, “It is unacceptable in 2016 when you hear that a group of female cyclists have been arrested in Iran for the crime of riding a bike in a public place and made to sign a pledge promising they will not cycle in public again.” She is speaking out from the relative safety of New York, however. And I am writing from the relative safety of New Zealand… I ask myself why that should matter.










Autism and Obstetrics

I’m an obstetrician caring for worried mothers. They’re worried about things that might put their developing foetuses at risk for a whole range of issues and ask me for advice. Obviously I’m neither a paediatrician nor a child psychologist, so questions about autism leave me alone in troubled waters. There are so many rumours of risk, so many studies that seem to implicate everything from diet to anaerobic exercise in pregnancy, vaccinations to mercury in calcium supplements.

I wish I knew more about autism; I wish I knew anything indisputable about it… Well, that’s probably a bit harsh. I know that it’s now referred to as ASD (Autism Spectrum Disorder) and that it’s a neurodevelopmental disorder with problems in at least two areas: social impairments –things like communication and interaction- and behaviour abnormalities like repetitive patterns of  activities and that sort of thing. But it all seems rather vague. Especially the social components. At the severe end of the spectrum it’s an unmistakable impairment, and yet at the milder end…

It may be a sensitive set of criteria that bundles all the right things in it, and yet it’s rather spotty on the specificity. An example might help. Let’s say you’re a fisher and you want to improve your ability to catch salmon so you’ve designed a special net. You pull it up and there are a hundred fish in it, so it works –it catches lots of fish, but only one salmon. But, it did catch a salmon so it’s sensitive for salmon, but not very specific for them.

I also know the DSM-5 criteria of ASD –I’ll quote them from a more readable source: the 2014 UpToDate data base we have in our hospital. ‘ASD is characterized by 1. persistent deficits in social communication and interaction (eg. deficits in social reciprocity; nonverbal communicative behaviors; and skills in developing, maintaining, and understanding relationships) and 2. restricted, repetitive patterns of behavior, interests, or activities.’ They also say that the symptoms must be present early in childhood development, but may not become manifest until social demands exceed limited capacities. And there are three levels of severity rated separately for social and behavioral characteristics.

Okay, I understand those criteria –sort of- but coming from a medical specialty that is used to more concrete, objectively provable, and investigatable symptoms, they still seem rather vague. And there remain the difficulties that I have with including the milder, vaguer, less impaired end of that Bell curve distribution of characteristics –the end that may include variations of normal, idiosyncratic behaviors which may represent other issues –parental, social, even poverty-related stresses that might impinge on the child’s behavior.

I suppose it’s the boundaries that trouble me. There seems to be a wide variability of the reported prevalence of ASD and some indication that it is increasing of late, perhaps related to changes in definition as well as increased awareness. But how valid is that?

I’m all for increased awareness of ASD, just as long as we can be sure it is ASD that we’re aware of. This is important for interpreting the studies that purport to assess various causes of autism. For example, a BBC article reported a study from the Harvard School of Public Health which implicated air pollution as yet another cause. But, as the article suggests: ‘Experts said pregnant women should minimize their exposure, although the link had still to be proven.’

Good advice, I’m sure –pollution likely has many adverse effects on a developing foetus. One more wouldn’t be much of a surprise. Avoid pollution when you are pregnant by all means. But place that in the context of a pregnant woman who lives in a city where she cannot avoid it, and then add the additional worry of a possible link to autism in her unborn baby and you have sewn the seeds of an intractable anxiety. Helplessness. Despair. The fact that it is as yet unproven gets buried in the message; the statement that it is biologically possible does not.

As the aforementioned UpToDate 2014 data concludes: ‘The pathogenesis for ASD is incompletely understood. The general consensus is that ASD has a genetic etiology, which leads to altered brain development, resulting in the neurobehavioral genotype. Epidemiologic studies indicate that environmental factors account for few cases.’

I realize that there is a fine line between informing the public, and frightening them unnecessarily (or inadvertently), and I recognize and accept that we should all have the right to know what is being said in scientific circles about topics that affect us. Clearly it is difficult to balance whether or not to publicize information that is still in the process of being assessed and integrated into a coherent and testable theory, versus information that has been collated into a more accepted and validated model, but I think it would be a sensible, albeit challenging, step. It is a serpent’s egg, and reminds me of the warning of Brutus in Shakespeare’s Julius Caesar: ‘a serpent’s egg, which, hatch’d, would as his kind grow mischievous.

I’m certainly not advocating censorship –maybe just awareness. Prudence… Judgment.