Bicentennial Summer: Big Hole National Battlefield

June 30, 2016
Big Hole Battlefield: Online Photo

Big Hole Battlefield: Online Photo

For thirty-six days we rode our bicycles from Portland, Oregon, to Indianapolis, traveling in reverse over routes explored by the Lewis and Clark expedition and half a century later by 400,000 pioneers on the Oregon Trail. At 44 years of age, I was the senior member of our threesome; my daughter, Sharon, recently graduated from college, and Paul, the son of a seminary classmate and an elementary school teacher near Indianapolis, were my companions on this 2,600-mile journey.

On our bicycles we carried clothes, personal items, tents, sleeping bags, tools, and a little food—a total of about thirty pounds each. Not counting our five rest days, we averaged 85 miles a day, despite daytime temperatures often approaching 100 degrees, mountain passes as high as 9,600 feet, heavy traffic, and a little rain.

For the western half of our journey we often were surrounded by many other cyclists, since a recently formed company—BikeCentennial—had developed a 4,200 TransAmerica Bicycle Trail and inspired 4,100 people to celebrate the American Bicentennial Anniversary by bicycling across the country. After riding through Yellowstone Park, we developed our own route for the rest of the journey.

I kept a journal, which for the most part records the externalities of the trip. Shortly before we started, I had bought a new camera, but I set it incorrectly and at the end of the trip discovered that most of the photos were seriously overexposed and so the visual record is sparse.

July 4, 1976, was a Sunday, and I had hoped to attend church that day to give thanks for the heritage of our land. Our camp site on Saturday, July 3, however, was in a public park near the summit of Chief Joseph Pass in western Montana, far from any town or church. On the great day, we cycled to the top of the pass where we encountered a band of cyclists, all of them young men about the same age as Sharon and Paul, who had reached the pass by cycling up another trail that came from a different direction.

Later in the morning, most of us stopped at Big Hole National Battlefield. Instead of celebrating our nation’s heritage of freedom in a church, we sat in the amphitheater overlooking the battlefield. A park ranger displayed a video describing the battle that had taken place there in 1877. There had been a decades-long struggle between the United States government and the Nez Perce Indians who were the long-time residents of this region. As often happened in these conflicts, there had been a history of friendly relations, treaties, broken treaties, military skirmishes, and outright military conflict. Chief Joseph had finally decided that their cause was hopeless and he had inspired a significant body of his people to flee to Canada where they would be safe.

In the pre-dawn hours of August 9, 1877, U. S. armed forces swept down upon the sleeping camp of men, women, and children. By the time the smoke cleared on August 10, almost 90 Nez Perce were dead along with 31 soldiers and volunteers. Big Hole National Battlefield was created to honor all who were there. Later, Chief Joseph made this declaration:

“I am tired of fighting. Our Chiefs are killed; Looking Glass is dead, Ta Hool Hool Shute is dead. The old men are all dead. It is the young men who say yes or no. He who led on the young men is dead. It is cold, and we have no blankets; the little children are freezing to death. My people, some of them, have run away to the hills, and have no blankets, no food. No one knows where they are – perhaps freezing to death. I want to have time to look for my children, and see how many of them I can find. Maybe I shall find them among the dead. Hear me, my Chiefs! I am tired; my heart is sick and sad. From where the sun now stands I will fight no more forever.”

After watching the video, we enjoyed a 30-mile downward sweep to Wisdom, Montana, where we ate lunch in a mosquito-infested restaurant and watched and listened to Walter Cronkite’s narration of the tall ships coming into New York Harbor. As we continued across the country, however, visiting many places that depict the glories of our nation, the tragic aspects of our history continued with me.

A Key to Good Health

June 23, 2016

Snowball in a Blizzard: A Physician’s Notes on Uncertainty in Medicine, by Steven Hatch (New York: Basic Books, 2016)

HatchWhen he started this book, Steven Hatch intended to write about issues with which he was struggling in his professional life as assistant professor of medicine at the University of Massachusetts Medical School. The focus would have been on “methodological aspects of human-subjects research, mainly the difficulties of study design and the subtleties of statistical interpretation” (p. 241).

Tepid responses from literary agents led him to realize that “more was to be gained by telling stories about the consequences of these issues, and that I could occasionally sprinkle the text with brief explanations of the more essential methodological points.” How should women decide when to have mammograms and how much confidence should they have in the results of these tests? How reliable are PSA scores in making decisions about possible prostate cancer? Why are guidelines for blood pressure levels changing, especially for older adults?

The first half of the book consists of Hatch’s narratives about the above illnesses and others, including infectious diseases, his own field of specialization. The mix of case study narration and description of how scientists and physicians conduct studies and reach conclusions provides a strong story line so that general readers can stay with his analysis and understand his interpretations.

Halfway through (p. 153), Hatch summarizes the book to this point. Studies discussed in previous chapters leave questions dealing with uncertainty about the values of a drug: “First, what will be the yardstick by which we will measure a drug’s value? … Second, how big will any potential observed benefit need to be before we consider it a success? . . . Third, what are the potential harms of the treatment?” After listing and briefly explaining these questions, Hatch states what could be considered the thesis of the book.

“Because the answers to these questions differ for each treatment, and the fact that the answers tend to fall onto a continuum rather than cozy themselves into a tidy binary yes and no category, both doctors and patients alike need to carefully consider the data before ‘knowing’ that a drug is right for them” (p. 153).

Hatch then begins a fuller discussion of the processes by which physicians and researchers reach their conclusions. The chapter title and epigram suggest the tone of what follows: “The Correlation/Causation Problem, or Why Dark Chocolate May Not Lower Your Risk of Heart Failure: The science was accurate, but it was extrapolated beyond imagination.”

He also gives a concise description of the kind of study that has been described and affirmed throughout the book and makes this assertion: “Nevertheless, the power of the double-blind, randomized, placebo-controlled trial lies in its ability to ask [the above questions] in an organized and systematic way. We can say this drug saves this many lives (great!) but comes at the cost of these side effects, of which these particular effects are truly dangerous (not great). They do not settle questions, but they give us a framework by which we can ponder uncertainty and allow us to decide where we can place a drug’s value on the spectrum (154).”

The ideas presented in this book lead to a specific kind of relationship between medical providers and patients and families. Instead of issuing decisions about treatment, doctors exercise humility, explaining the basis for their proposals for treatment and acknowledging the limitations of their knowledge and certainty. Patients and families need to be active participants in the discussion, asking questions and responding to the guidelines that physicians present.

This relationship is illustrated in a pattern of consultation that is developing in intensive care units. Families are encouraged to be present at the bedside when the medical team makes its daily rounds to evaluate the patient and the care that is being given. In this way, the conversational, collaborative nature of the doctor-patient relationship is manifested.
Hatch frequently describes the role of the media in describing medical matters and developing public opinion. Much of his commentary is negative and he supports the importance of good coverage that reports carefully on studies, recommendations, and guidelines.

Despite Hatch’s emphasis upon uncertainty, humility, and collaboration, he does make one unqualified assertion at several points throughout the book: “Exercise more. Eat less. Don’t smoke. Everything else is commentary (p. 225). Hatch also writes that there is one aspect of medicine where the benefits are so great and the risks so minimal that it is on the far left of the “spectrum of certainty.” That procedure is vaccination, which has to be considered “the single greatest triumph of modern medicine” (222).

My wife died of metastatic breast cancer, and I deal with prostate and blood pressure issues. During the past decade, we had many conversations with a wide range of doctors and consultants. Our experience has been increasingly along lines that are consistent with Hatch’s recommendations. We would have been helped if we had been able to read a book like Snowball in a Blizzard.

This book is a key to good health!