| Recently, I
heard the presentation of a patient who had elevated
blood pressure, elevated blood lipids, and elevated blood
glucose, and the discussion centered on appropriate
treatment to lower the elevated levels. The patient was
discussed for 30 minutes before I heard the patient's
body weight and height mentioned. It turned out that her
body mass index was 33. This patient's problem was not
elevated blood lipids, pressure, and glucose: her problem
was obesity. Nothing improves cardiovascular and diabetic
health like maintaining an ideal body weight or losing
weight if one is overweight. ATKINS, ORNISH,
BETHEA, SEARS, AND McDOUGAL
On February 24, 2000, Agriculture Secretary Dan
Glickman sponsored the Great Nutrition Debate. The
debaters included cardiologist Robert Atkins, whose
program, outlined in Dr. Atkins' New Diet Revolution,
encourages dieters to eat bacon, pork, steak, butter,
cheese, olives, nuts, and other high-fat, high-protein
foods and to avoid carbohydrates, including pasta,
sweets, some starchy vegetables, and many fruits (2).
Another debater was Dean Ornish, an internist originally
from Dallas, who wrote Eat More, Weigh Less. He
promotes the use of a very low fat diet--fruits,
vegetables, brown rice, whole grain pasta, soy products,
and some fish--for the prevention of heart disease. He
advises limiting meat, poultry, egg yolks, high-fat
cheese, and simple carbohydrates, such as sweets and
white bread. Other debaters were cardiac surgeon Morrison
Bethea, one of the authors of Sugar Busters;
biochemist Barry Sears, coauthor of The Zone; and
internist John McDougal, author of The McDougal
Program. I subscribe to the Dean Ornish plan.
The Atkins plan, in my view, will prove to be
detrimental in the long run. It originally appeared in
1978, and as yet there are no outcome studies concerning
it. I understand that the National Institutes of Health
is considering sponsoring such a study. Although dieters
on the Atkins diet may lose weight, it's mainly water
weight. They lose weight primarily because they have lost
their appetites and decreased total caloric intake.
Although telling people that pork rinds and sausage are
good for them is a great way to sell books, it is
irresponsible and dangerous. If a diet sounds too good to
be true, it probably is. The Atkins diet produces bad
breath, bad body odor, constipation, lethargy, and
occasionally lightheadedness.
In contrast, it is clear that when people switch from
a meat-based, high-protein diet to one that is based on
whole foods and plant foods, the risk of heart disease,
stroke, and some types of cancer, such as breast and
prostate gland, is reduced. In Barry Sears' new book, A
Week in the Zone, he recommends eating 10 to 15
servings of fruits and vegetables a day, eating adequate
amounts of protein, and treating pasta, bread, grains,
and starches like condiments. Bethea's Sugar Busters
is a commitment to choose correct carbohydrates. He
emphasizes eating whole grains and few sweets, not
processed grain products that have had their fiber and
nutrients removed. He advises eating lean and trimmed
meats--preferably baked, boiled, or grilled--and eating a
lot of high-fiber vegetables, fruits, and whole grains. I
congratulate the secretary of agriculture for pulling
these diet authors together. Possibly his department
would be willing to sponsor a study to see whether the
high-protein and low-carbohydrate diets actually have any
scientific benefit. The low-fat diets have been proven to
have health benefits. On the other hand, weight loss is
beneficial irrespective of the means by which it is done.
WILLIAM BANTING, WILLIAM HARVEY, AND THE
VICTORIAN WEIGHT LOSS DIET
Gary Critser (3) provided the following story in a
recent piece in USA Today. A high-protein,
low-carbohydrate diet was first popularized in 1863 by
William Banting (no relation to the discoverer of
insulin), a retired London undertaker who weighed 202
pounds and measured 65 inches in height (body mass index,
34). For decades he had struggled with obesity
(corpulence), and at age 60 he was near his wit's end. He
had to walk down stairs backwards, “and with every
exertion puffed and blowed in a way that was unseeming
and disagreeable.”
One day in 1862, Banting had a serendipitous encounter
with a young physician named William Harvey (not the
17th-century Harvey of blood circulation fame). Harvey
had spent time in Paris during the 1850s studying under
Claude Bernard. One of Bernard's ideas was that the liver
secreted glucose. As Harvey understood it, “this
glucose could be directly produced in the liver by the
ingestion of sugar and starch and . . . [because] a
purely animal diet greatly . . . checked the secretion of
diabetic urine . . . it occurred to me that if a purely
animal diet was useful in the latter disease, a
combination of animal food with such vegetable matters as
contained neither sugar nor starch might serve to arrest
the undue formation of fat.”
That is exactly what he prescribed to Banting. It was,
in short, the first time anyone had formally prescribed a
low-carbohydrate diet for weight loss. In less than a
year, Banting had lost 46 pounds and pronounced himself
“cured” of his “insidious creeping
enemy.” Convinced that his mission in life was to
help his fellow corpulents onto what he called his
“tramway of happiness,” Banting wrote a short
account of his experience and cure, A Letter on
Corpulence, Addressed to the Public. The response was
the first mass dieting craze. After 2500 copies were
given away, Banting's Letter went into 3
editions in as many years, selling upward of 100,000
copies. His name became a verb; until 1963, the Concise
Oxford Dictionary defined “banting” and
“to bant” as meaning “treatment of obesity
by abstinence from sugar and starch.”
Banting and Harvey did not want any publicity, and
Banting--fearing that “it might appear a puff which
I know he abhors”--refused to identify Harvey in his
first 4 editions. Moreover, when the money rolled in, it
became, in Banting's word, an “embarrassment.”
Banting donated all profits from his writing to charity
and in later editions of his pamphlet published all
criticisms he had received of the diet.
The diet was taken up in 1879 with great fanfare by
the Comte de Chambord, the expatriate king of France. De
Chambord quickly lost >50 pounds. But in 1883, the
Comte fell ill. Although the immediate cause of his death
still is unclear, his doctors all agreed that he had
undermined his health by losing so much weight so
quickly. Harvey had written: “Extremes should be
avoided. As a rule, the diminution should not be allowed
to progress more rapidly than at the rate of 1 pound per
week and it ought not to be carried to too great an
extent.”
By then, however, both Banting and Harvey were dead.
The latter had lived the productive life of a
physician-scholar. Banting had lived to age 81,
maintaining his reduced size. His success in doing so may
suggest a middle way for today's warring factions of
those for and against low-carbohydrate diets. Beginning
in the late 1860s, Banting had slowly shifted his diet in
the direction of reducing proteins and fats, controlling
portion size, and eating carbohydrates in moderation.
Later he wrote, “This deviation convinces me that I
have hold of the power of maintaining the happy medium in
my own hands.” In other words, science or not,
proteins or carbohydrates, it is human will and humane
advice--not bestsellers--that make for a good diet.
HEALTH BENEFIT OF VACATIONS
Gump and Matthews at the University of Pittsburgh
recently reported findings of the Mr. Fit study (4). The
participants, 12,338 men who were 35 to 57 years of age,
had no clinical signs of heart disease at the onset of
the study. The investigators asked them about vacations
every year for 5 years and then looked at the medical and
death records over 9 years for the men who had lived for
at least a year after the last vacation survey. Compared
with those who never took vacations, men going on annual
vacations were 21% less likely to die over the 9 years
and 32% less likely to die of coronary heart disease. The
more often the participants skipped a vacation, the
higher their risk of death. Go on a vacation!
WEIGHT GAINED IN PREGNANCY
According to the March 2000 National Vital Statistics
Report, during their pregnancy 22% of women gain <20
pounds, 32% gain 21 to 30 pounds, 27% gain 31 to 40
pounds, and 19% gain >40 pounds (5).
MOM'S GUM DISEASE AND PREMATURE BIRTH
At the American Academy of Periodontology conference
on May 7, 2000, in Washington, DC, a study of 3000
pregnant women with severe gum disease indicated that
they were 8 times more likely to have underweight
premature babies than moms with healthy mouths (6). The
likely culprit is prostaglandin, which is
labor-inducing and is present in dental plaque. The study
by Marjorie Jeffcoat of Alabama showed that prostaglandin
levels increased as gum infection worsened.
(Prostaglandin injections, of course, are used to induce
abortions.) Daily flossing plus good teeth and gum
brushing is the best prevention for gum disease.
EPISIOTOMY
Episiotomy, a small cut in the mother's perineum,
apparently is no longer routine (7). Once considered
“the kindest cut,” episiotomy has been
performed on millions of American women for its supposed
benefits. Surprisingly, statistics now suggest it was not
such a good deal, and many obstetricians are pulling back
from the procedure. The episiotomy rate at the
Massachusetts General Hospital has fallen to between 10%
to 15% of deliveries.
Episiotomy was invented in Europe in the 1740s and
popularized in the USA in the early 20th century. At that
time, however, obstetricians had few tools, fetal
monitoring was primitive, and rates of birth-related
injury to mother and child were much higher than today.
So to spare women the wear and tear of delivery,
obstetrician Joseph DeLee of Chicago Lying In Hospital
proposed that cutting a small incision would speed labor,
lessen trauma, and restore prepregnancy vaginal
conditions.
As childbirth moved from home to hospital during the
1940s, episiotomies took off. By the 1970s and 1980s, the
procedure was entrenched as a routine part of normal
delivery. It was performed on >60% of all women giving
birth in the USA, including 80% of first-time mothers.
Driven by faith and the rationale that a little cut could
prevent far more severe lacerations, it became one of the
most common surgical procedures in the country after the
cutting of umbilical cords.
But was the rationale scientifically sound? No one
actually knew. Obstetric practice before the advent of
randomized clinical trials in 1948 was more of an art
shaped by tradition. A review in 1983 from the US Centers
for Disease Control and Prevention (CDC) concluded that
arguments in favor of routine cutting--preventing
lacerations, protecting pelvic muscle tone, and
preserving sexual function--do not withstand scientific
scrutiny.
A clinical trial headed by Jose Belizan in Argentina
randomly placed >2600 pregnant women into 2 groups.
The women in one group got a routine episiotomy; the
women in the other group selectively got one based on
need. The study, published in 1993 in the Lancet,
found that pain and healing problems were actually more
common among women who were routinely given episiotomies
than in the group where it was restricted.
In a 1995 review, British epidemiologist Archie
Cochran indicated that routine episiotomy adds to the
trauma, suturing, and complications of delivery. More
recently, a study by Repke of Nebraska in collaboration
with colleagues at the Brigham and Women's Hospital in
Boston reviewed cases of 600 new mothers and found that
the women who had episiotomies had an increased risk of
intestinal problems for as long as 6 months after
delivery. They found that women with the incision had
even more complications than women who experienced
spontaneous tears during labor. That study was published
in the British Medical Journal in January 2000.
Episiotomies still are useful in emergencies: when a
baby is very large, labor is very long, or the fetal
heart rate is depressed. Some doctors do them when a bad
tear seems imminent. Others use them in deliveries when
instruments are needed to help the baby out. Episiotomy
shortens the last stage of labor by 10 to 20 minutes. So
when speed is needed to prevent injury or asphyxiation,
it can be essential.
As the pendulum of medical fashion swings from routine
to restricted episiotomies, physicians disagree about
what constitutes just the right amount of intervention.
Whatever that “right amount” is, it is clear
that episiotomy as a routine procedure for delivery is
gone.
OBSTETRICIAN'S INITIALS CARVED ON MOTHER'S
BELLY
Dr. Allan Zarkin was sentenced to 5 years' probation
for carving his initials into the belly of one of his
patients after delivering her child (8). The sentencing
occurred on April 25, 2000. Dr. Zarkin will be barred
from applying for a medical license for 5 years. The
patient was Dr. Liana Gedz, a dentist who was close to
Dr. Zarkin before the incident. She had earlier settled a
lawsuit against him for $1.75 million. After successfully
performing a caesarean section on Dr. Gedz at Beth Israel
Medical Center in New York City in September 1999, Dr.
Zarkin stunned nurses by carving his initials into Dr.
Gedz's belly. He was indicted in February 2000 and faced
up to 25 years in prison if convicted of the most serious
charge he faced, first-degree assault. The State Supreme
Court Justice in Manhattan cited Dr. Gedz's desire and
Dr. Zarkin's lack of a criminal record as reasons for
agreeing to the plea bargaining. In February 2000, the
State Department of Health fined Beth Israel Hospital
$14,000 and ordered it to improve its oversight of
physicians. Dr. Gedz plans to undergo plastic surgery to
obscure the carved initials on her belly.
HEARING LOSS IN NEWBORNS
Only 35% of newborns in American hospitals have their
hearing tested before they go home, and 33 infants a day
go home with undiagnosed hearing loss according to the
National Campaign for Hearing Health (9). At least half
of the newborns in 24 states have their hearing tested
before leaving the hospital. The campaign is to make that
universal in all states. New screening hearing tests cost
only $15 to $40 each. Babies do much better if hearing
deficiencies are diagnosed before 6 months of age. Maybe
parents should not take the baby home without knowing if
the baby can hear.
BABY ABANDONING
Tens of thousands of unwed birth mothers abandon their
unwanted babies every year (10). That's a crime in every
state except in Texas under certain conditions. So the
mothers often dump the babies, run, and hide. Dozens of
newborns are found dead in garbage cans or other trash
depositories every year. Most of those abandoned are left
in hospitals, in churches, or on doorsteps. Those babies
live and generally acquire loving adoptive parents. But
they lack medical records or parental background. In
1998, at least 31,105 babies were abandoned in the USA,
and 33 were found dead. It is believed that many more
dead babies are never found. Most of those found are
never identified.
A law enacted in Texas helps protect from prosecution
a mother who abandons her baby within 30 days of birth if
she delivers it safely and unharmed to a hospital or
other emergency medical center. Al Neuharth, the founder
of USA Today, believes that such a law is a
realistic way to save the lives of unwanted babies. Most
pregnant unwed mothers who give birth are scared. Child
dumpings are acts of desperation. Decriminalizing safe
child abandonment can save babies' lives and find them
families. It also can enable unfortunate unwed birth
mothers to find their place in society without fear.
Twenty-three state legislatures now in session, including
California, New York, and Florida, are considering
infant-abandonment laws similar to that in Texas. They
should enact them. So should the rest of the states and
the federal government. Good for you, Al Neuharth!
GENDER REASSIGNMENT
John Colapinto has written a compelling story, As
Nature Made Him: The Boy Who Was Raised as a Girl
(11). In 1966, a tragic accident in a Winnipeg hospital
resulted in Bruce Reimer's losing his penis. It was
burned beyond repair during cauterization. He and his
identical twin were born to very young parents.
Devastated, Bruce's parents sought out the advice of
experts, eventually coming to John Money at The Johns
Hopkins Hospital in Baltimore. A leading expert on human
sexuality, Money believed that gender was imposed not by
nature but by nurture. Although he had worked with
infants born with ambiguous genitalia, Money realized
that here was an opportunity to prove his theories. One
twin would be raised as a boy and the other as a girl. A
surgical castration was performed at age 22 months.
There was one problem. The new little “girl”
didn't feel or act like one, something that became
apparent when the child, now called Brenda, entered
kindergarten. Colapinto details Brenda's misery, her
social failures, the cruelty of other children, and the
enormous strain experienced by the family. Clearly, this
experiment in gender reassignment wasn't working, and the
multitude of psychiatrists consulted didn't help. But
Money continued to promote the experiment as a triumph,
encouraging other doctors to reassign genders to newborns
of ambiguous sexuality. He also pressured Brenda to have
more surgery.
Eventually, an older female psychiatrist befriended
the distraught “girl,” who insisted on
urinating standing up. By age 14, Brenda had had enough.
She had a double mastectomy to remove the breasts created
by female hormones and let her extended family know that
“she” was now David Reimer. The
“expert” here, namely John Money, was wrong. It
might be better to listen to small children.
CHILDHOOD POVERTY
A booming economy, huge tobacco settlements, and large
budget surpluses have done little to lift 1 in 5 American
children out of poverty, and 74% of those children in
1998 lived in families where at least 1 adult was working
(12). That rate is up from 61% just 5 years ago. The
number of children without enough food increased by more
than 3.7 million in the USA between 1997 and 1998. Nearly
12 million children lack health insurance. Only 1 in 10
children of the nearly 15 million families eligible for
child care assistance get aid. Roughly 850,000 children
are homeless. A record 547,000 children were in foster
care last year, a 35% increase since 1990. States have
not spent the billions of federal welfare funds designed
to ease poverty. Poor children are twice as likely to be
delivered at low birth weights and to die before reaching
their first birthday as nonpoor children. They are also
twice as likely to be abused or neglected and 3 times as
likely as the nonpoor to live in substandard housing.
Texas is not doing so well either. Texas is 50th in
the number of children with health insurance; 48th in the
amount of welfare given to poor people; 47th in the
number of children with up-to-date immunizations; 46th in
the number of children living in poverty; and 45th in the
number of women receiving early prenatal care according
to The Children's Defense Fund, the State of America's
Children: Yearbook 2000.
TEENAGE SLEEP
A new study shows that, on average, teenagers in the
USA are getting about 2 hours less sleep a night than
they need, putting them at risk for automobile accidents,
falling asleep in class, and general moodiness (13). The
National Sleep Foundation released a poll in March 2000
confirming that teens are staying up too late and waking
up too early.
How much sleep is enough? Sleep needs vary by age and
from person to person, but here are some general nightly
guidelines. Toddlers need 11 hours plus a 2-hour
nap during the day. Preschoolers need 11 to
12 hours. Half of preschoolers also nap during the day. School-aged
children need about 10 hours. Teens need an
average of 9 hours, although realistically they can
function on 8 hours. Adults generally need 8 hours
but needs vary. The average adult gets slightly under 7
hours on weeknights and 7.5 hours on weekends.
Sleep deprivation is a serious matter for teens. Of
the estimated 100,000 car crashes a year linked to drowsy
driving, almost half involved drivers aged 15 to 24
according to the US Department of Transportation's
National Highway Traffic Safety Administration. Students
who are tired, of course, are more likely to doze off in
class and are less able to concentrate, learn, and solve
problems. Sleep deprivation translates into impaired
performance.
Too little sleep also makes adolescents grumpy and
irritable at a time in their lives when they are already
on an emotional roller coaster. When adolescents don't
get as much sleep as they need, it changes their outlook
on life. Things that are happy and pleasant seem less so,
and things that are sad and unpleasant seem more so.
Teens, like adults, become more emotional when they are
sleep deprived. If something strikes them as funny, they
may get silly and giggly. If something is sad, they are
more likely to cry, and if they are frustrated or angry,
they have a harder time controlling their emotions. Maybe
schools need to teach children more about the importance
of sleep, and both parents and teens might try to cut
back on activities so sleep is not squeezed out.
WORK, WORK, WORK
For years there was a belief that physicians worked
longer hours than anyone else. That's no longer the case.
One of my sons works in Silicon Valley for a computer
firm (BroadVision), and he works at least 12-hour and
occasionally 15-hour days. He has told me that is typical
of his colleagues. Young lawyers apparently put in
similar days in their first few years. According to a
report in US News & World Report, the average
workweek (among salaried Americans working >=20 hours)
lengthened from 43 to 47 hours a week from 1977 to 1997
(14). Over the same years the number of workers putting
in >=50 hours a week jumped from 24% to 37%.
Scarcely a decade ago, Americans viewed the work
habits of the Japanese with some awe. Now according to a
recent report of the International Labor Organization,
the USA has moved past Japan to become the longest
working nation in the industrial world. The average
American now works the equivalent of 8 weeks a year
longer than the average Western European. In Norway and
Sweden, ordinary workers get 4 to 6 weeks of vacation and
up to a year of paid parental leave. In France, a 35-hour
maximum workweek is becoming the law of the land.
Work-happy America is enjoying unparalleled prosperity.
Unemployment is at a 3-decade low of 4.2%. In Western
Europe the unemployment rate by contrast is 10%.
Over the past century as a whole, physical work has
become easier, and work has become less physical.
White-collar workers, however long they work, have more
control over their time than factory workers do. In 1900,
men in America worked 10-hour days and 6-day weeks in
factories and even longer on farms; shorter hours were
mostly the lot of desperate people who couldn't find
work. Vacations were an exotic exception in 1900 and
enjoyed by less than 2% of the population. The USA, of
course, was built on a foundation of hard work as well as
natural bounty. As an immigrant nation, the USA benefited
from a large pool of workers self-selected for their
long-term goals and their readiness to endure hardship in
the here and now.
SAFETY DURING TORNADOES
The recent destructive tornado in Arlington, Texas,
stimulated investigation into safety during such events
(15, 16). The wind speed during tornadoes can be anywhere
from 70 to >260 miles per hour. At lower speeds, tree
trunks, tree limbs, and signs are broken. At higher
speeds, homes and buildings may be completely blown away,
cars disintegrated, and the ground scoured of trees and
grass.
The danger of a tornado is not simply the tornado's
wind but what's in the wind. There is really no good
place to hide during a tornado. Safety from a tornado
under the girders of a highway overpass is a myth. In
reality, this inadequate shelter is more likely to kill
than to save lives. When tornado winds squeeze under the
overpass, they speed up, increasing as much as 25%. The
shifting winds will most likely blast a person with
debris and then blow the person away.
The best shelter in a tornado is a basement or an
interior room on the lowest floor of a sturdy building.
If caught in the open when the tornado is spotted, it is
best to drive perpendicular to the tornado if possible to
get out of its path. If there is time, the car should be
abandoned and a permanent building sought. Vehicles can
become airborne or roll over, so they are not good
tornado shelters. Abandoning a car for a ditch means
being in the open and therefore a target for debris.
Thus, a ditch should be a “last ditch” action,
the last resort. Some experts believe it's even better to
stay in a vehicle than to leave it for a ditch. If a
permanent shelter is found, it's good to cover oneself
with a mattress or at least a blanket. Tornadoes in Texas
are most frequent, of course, in April, May, and June.
GUNS IN HOMES
The number of guns in homes is declining. In 1968,
apparently 50% of homes in the USA had guns according to Sourcebook
of Criminal Justice Statistics, 1999 (17). By 1983,
the percentage had fallen to 40%, but in 1993 it had
risen again to 51%. In the last 6 years it has fallen to
36%.
HOMICIDE AND ROBBERY RATES
Homicide and robbery rates decreased nationwide from
1991 to 1998 (18). In 1991, the homicide rate in Dallas
was 48.64 per 100,000, and by 1998 it had fallen to 23.14
per 100,000, a 52% decrease. The robbery rate in Dallas
in 1991 was 1095 per 100,000, and in 1998 it had fallen
to 540 per 100,000, a 51% drop.
ACCIDENTAL DEATHS
The number of accidental deaths in homes and public
places other than roads rose 21% from 1992 to 1999,
according to the National Safety Council, which
attributed much of the increase to a larger number of
elderly people prone to falls and more drug overdoses
(19). The number of unintentional deaths in those places
rose by 3800 (8%) in 1999 over 1998. One quarter of the
people who fall and fracture a hip die within a year of
the fall, and half never return to their prior level of
mobility or independence. Fatal falls rose to 15,900 in
1999 compared with 12,100 in 1992. Poisonings from solids
or liquids rose to 9500 from 6400. Death rates from
poisoning for people <25 years of age were constant,
but rates rose 40% among those aged 25 to 44 and 111%
among those aged 45 to 64. The rate among people aged
>=65 fell 23%. Illegal drugs were responsible in 37%
of the poisonings in the persons aged 45 to 64. The
number of unintentional firearm deaths fell by about 100,
to 900, in 1999 compared with 1998.
TRAFFIC FATALITIES
Americans are logging an unprecedented number of miles
behind the wheel, but the death rate on US roads dipped
to its lowest in 1999 (20). Overall, 41,345 people died
on US highways in 1999. That's the lowest number in 5
years. Although Americans drove more than 2.6 trillion
miles last year, the fatality rate dipped to 1.5 per 1
million miles driven, the lowest rate since the
government began keeping track in 1966. The fatality rate
based on population also hit a record low, 15.2 deaths
for every 100,000 people. Alcohol was involved in 15,794
deaths, or about 38%, of all highway fatalities last
year. That's the lowest number of alcohol-related highway
fatalities recorded. Seat belts were worn regularly by
67% of Americans in 1999 compared with 70% in 1998. At
least 63% of those killed in traffic accidents in 1999
were not wearing seat belts. The number of pedestrians
killed in 1999 dropped 10%, from 5220 in 1998 to 4695 in
1999. Fatalities involving trucks dropped to 5203 last
year from 5374 in 1998. Motorcycle crashes killed 2537
people in 1999 compared with 2284 in 1998. The number of
people injured in crashes was the same in 1999 and 1998:
3.2 million. The best remedy appears to not drive too
much or, if driving, to wear a seat belt, get plenty of
sleep beforehand, and avoid alcohol.
GLOBAL AVIATION SAFETY
USA Today did a computer search of 2300
publications worldwide, the Associated Press wire, and
aviation databases for accidents and incidents in the
month of February 2000 (21). There were 3 findings. 1) An
average of 3 times each day, a safety-related accident,
incident, or threat was reported. For US-based airlines
flying about 22,000 flights a day, the average was at
least 1 per day. 2) Airlines worldwide made at least 35
emergency landings. US airlines made at least 20 of them.
3) Most incidents probably went unreported. Most
countries did not show up even once in the search.
Most incidents that were found happened in the USA,
one of the countries that aviation experts say has the
highest safety standards. Federal Aviation Administration
inspectors find or take administrative action against US
passenger airlines an average of 170 times a month for
violating safety rules. In February 2000, the Federal
Aviation Administration issued at least 40 directives
ordering airlines to inspect or correct an unsafe
condition in a plane or a part. Thus, although the odds
of being in a fatal airline crash are extremely small,
less serious accidents and incidents occur almost daily
worldwide.
KENTUCKY AND TOBACCO
Of the 50 states, Kentucky is number 1 in smoking and
number 2 in tobacco growing (22). More than 30% of
Kentucky adults smoke. The national rate is 23.2%
according to the CDC. Kentucky produced 400 million
pounds of tobacco in 1999, second only to North
Carolina's 429 million. In May 2000, Kentucky launched
its first statewide kick-the-habit campaign with an
initial goal to fall to number 2 in its smoking rate. It
will spend $5.5 million over 2 years on smoking
prevention programs, $25 million less than the CDC
estimated Kentucky should be spending considering the
size of its smoking habit. Nevertheless, this is the
first time Kentucky has attempted a statewide antismoking
campaign. Kentucky also has the highest rates of youth
smokers and smoking-related deaths and runs up $800
million a year in medical bills for smoking-associated
illnesses according to the CDC.
CIGARETTE TAXES
The average state tax on cigarettes was 34? per pack
in 1999 (23). States with the highest cigarette taxes per
pack include Alaska, $1.00; Hawaii, $1.00; California,
87?; Washington, 83?; New Jersey, 80?; Massachusetts,
76?; Michigan, 75?; Maine, 74?; Rhode Island, 71?;
and Oregon, 68?. The states with the highest taxes per
cigarette pack tend to have the lowest cigarette smoking
rates. Despite these taxes, cigarette-related illnesses
in smokers are inadequately paid for by the smokers.
MORE ON ALCOHOL
The nation's drug czar has purview over heroin,
cocaine, and marijuana, but not alcohol (24). A policy
research group called Drug Strategies has produced a
report that calls alcohol “America's most pervasive
drug problem.” Alcohol-related deaths outnumber
drug-related deaths 4 to 1. Alcohol is a factor in more
than half of all domestic violence and sexual assault
cases. Between accidents, health problems, crime, and
lost productivity, researchers estimate that alcohol
abuse costs the economy $167 billion a year. In 1995, 4
of every 10 people on probation said they were drinking
when they committed a violent crime, while only 1 in 10
admitted using elicit drugs. The argument for not putting
alcohol under the nation's drug czar is that heroin,
cocaine, and marijuana are harmful and against the law
but alcohol is used in moderation with no ill effects by
many people. The counterargument is that an enormous
number of people can't and never will be able to drink in
moderation, and that number may be as high as 10 to 15
million Americans.
PREVENTIVE CAT SCAN SCREENING
The CAT scan, designed to diagnose illness, is gaining
use among people who feel fine (25). Some physicians are
promoting it as the most credible provider of a clean
bill of health and the surefire detector of incipient
disease. Never mind that insurance does not cover it on a
preventive basis. The number of CAT scans--which reached
26 million in the USA in 1997, the most recent year for
which figures are available--has been rising by about a
million a year, and a big chunk of that growth is coming
from seemingly healthy Americans willing to fork over
$700 of their own money for it. The US Army this year is
spending $1 million to provide preventive screening for
4000 soldiers as part of routine physical examinations.
The army hopes to gain sufficient funding to cover
full-body scans for all its troops, according to the
surgeon general of the army. The union representing Los
Angeles police officers has arranged for a $190
discounted rate for its healthy members to get a scan.
Kenneth Cooper, head of the Cooper Clinic in Dallas, is a
major proponent of CAT scanning.
Critics see more at stake than the out-of-pocket
expenses. Results riddled with false positives can turn
healthy CAT-scanned customers into patients, forcing
insurance companies to provide coverage of unnecessary
and potentially dangerous biopsies and other procedures.
Critics say the problem is that almost any medical
treatment applied to the masses will produce startling
results in a few. The question is whether the benefits
for those few outweigh the total cost. The same treatment
that saves a few lives can ruin a few more. Moreover,
it's rarely clear that a life has been saved. A malignant
tumor found in a CAT scan may have sat dormant for years
and might never have grown threatening. But the discovery
of a tumor, indolent or not, almost certainly sets in
motion a set of exploratory procedures that themselves
could prove life threatening. Without question, early
detection is crucial in certain kinds of cancers.
Proponents say this opposition to CAT scan screening
is reminiscent of early resistance to mammograms, which
many physicians insisted were useless until overwhelming
evidence emerged to the contrary. As technology plays a
larger and larger role in diagnosing illness, the role of
physicians, especially internists, could shrink.
Whole-body CAT scans for someone without symptoms may not
be routine in 2000, but I suspect by 2010 they will be
used far more frequently.
ORGAN TRANSPLANTS AND WAITING PERIODS
In 1997, the nationwide average waiting period to
receive a donated heart was 740 days; for a kidney, 962
days (26). Nearly 70,000 people in the USA are on waiting
lists for organs, a number that has more than tripled
since 1990. The number of donated organs each year, about
20,000, has remained steady during the 1990s.
THE CLONED-PIG CAPITAL OF THE WORLD
The cloned-pig capital is Blacksburg, a city of nearly
40,000 residents in southwestern Virginia and the home of
Virginia Polytechnic Institute and State University (27).
Scientists and PPL Therapeutics, a subsidiary of the
Scottish firm that cloned Dolly the sheep in 1997,
announced in March 2000 that they had cloned 5 pigs at
their research facility in Blacksburg. The pigs were
created through a process that involves fusing an adult
pig cell with another pig's egg cell, the DNA of which
has been removed. The resulting embryo is then inserted
in a surrogate sow. In winning the international race to
clone pigs, the Virginia-based PPL team heralded a
revolution in cross-species transplantation. In the past
3 years, sheep, cattle, and mice have been cloned in
Scotland, Virginia, and Hawaii, but scientists have been
vying to clone pigs because their organs are more
compatible with human organs.
The market for pig organs could exceed $6 billion a
year. Pig hearts and kidneys fit for transplant are
estimated to cost around $50,000 a piece. The scientists
at PPL say this month's breakthrough could end a global
shortage in hearts, kidneys, livers, and other organs
needed by thousands of people worldwide, including about
70,000 in the USA. An official of PPL expects the company
to begin clinical trials for pig-to-human organ
transplants in 4 years. To breed successful organ donors,
scientists must now work on genetically altering
problematic pig cells, including eliminating a pig gene
that adds a sugar group to pig cells that is rejected by
the human immune system and adding at least 3 genes to a
cell to prevent delayed rejection of pig organs.
Meanwhile, the world's first cloned piglets are living
the life of celebrities. When they're not hamming it up
in front of cameras, the piglets are suckled by their
surrogate mother, Destiny, in a secret barn in
Blacksburg, hidden from animal rights activists and other
potential threats. The prospect of breeding pigs as organ
donors gives some Blacksburg residents the creeps. Those
people having the creeps, however, will be very happy if
they need a new organ. This research is clearly at the
cutting edge. Pigs appear to be the big hope of
transplantation.
FRUIT FLY'S DNA IS MAPPED
The March 24, 2000, Science announced that the
entire gene sequence, or DNA coding, of the fruit fly has
been completed (28). The fruit fly has been used as a
model for human biology for a century. The researchers
also found that it possesses genes similar to 60% of the
genes known to cause human diseases, including cancer and
Parkinson's disease. The study, called the Berkeley
Drosophila Genome Project, was done at the University of
California, Berkeley. The entire gene sequence was not
expected to be completed until 2002. The drosophila
blueprint, about 13,600 genes, is in a database at the
National Institutes of Health. Scientists and companies
can use it for research and drug development.
EXPIRATION DATES ON MEDICINES
Fifteen years ago, the US military decided to find out
if drugs stopped working after the date stamped on the
bottle (29). Sitting on a $1 billion stockpile of drugs
and facing the possibility of destroying and replacing
its supply every 2 or 3 years, the military began a
testing program to see if it could extend the life of its
inventory. The testing, conducted by the Food and Drug
Administration, ultimately covered more than 100 drugs,
both prescription and over-the-counter. The results,
never before reported, showed that about 90% of them were
safe and effective far past their original expiration
date. At least one drug worked 15 years after its
expiration date.
Thus, the expiration dates put on drugs by
manufacturers typically have no bearing on whether they
are usable for longer periods. The drug maker is required
to prove only that a drug is still good on whatever
expiration date the company chooses to set. The
expiration date does not mean, or even suggest, that the
drug will stop being effective or will become harmful
after that date. Manufacturers may put expiration dates
on for marketing rather than scientific reasons.
Turnover, of course, is more profitable than products on
a shelf for 10 years.
Drug industry officials apparently do not dispute the
results of the Food and Drug Administration's testing,
within what is called the Shelf Life Extension Program.
They also acknowledge that expiration dates have a
commercial dimension. Drug manufacturers say, however,
that relatively short shelf lives make sense from a
public safety standpoint. From the companies'
perspective, any liability or safety risk is diminished
by limiting the period in which the consumer might misuse
or improperly store a drug. It is not known how much of
the >$120 billion spent annually in the USA on
prescription and over-the-counter medicines goes to
replace expired drugs. A poll done for the Wall Street
Journal showed that 70% of 1000 respondents said they
would not take a prescription drug after its expiration
date; 72% said the same of an over-the-counter remedy.
Some people apparently believe that drugs suddenly turn
toxic or lose all of their potency upon expiration. This
simply is not the case.
BLOOD TRANSFUSIONS
According to the World Health Organization (WHO),
about 75 million pints of blood are given worldwide each
year (30). More than half that amount, 45 million pints,
are given in the richest third of the world's countries.
The poorest third account for just 1.3 million pints.
More than half of the world's countries fail to perform
full tests on donated blood, increasing the risk of
spreading AIDS and other diseases, according to the WHO.
About 5% to 10% of people with the AIDS virus are
estimated to have been infected via blood transfusions.
Only 43% of the WHO's 199 member states test blood for
HIV/AIDS, hepatitis B, or hepatitis C. Malaria and
syphilis also can be transmitted through transfusions.
Each year, unsafe transfusions and injection practices
are estimated to account for 8 to 16 million hepatitis B
infections, 2.3 to 4.7 million hepatitis C infections,
and 80,000 to 160,000 HIV infections. If one needs a
blood transfusion, it's a good idea to be a patient in
the USA.
HIV/AIDS
According to Global Infectious Disease Threat and
Its Implications for the United States, prepared by
the National Intelligence Council (http://www.cia.gov/cia/publications/nie/report/nie99-17d.html),
>33 million people on earth are living with AIDS or
infected with HIV: 23.3 million live in sub-Saharan
Africa and another 6 million in South and Southeast Asia
(31). An estimated 650,000 to 900,000 people in the USA
have HIV/AIDS. By 2010, Asia and the Pacific could
surpass Africa in the number of HIV infections. In India
alone, the number could be as high as 40 million in a few
years. Russia's HIV-infected population could exceed 1
million by the end of 2000 and double yet again by 2002.
HIV/AIDS is undermining economic growth in Africa and
could cause more political destabilization. It appears
that HIV/AIDS is more effective than war in destabilizing
certain countries.
SAVING MONEY AND IMPROVING HEALTH
The personal savings rate in the USA has been
declining steadily over the past few decades, and
recently the savings rate dipped into negative territory
(32). The savings rate in the USA is the lowest among
industrialized nations. The US Census Bureau recently
reported that half of American families have net
financial assets of <$1000. Personal bankruptcies
continue to climb despite low unemployment rates and the
soaring stock market of the past few years. The best
long-term solution to the nation's savings crisis is to
teach our children good financial habits. The foundation
of saving, of course, is delayed gratification. An
accessible nonbreakable bank is a good beginning.
Matching money saved by a child is an added incentive.
When my grandchildren were about 5 years of age, I
wrote each a check for $10 with the understanding that if
they retained that check and returned it to me the next
year, I would double the amount. If they retained that
check until the following year, I would double the amount
again. By doubling the amount for 12 years and assuming
no interest or dividends collected, the account would
have $20,480 in it. Assuming that that money would double
each 7 years thereafter, the account would be worth over
$5 million when the child reaches age 65. It would
actually be more than that because of interest and
dividends accrued during the first 12 years. Most health
bills start accumulating after age 65. Sixty years from
now $5 million will probably be able to pay for pretty
good health insurance, assuming we don't have any radical
change in our health care delivery system by that time,
something which is certainly unlikely.
DINOSAURS WERE WARM-BLOODED ANIMALS
In April 2000 in South Dakota, a heart the size of a
grapefruit was discovered in a natural sarcophagus of
stone in the chest cavity of a dinosaur's fossilized
skeleton (33). A report of the discovery was published in
the April 21, 2000, issue of Science. Examining
this stony material with computerized imaging techniques
disclosed that the heart was more like that of a bird or
a mammal than any known reptile. The evidence for a
4-chambered heart with a single aorta strongly suggests
that this dinosaur, and perhaps many others, had a higher
metabolism than previously believed. If this is true,
dinosaurs may have been warm blooded instead of cold
blooded like reptiles and thus could have engaged in more
sustained activity in foraging and fighting, chasing
prey, or escaping predators. Such advanced hearts are
capable of distributing oxygenated blood more completely
throughout the body. The finding also seems to strengthen
the hypothesis that some dinosaurs were ancestors of
today's birds, which are warm blooded.
Fossils retain the original shape and structure of the
body part, if not the original matter and cellular
structure. Scientists suspect that when this dinosaur
died, it was almost immediately buried in waterlogged
sand, perhaps the sediment beneath a stream. Submerged in
such an oxygen-poor environment, some of the animal's
tissues petrified before decomposition set in. Unlike
teeth and bones, the tissues of organs usually rapidly
decay before they can be fossilized through mineral
replacement. Previously, the only known internal traces
of a dinosaur were fossilized intestines found in
sediments from a former lake bed in Italy. The most
recently found dinosaur was a 660-pound, 13-foot-long,
plant-eating animal that lived and died not long before
the extinction of all dinosaurs, which occurred about 65
million years ago.
What makes the discovery especially surprising and
puzzling is that the heart resembles a mammal's or a
bird's but belonged to an ornithischien, or bird-hipped,
dinosaur, one of the 2 main lineages of these great
animals. Despite the name, these dinosaurs were far
removed from those that are presumed by many
paleontologists to have been ancestors of birds; these
ancestors are presumed to be theropods, members of the
other main lineage known as the saurischien, or
lizard-hipped, dinosaurs. Thus, it is possible that
dinosaurs of both lineages--not just the bird
ancestors--had advanced hearts and high metabolisms.
CHIEF EXECUTIVE OFFICER COMPENSATION
USA Today analyzed compensation packages at 389
of America's largest companies and published details of
the top 200 compensation packages on April 5, 2000 (34).
The pay included salary, bonuses, long-term incentives,
other compensation, and the value of restricted stock
awards. The 1999 compensation for Timothy Koogle of Yahoo
was $1.7 billion and for Steve Case of America Online,
$1.1 billion. That works out to >$4 million a day
compared with the US median household income of about
$40,000, or $110 a day. Seven of 1999's 10 most highly
compensated chief executive officers (CEOs) run
technology companies, and the other 3 oversee new economy
transformations. The median compensation package of 200
highly paid big-company CEOs jumped to $17.6 million in
1999, up 111% from a similar group of CEOs in 1998. Four
of the 10 highest compensated CEOs are <=50 years of
age. The median compensation last year for an old economy
CEO was $13 million and for a new economy CEO, $46
million. In contrast, the median salary for a special
education teacher is approximately $40,000. President
Clinton was paid $200,000 in 1999, and Tiger Woods made
$49 million in 1999. Something seems a bit out of kilter
here.
BASEBALL SALARIES
Each of the 30 major league teams has 25-man rosters
plus those on the disabled list. The year 2000 salary
survey revealed that only 14% of the players accounted
for more than half of the player payroll for the 30 major
league clubs (35). The average salary was $1,983,849 in
2000, up from $1,724,310 in 1999, an increase of 15%. The
median salary was $700,000, up from $495,000 in 1999, a
rise of 41%. The New York Yankees have the highest
payroll, namely $92.9 million, almost 6 times Minnesota's
$15.7 million, the lowest figure. The highest paid player
is Los Angeles ace right hander Kevin Brown, at $15.7
million. Of the 2000 players, 382 were paid at least $1
million. The highest paid position on average is first
base at $2.88 million. The lowest paid are catchers at
$1.37 million on average. If money is your game, it's
better to be a great baseball player than a great
physician. Most physicians today know more about the
great baseball players than about the great physicians.
ONLINE HEALTH DATA
About 60 million Americans looked for health
information online in 1999 (36). Some of the most
researched health conditions included depression (19%),
allergies or sinus problems (16%), cancer (15%), bipolar
disorder (14%), arthritis (9%), heart disease (8%), and
sleep disorders (8%).
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