William C. Roberts, MD

Oxygent is a milky white concoction now being used in clinical trials, and it appears to be headed for federal approval and widespread use (1). It is an oxygen carrier, not a blood substitute, but it delivers oxygen in ways that are often better than those of the body's own red cells. It is made by Alliance Pharmaceutical Corporation of San Diego. There appears to be growing optimism that Oxygent and other oxygen carriers might finally provide a safe alternative for donated blood and ease the strain on the nation's overtaxed blood banks.

The US blood supply is chronically low. American blood banks are expected to come up about 250,000 units short in 2000. Donated blood is good for only about 42 days, and <5% of eligible donors give blood. While blood is a scarce resource, it also comes with a risk. Donated blood cannot be 100% safe. Hepatitis C is transmitted about once in every 100,000 transfusions and HIV, about once in every 675,000. There are 11 million transfusions a year in the USA.

If Oxygent is approved for use in surgery, it is likely that it will be used “off label” for other purposes, such as in stroke patients. One recognized adverse effect of Oxygent is that patients sometimes get flulike symptoms, and platelet counts usually drop several days after Oxygent has been administered. Alliance hopes to have tested Oxygent on >1000 patients by the end of 2000. More trials, including trials of emergency room administration, will likely follow. Even so, side effects that occur only once in 10,000 cases might remain hidden. Eventually, the Food and Drug Administration (FDA) must decide if the risk of what is still unknown outweighs the benefit of a substitute for blood.

BLOOD DONORS

A blood transfusion is needed in the USA every 2 seconds (1). Donors can give blood every 56 days if they are >=17 years of age, weigh >=110 pounds, and are in good health. To find the nearest blood center or blood drive, call 800-448-3543 or 888-256-6388. Donating blood regularly is good for the heart and increases longevity. One study showed that men who donate at least 1 pint a year reduce their risk of heart attack substantially, up to 85%. Some researchers believe that the differences in frequency of atherosclerotic coronary heart disease between men and women are not due to differences in hormones but to the benefit women derive by shedding old red blood cells during their monthly cycles. When blood is lost, either through menstruation or donation, the body makes flexible new erythrocytes. The body replaces the donated pint of blood in about 12 days. Young red blood cells are more flexible than older ones and therefore pass through capillaries more easily.

ANGER EPIDEMIC

Bad tempers are on display everywhere--roads, airplanes, biker trails, surfer waters, grocery stores, and sporting activities (2). The anger epidemic in its mildest form is unsettling and at its worst, deadly. Stress apparently is a hallmark of the anger epidemic, and the major contributing factors are time and technology. There is not enough of the first and there is strong fallout from the second. Cellular phones, pagers, and high-tech devices allow us to be interrupted anywhere and at any time. Constant accessibility and compulsive use of technology fragment what little time we have, adding to our sense of urgency, emergency, and overload. Office workers arrive to find dozens of e-mail messages that must be processed before the business day can start. There are now 273 million Americans, and our roads were not built to accommodate that many people. Many shopping parking lots are filled. It is hard to get into the bank. The airline carriers tell us to arrive 90 minutes before flights. Parking is at a premium at airports. Overcrowding has become part of our society. Most people are impatient while waiting in lines. When someone is in a rush and another person slows that person down, the person in a state of “hurry sickness” can get extremely angry.

We are going through one of the greatest periods of change in history. Change of any sort, of course, is stressful. There also is a loss of privacy. Computer records make it possible for bosses to monitor and record everything one does at work. E-mail messages can be retrieved, Web sites visited can be tracked, and the volume of work can be documented. Some believe that there is an increasing sense of entitlement today. Materialism, consumerism, and advertising have joined together to create very high expectations for the good life and a belief that we all are entitled to these expectations. This view may lead to a belief that life should be easy: People should get out of my way, or my child should win this game. And, finally, there might be a lack of connection. Families are not doing things together like in the past. Instead, parents are getting kids involved with activities that have rules and structure. The family is no longer the private place where people spend time relating. The USA is a nation of overstressed people.

ESCHERICHIA COLI, SUMMER, AND THE BOVINE SLAUGHTERHOUSE

Escherichia coli 0157:H7 is 10 times more prevalent in the summer than previously thought. At this time of year, as many as 1 in 4 cattle being herded into the slaughterhouses in the USA harbor the deadly human pathogen (3). The bacteria proliferate in warm weather. Before meat reaches consumers, the cattle and their carcasses are scrubbed, washed, rinsed, and steam pasteurized in an effort to remove or destroy the bacteria. Nevertheless, some tainted meat still reaches consumers. The bacteria kill an estimated 60 Americans each year and sicken an estimated 73,000, mostly children and the elderly.

The microbe first appeared in cattle in the late 1970s and now shows up in entire herds. Cattle carry the bacteria on their hides as well as in their intestines. About 40% of skinned carcasses now test positive prior to being eviscerated, suggesting that the microbes are being spread within the facility. By the time the carcasses are cleaned and sent to a cooler to be readied for processing, E. coli is still present in 2% of the sampled carcasses. The US Department of Agriculture, which mandated testing of ground beef after an E. coli outbreak in the Pacific Northwest 7 years ago, is negotiating with packers on the new set of testing requirements that were announced in summer 2000. The bottom line for the meatpacking industry is that it has to assume that its cattle are contaminated. The cattle industry and the meatpackers are not required to monitor either the cattle or the carcasses for E. coli. The modern beef slaughterhouse fundamentally is similar to the place described by Upton Sinclair 95 years ago in The Jungle!

The roar of the machinery, the odor of blood and raw flesh, the sight of cattle dangling in the air, blood spilling from their slashed throats, overwhelm visitors. The “kill floors” of some present-day plants are as long as a football field and nearly as wide. A special circulation system is designed to keep dust and bacteria from spreading from freshly slain cattle to exposed carcasses. Live cattle are killed one by one and then hoisted onto a conveyor that carries them through the plant's “beauty parlor” where car-wash-like scrubbers remove mud and bacteria-carrying manure from the hide. From the “beauty parlor” the cattle are bled and then skinned. The hide is removed piece by piece to avoid contaminating the exposed flesh. The tail is bagged in a plastic sheath to prevent it from flopping forward and contacting the skinned belly. The carcasses are then rinsed with an organic acid, eviscerated, steam vacuumed, sawed in half, washed again, and finally scalded with steam before heading to the cooler.

The US Department of Agriculture does not track the sanitation methods used by beef processors. Industry experts say the 4 largest packers that control 80% of the nation's cattle slaughter use one or several of the processes, including steam pasteurization. One sure way of destroying microbes is for processors to irradiate ground beef. They got governmental approval this year to start doing that, and the product is being tested in a few markets. How consumers will accept irradiated meat is unclear, and the technology has not advanced enough for companies to do it on a large scale.

Ground beef is the most common source of E. coli bacteria, but not the only one. Fruits, vegetables, and drinking water also can harbor the deadly pathogen. How can we prevent E. coli infections? Cook all ground beef and hamburger thoroughly. Ground beef can turn brown before the bacteria are killed, so it should be heated until a thermometer inserted into several parts of the patty, including the thickest section, reads >=71.2?C (160?F). Do not eat undercooked hamburger or other ground beef products. To avoid spreading the bacteria at home, keep raw meat separate from ready-to-eat foods. Wash hands, counters, and utensils with hot, soapy water after touching raw meat. Never place cooked hamburgers or ground beef on unwashed plates that held raw patties. Wash meat thermometers in between tests of patties that require further cooking. Drink only pasteurized milk, juice, or cider. Wash fruits and vegetables thoroughly, especially those that will not be cooked. People with depressed immune systems should avoid eating alfalfa sprouts. Drink municipal water that has been treated with chlorine or other effective disinfectants and avoid swallowing lake or pool water while swimming.

THE PORCINE SLAUGHTERHOUSE

Charlie LeDuff, a New York Times reporter, briefly worked at the Smithfield Packing Company, the largest pork-processing plant in the world located in Tar Heel, North Carolina. The following are some of his observations (4). It's called the “picnic line”: 18 workers line up on both sides of a conveyor belt, carving meat from bone. Up to 16 million shoulders a year come down that line. That works out to about 32,000 a shift, 63 a minute, 1 every 17 seconds for each worker for 8.5 hours a day. The Smithfield is a 973,000-square-foot leviathan of pipe and steel near the Cape Fear River, located 75 miles west of the Atlantic and 90 miles south of the Research Triangle around Chapel Hill. The factory towers over the adjacent tobacco and cotton fields. It was built 7 years ago and is the biggest employer in the region. The workers punch the clock at 5 am and the whistle blows at 3 pm. The workers get home by about 4 pm, pour peroxide on the nicks, take pills for the pain, and stand in a hot shower trying to wash it all away. By 8 pm they are in bed, exhausted.

The first thing learned in the hog plant is the value of a sharp knife. The second thing is that you don't want to work with a knife. Finally, one learns that not everyone works with a knife. The few whites on the payroll tend to be mechanics or supervisors. A few Indians are supervisors; others tend to get clean menial jobs like warehouse work. With few exceptions, that leaves the blacks and Mexicans with the dirty jobs, some of the few available within a 50-mile radius in which a person might make >$8 an hour. While Smithfield's profits nearly doubled in the past year, wages remained flat. As a result, many Americans at this plant have quit, and a lot of Mexicans have been hired to take their places. The new applicants are told to “treat the meat like you're going to eat it yourself.” The Smithfield plant will take about any man or women with a pulse and a clear urine sample, with few questions asked. Reporter Charlie LeDuff was hired using his own name. He acknowledged that he was currently employed but was not asked where, and he did not say.

Slaughtering swine is repetitive, brutish work, so grueling that 3 weeks on the factory floor leave no doubt why the annual turnover is 100%. Five thousand quit and five thousand are hired every year. It is said in the plant that they don't kill pigs, they kill people. So desperate is the company for workers, its recruiters comb the streets of New York's immigrant communities, and word of mouth has reached Mexico and beyond. The company even procures criminals. Several inmates on work release are bused in from the county prison every day.

The new workers are given a safety speech and tax papers, shown a promotional video, and informed that there is enough methane, ammonia, and chlorine at the plant to kill every living thing in Bladen County. Of the 30 new employees, the black women were assigned to the chitterlings room, where they would scrape feces and worms from intestines. The black men were sent to the butchering floor. White men and Indians were more likely to be given jobs making boxes.

The kill floor sets the pace of the work, and for those jobs they pick strong men and pay a top wage, as high as $12 an hour. If the men fail to make quota, plenty of others are willing to try. It is mostly the blacks who work the kill floor, the stone-hearted jobs that pay more and appear out of bounds for all but a few Mexicans. Kill floor work is hot, quick, and bloody. The hog is herded in from the stockyard and then stunned with an electric gun. It is lifted onto a conveyor belt, dazed but not dead, and passed to a waiting group of men wearing bloodstained smocks. They slit the neck, shackle the hind legs, and watch a machine lift the carcass into the air, letting its life flow out in a purple gush into a streaming collection trough. The carcass is run through a scalding bath, trolleyed over the factory floor, and then dumped hard onto a table. In the misty red room, men slit along its hind tendons and skewer it with hooks. It is again lifted and shot across the room on a pulley and bar, where it hangs with hundreds of others. It is then pulled through a wall of flames and met on the other side by more black men who, stripped to the waist beneath their smocks, scrape away any straggling bristles. The place reeks of sweat, steam, and blood. Nothing is wasted, not the plasma, not the glands, not the bones. The kill men say that even the squeal is sold.

The carcasses sit in the freezer overnight and are then rolled out to the cut floor. The workers here are mostly Mexican; the lighting is yellow, not red. The vapor comes from cold breath, not hot water. It is here that the hog is quartered. The pieces are parceled out and sent along the assembly lines to be cut into ribs, hams, bellies, loins, and chops. There is tremendous pressure on workers in the cut lines to keep the conveyor belts moving. If the line fails to keep pace, the kill men must slow down, backing up the slaughter. The boxing line will have little to do, costing the company money. The blacks who kill will become angry with the Mexicans who cut, who in turn will become angry with the white superintendents who push them. Think of Tar Heel, North Carolina, and “the plant” when you eat that packaged bacon or sausage.

PORCINE AND BOVINE DISEASES

An outbreak of swine fever occurred in Britain this summer, and thousands of pigs were slaughtered (5). In August 2000, the USA joined several European countries in banning imports of live pigs, pig semen, and related products from Britain, which is still struggling with huge economic losses from an outbreak of bovine spongiform encephalopathy (mad-cow disease) that began several years ago. Swine fever, like mad-cow disease, is usually controlled only by the destruction of infected animals. Outbreaks decimated herds in the Netherlands and Germany in recent years. But unlike mad-cow disease, swine fever is not thought to be a threat to humans. In Malaysia, about 100 people died last year, and a million pigs were slaughtered because of the spread of the newly discovered Nipah virus, which is in the same class of viruses as Ebola and AIDS. Recently, a chain of infection from fruit bats to pigs and then to humans was confirmed. Meanwhile, an outbreak of hoof-and-mouth disease in Argentina prompted the announcement in August 2000 of a temporary halt in beef exports to the USA. Also in August 2000, a federal judge ordered 2 flocks of sheep belonging to a Vermont couple to be destroyed out of concern that they had a version of mad-cow disease. Bon app?tit.

MEAT INSPECTION RULES CHANGE

Delmer Jones, a federal food inspector for 41 years in Alabama, doesn't buy meat at the supermarket anymore because he doesn't trust it to be safe to eat (6). A 1959 federal law requires inspectors from the Agricultural Department's Food Safety and Inspection System to inspect all slaughtered animals before they can be sold for human consumption. In 1998, the inspections and safety system reclassified an array of animal diseases as being “defects that rarely or never present a direct public health risk” and said that “unaffected carcass portions” could be passed on to consumers by cutting out lesions. Among animal diseases that the agency said do not present a health danger are cancer, a pneumonia of poultry called airsacculitis, glandular swellings or lymphomas, sores, infectious arthritis, and diseases caused by intestinal worms. The new rules reclassify as safe for human consumption animal carcasses with cancers, tumors, and open sores! Federal meat inspectors and consumer groups are protesting the new classification. The Agriculture Department now plans to rely on scientific testing of samples of butchered meats to determine the wholesomeness of meat rather than traditional item-by-item scrutiny by federal inspectors. It's simply healthier to be a vegetarian. Flesh poisoning is clearly increasing in the USA.

WALKERTON, CANADA, E. COLI, AND CONTAMINATION OF THE CITY'S WATER

Walkerton, Ontario, is about 3 hours northwest of Toronto. On May 12, 2000, a heavy rain fell after a chlorinator on 1 well had been out of service for a month (7). Flood waters washed into wells manure contaminated with E. coli, a bacterium found in roughly 10% of North American cows, sheep, and deer. On May 14, many town residents and visitors developed diarrhea, and water samples showed high levels of total coliform and E. coli. Well 7, the only town water source at the time, was not receiving chlorine, which normally would have killed the bacteria. Of the 4800 Walkerton residents, >2000 developed cramps and diarrhea, often bloody, and 7 people died as a consequence of the E. coli infection. Although most people believe E. coli 0157:H7 contaminates only food, this outbreak shows that this fatal strain can also infect a municipal water system. It could happen anywhere.

GLOBAL WARMING

The July 14, 2000, Science contained an article by Thomas Crowley, an oceanographer at Texas A&M University (8). Crowley calculated temperature changes due to volcanic eruptions and variations in the sun's intensity during the last 1000 years and compared the changes--which came from tree ring patterns, glacial ice, and other natural records--with the new climate data. The calculations were strikingly similar to climate data for the 850 years leading up to the industrial revolution. The calculations reproduced many of the unusual climate events of the past millennium--including a previously unexplained cold spell known as the Little Ice Age, which chilled Europe in the 17th and 18th centuries.

In the mid-19th century, just as humans began burning large amounts of fossil fuels, the calculations and the natural record diverged. Crowley's calculations showed a continuation of the slow but steady warming that began at the end of the Little Ice Age. Observed temperatures for that period jumped dramatically. Most scientists believe burning of fossil fuels, such as oil and gas, is the largest cause of human-induced warming. Carbon dioxide and other so-called greenhouse gases, released by the burning, trap much of the heat that would otherwise escape the earth's atmosphere. Crowley added to his calculations a conservative estimate of the 150 years of temperature change due to industrial greenhouse gas omissions. Much of the discrepancy between his results and the recent climate record disappeared. This suggests that human activity explains much of the 1?F warming observed during the 20th century. Volcanic activity and changes in ocean circulations may contribute to some extent, but they cannot explain the increase. Crowley's study also bolsters the complex computer models used to predict future climate change. By adjusting for the effects of changing sunlight, volcanoes, and human activity, Crowley was able to estimate the range of inherent variability or “wobble” in the earth's temperature. The size of the temperature fluctuations in Crowley's analysis agreed precisely with the levels of variability produced by the models.

Is the frightening weather in southern Europe in July 2000 a manifestation of global warming? Temperatures reached as high as 48.8?C (120?F) and many people died (9). In some places the problems were worsened by drought, the worst in the Balkans in 50 years, and it caused record crop losses. Ambulances patrolled streets in southern Romania to pick up individuals who fainted in temperatures that were well over 37.8?C (100?F). Soldiers in western Bulgaria fought a major forest fire. At least 10 people died from the heat in Turkey. Intense fires raged on a number of islands in the Aegean. Wildfires in Italy consumed hundreds of acres of forest in the southern Gargano region. No single weather event can be attributed to global warming, but this is the kind of terrible weather that scientists have long predicted would accompany the warming of the planet. That warming is not only well under way, it is accelerating. A study commissioned by the federal government, released in June 2000, warned of destructive storm surges, chronic erosion of the US coastline, extreme water shortages in some places, and frequent and severe flooding in others. Continued thawing of the permafrost and melting sea ice in Alaska is predicted to cause severe damage to its forests, buildings, roads, and coastlines. There is evidence of less ice in the North Pole area than even 10 years ago. Global warming? Probably. Are the 60+ days without rain in Dallas a manifestation of global warming? It is too early to know.

Until the greenhouse gases are brought under control, the climate on earth is going to continue to warm. It has been projected that declines in agriculture, particularly in low-latitude areas, could create large masses of environmental refugees. The same thing could happen as a result of the rising of the sea level. Much of Bangladesh, with a population of about 120 million in an area the size of Wisconsin, is projected to go under water in the next 100 years. Where are these people going to go? There is no room left. Can an international effort to cut the emissions of greenhouse gases ward off a global catastrophe? It's possible but unlikely. Doctoring has got to start before the patient gets to the hospital!

HIGHEST TEMPERATURES EVER RECORDED IN THE USA

States with the highest temperatures ever recorded through 1999 include California, 56.7?C (134?F) (July 10, 1913); Arizona, 53.3?C (128?F) (June 29, 1994); Nevada, 51.7?C (125?F) (June 29, 1994); New Mexico, 50?C (122?F) (June 27, 1994); and North Dakota, 49.5?C (121?F) (July 6, 1936). These 37.8 to 40.6?C (100 to 105?F) temperatures in Dallas don't seem so bad after all (10).

WILDFIRES

The most intense wildfires in >50 years still rage in the West, producing huge clouds of thick, billowing smoke and causing health and visibility problems (11). So far 6 million acres have burned in 12 western states, doubling the 10-year average. Hundreds of residents have been evacuated. There are now >25,000 firefighters on the lines. The smoke in the burning areas is causing many patients with chronic lung disorders to come to the hospital, and many others complain of headaches, burning eyes, and breathing difficulties. In many places, people are walking around with masks or wet handkerchiefs pressed to their faces. Asthma sufferers are taking extra puffs on inhalers to assist breathing. The best way to avoid the smoke is to stay inside. Strenuous exercise outside in these smoky areas is particularly harmful.

SEAT BELTS WITH BELT EXTENDERS

There are far more overweight Americans in 2000 than there were in 1960, but national seat belt standards have not changed in the past 40 years (12). In 1960, the percentage of overweight Americans aged 20 to 74 was 56%, and 23% of them were obese; by 1990, according to the National Center for Health Statistics and the Centers for Disease Control and Prevention, 77% of Americans were overweight and 29% of them were obese. There now seems to be a push to ask the National Highway Traffic Safety Administration to require all automobile manufacturers to make sure that anyone who can sit behind the wheel of a car has the ability to fasten a factory-installed or otherwise government-tested safety belt. Because Americans are heavier than ever, many people are finding belts that meet today's federal standards difficult if not impossible to wear, thus causing the push to have seat belt extenders just like those in the seats of commercial airplanes.

PAY FOR 1 SEAT AND OCCUPY 1 1/2 SEATS VS PAY FOR 1 SEAT AND RECEIVE 1/2 SEAT

Such was the situation recently when a man and his wife boarded a plane from London to the USA and found a huge woman sitting in an aisle seat (13). It was extremely difficult for them to get around her so they could sit in the middle and window seats. When the husband sat down, he attempted to lower the armrest. The woman said, “You can't do that; my hips won't allow it.” She was right. She took up her seat plus half of the husband's seat. At takeoff the flight attendant apologized to the obese woman because there was no double seat available for her. There was no apology to the husband for his half seat! It was obviously uncomfortable to occupy the half seat for the entire 7-hour flight! The airlines have a difficult time dealing with obese passengers because the latter can sue for discrimination if they are treated disrespectfully because of their size. But those who pay for a full seat and receive a half seat also need an apology. Overweightness raises our cholesterol levels, our blood pressure, and our blood sugars, and it may cause other problems as well.

THE EMPATHY SUIT

Harvard professor George Blackburn, a surgeon, is leading an effort to teach primary care physicians how to treat overweight patients (14). We now have 97 million Americans who are overweight, and those numbers rise yearly. Many of us gain a pound a year after age 20, resulting in a weight gain of 30 pounds by age 50. Blackburn wants physicians to understand the agony of being too heavy. He has developed a 34-lb “empathy suit.” Moving around in that suit allows the ideal-body-weight physician or others to understand better the problems of obesity. In his program, health care professionals learn how to approach patients about their weight. A physician might gently say, “How much do you exercise in a week?” or “Do you think you're eating a healthy diet?” or “How do you feel about your weight?” or “Do you think your weight is a problem to your health?” They learn not to say, “You're fat. You need to go on a diet.” Blackburn suggests that practitioners may want staff to call patients who are trying to lose weight to see how they are doing. That kind of gesture goes a long way in motivating patients. Studies show that most weight loss occurs in the first 13 weeks of a program. Blackburn encourages all physicians to have oversized chairs in their waiting rooms, along with magazines that feature larger models, and larger gowns and blood pressure cuffs in the examining rooms. He also suggests that physicians be reasonable in their expectations and aim for an initial 5% to 10% weight loss, which can lead to improvements in blood pressure, blood sugar, and blood cholesterol. He suggests giving no points for taking it off, only points for keeping it off.

ISLET CELL TRANSPLANTATION

Researchers from Edmonton, Canada, reported in June 2000 that they had transplanted pancreatic islet cells into 11 patients in 15 months (15). The patients had type 1 diabetes mellitus, which accounts for about 10% of the USA's 16 million diabetics. So far, all 11 patients are producing insulin on their own and are free of insulin injections. Also, there has been no rejection so far. The investigators in Canada used freshly harvested islets, not frozen cells. In the first 9 patients, 10,000 islets per kilogram of patient weight were infused; in the most recent transplant, 5000 islets per kilogram were given with no negative effect. Apparently, the procedure is easy. Patients are fully conscious and talking to physicians while about a teaspoon of pure islet cells is piped through a tiny catheter into the liver. One half of the patients went home or back to work 12 to 24 hours after the procedure. So far, mainly because of a shortage of available islet cells, only very ill patients with type 1 diabetes whose blood sugar can't be controlled by insulin therapy are being considered for transplant. With time, this surely will change. The procedure looks as if it might be performed on an outpatient basis.

The biggest problem remaining is a steady supply of islet cells, which now are harvested from cadavers. The organ-donor rate in the USA is abysmally low, and the supply of islet-rich pancreases is not reliable. In the future, if a clinical source of islet cells can be generated, the technology could be expanded to patients who have type 2 diabetes. Recently, investigators from the University of California in San Diego were able to grow human beta cells in the laboratory. Beta cells are 1 of the 4 types of cells in the islets and the ones that produce insulin. They are also the cells that are destroyed by the autoimmune process that causes type 1 diabetes.

The Canadian researchers used whole islet cells rather than only beta cells. The goal for the future is to transplant islets along with the natural antirejection proteins so that the recipients will not have to take immunosuppressive drugs for the rest of their lives.

DECLINING RUSSIAN POPULATION

Russia's population, around 145 million, is decreasing, and demographers predict that the world's largest country in land area will have a population of about 125 million within 20 years, a population smaller than Japan's (16). Half of Russian men die before they reach age 60, mainly from coronary artery disease, alcoholism, and smoking. Russian women are having fewer children. The country's birthrate has halved since 1988 to 1.3 children per woman. (Population replacement requires this rate to be 2.2.) Most women in Russia avoid childbirth by choice--either by not having children or by ending their pregnancies. Russia has the world's highest abortion rate, with 2 of 3 pregnancies ending in abortion. And, up to 25% of Russian couples are infertile. One reason for increasing reproductive problems is that Russian women are having sex earlier. That gives a woman more chances to contract infections that could affect childbearing, and it increases her chances of having >1 abortion before she has a baby. Multiple abortions increase the risk of complications during pregnancy. Although contraceptives are increasingly available in Russia, they tend to be mistrusted or misunderstood, and abortion remains the primary method of birth control. Abortion is also free, unlike birth control, which is relatively expensive. Infant mortality also is on the rise. As many as 10% of Russian newborns die of infections. Soviet environmental destruction has damaged the health of millions of Russians.

RUNNING RED LIGHTS

When I moved to Dallas from the Washington, DC, area in 1993, I was a bit surprised to observe more cars running red lights in Dallas than I had noticed in Washington. A recent piece summarized a report from the Insurance Institute for Highway Safety, which found that Texas has the fourth highest rate of deaths from red light runners in the union (17). The highest death rate per 100,000 was Arizona (7.1), followed by Nevada (3.9), Michigan (3.7), and Texas (3.5, or a total of 663 deaths during the 6-year period of the study). Fatal crashes at traffic signals rose 18% from 1992 to 1998, according to the national survey. But in 40 communities where cameras help enforce traffic laws, red light running dropped about 40%. These cameras also have helped reduce the number of injuries in crashes in both Europe and Australia. The cameras cost $60,000 per intersection, but officials in cities that use them say they are worth it by increasing public safety.

COMMERCIAL AIRLINE CRASHES in the USA, 1960 to 1999

Table 1 shows the numbers of airline crashes involving US-based carriers or international flights originating in the USA from 1960 to 1999 (18). The list is limited to commercial flights in which there were fatalities and the jet was considered a total loss. During these 40 years, there were 73 crashes with 5106 deaths, an average of 70 per crash. Crashes occurred during the approach (37%), while cruising (26%), during takeoff (19%), and while landing (8%). Compared with most other types of transportation, the commercial airliner continues to be the safest. I am always amused when the taxi driver dropping me off at the airport says, “Have a safe flight.” His chance of an accident while driving the taxi back into town is far higher than the chance of an accident while flying on a commercial airline in the USA.

GUNS

Michael Barnes, a former representative to Congress from Maryland, recites some depressing gun statistics (19): 1) In 1999, more people were killed by guns in the state of Maryland than in Australia, New Zealand, Korea, Singapore, Japan, Canada, Germany, and Great Britain combined. 2) A child in the USA is more likely to die from gun violence than from all diseases combined. 3) Water pistols are regulated by the federal government (the Consumer Product Safety Commission), whereas real guns, the ones that kill people, are not. Mr. Barnes now heads Handgun Control. He describes the clout of the gun lobby as the “circle of violence,” which includes the gun manufacturers, the gun lobby, the politicians who get huge contributions from the pro-gun forces, and criminals who have easy access to firearms.

A seminal moment in breaking this circle, Mr. Barnes believes, occurred in March 2000 when Smith & Wesson, one of the largest gun manufacturers, agreed to institute gun-safety measures to settle a lawsuit brought by state and local governments. This, coupled with a growing public revulsion over the easy-access-to-guns culture, promises to change the social and political landscape as well as the dominance of the gun lobby. Smith & Wesson agreed to design changes, including a trigger lock on all handguns, and to develop “smart gun” technology within 3 years so only the owner of a gun can fire it. The company also will sell only to dealers and gun shows committed to improved gun safety. Law enforcement agencies account for >20% of the $1.5 billion in annual gun sales, and so far >3 dozen cities and localities have agreed when buying guns to give preference to manufacturers who make the weapons safer and less accessible.

In 1998, 11 children died when they were accidentally locked in car trunks. Now automobile manufacturers are voluntarily installing internal trunk release handles to prevent future tragedies. There were 35,000 gun deaths that same year! Even if the Smith & Wesson deal spreads across the industry, the USA is still going to be the most gun-violent nation in the world. Nevertheless, the politics of gun control are changing. Public opinion may be changing a bit. The rash of recent violence, particularly in schools, and the strong support for gun control by most police groups have changed the dynamics. Mr. Bush has opposed all major gun controls and supported a concealed-weapons initiative in Texas. But every day this fall, the Bush camp may be nervously hoping that there isn't another Jonesboro, Pearl, or Columbine. They probably won't get their wish.

DR. DEATH

Dr. Michael Swango graduated from Southern Illinois University Medical School in 1983 (20). According to James B. Stewart, the author of Blind Eye: The Story of a Doctor Who Got Away with Murder, he was dubbed “Double-O Swango” by classmates who joked that he had a license to kill after several of his patients died. He's accused of killing a 19-year-old gymnast with a fatal dose of potassium while he was an intern at Ohio State University (OSU) Hospital in 1984. He was never prosecuted for that death or for another alleged poisoning of an OSU patient who survived. Dr. Swango was not permitted to return for the first-year residency. Instead, he returned to his Quincy, Illinois, home and took a job as an emergency department medical technician. His stint ended with his conviction for lacing his coworkers' coffee and donuts with ant poison. Dr. Swango served 2 years of a 5-year prison sentence, and he also lost his medical license.

After release from prison and various unsuccessful attempts to revive his medical career, he eventually landed a 1993 residency at the State University of New York (SUNY) at Stony Brook by lying on his job application. That lie resulted in a 42-month prison sentence in Colorado. Three Long Island patients he served died between July and October 1993. Dr. Swango was dismissed by SUNY at Stony Brook after his record became public knowledge, and he soon relocated to Zimbabwe. Within a year of his arrival, patients in a hospital there were showing signs of poisoning. In July 1995, a Zimbabwe hospital suspended Dr. Swango from practice. He was finally arrested 2 years later at O'Hare Airport in Chicago as he was boarding a flight to Saudi Arabia for a new medical job. In early July 2000, the 45-year-old physician--just days from release at a Colorado prison on unrelated charges--was accused of the 1993 murders of 3 patients at the Veterans Administration hospital in Northport. He is accused of injecting the 3 with toxins. In 2 of the cases, he told other hospital staff members that the patients' families had issued “do not resuscitate” orders. The author of Blind Eye believes that Dr. Swango may have killed as many as 35 patients on 2 continents!

NATIONAL INSTITUTES FOR HEALTH RESEARCH FUNDING

Not all disease-fighting efforts are funded according to how many people are affected or die (21). Heart disease is by far the nation's biggest killer, but AIDS research gets nearly 7 times more government research money. Table 2 lists the amount of National Institutes of Health research money spent on some of our most common diseases.

BEIJING PLUS FIVE

In June 2000, a conference was held at the United Nations in New York City bearing the name “Beijing Plus Five” for a 5-year checkup on the platform for action approved at the global meeting for women in Beijing in 1995. Ellen Goodman summarized her observations of this conference (22). The idea that women's rights are human rights has solidified. Honor killings, bride burnings, and female genital mutilation are regarded no longer as “cultural” matters, but as human rights abuses. Sexual trafficking in women is an international scandal. Governments are being held accountable for what they said they were doing for women.

The world, however, has barely begun to implement the commitments made in Beijing 5 years ago. Many countries thought their signature on a document would get them off the hook. Others, from the Vatican to Libya, remain adamantly opposed to parts of the platform, especially reproductive rights. Many countries have failed to meet the Beijing timetable for repealing laws that discriminate against women, such as inheritance and custody laws. Five years ago, Kuwait was the only country where men could vote and women couldn't. That is still the situation. More than half of the college graduates in Kuwait are women. When Kuwait was invaded by Iraq in 1991, women worked and fought beside men and were called “the sisters of men of Kuwait.” Each year since, Parliament has turned down women's right to vote. In many places, like Kuwait, the reality and fear of a fundamentalist backlash are inhibiting the progress that governments promised when they signed the plan.

HIGH HEELS AND SORE FEET

A new survey from the American Podiatric Medical Association shows that 25% of women wear high heels even though they hurt their feet, and 35% wear them even though they know high heels cause damage (23). Foot specialists define high heels as anything over 2.25". The most popular ones are 3" and 4" heels. But, a change is brewing, especially at the office and among younger women. The number of high-heel abusers has been dropping steadily over the past few years. Shoe manufacturers also are offering a better selection of stylish but comfortable shoes without high heels. The workplace is becoming more casual, lessening the need for high heels. Women apparently thought at one time that they had to be eye-to-eye with men to have a presence. That view no longer holds. A study by the American Orthopedic Foot and Ankle Society (AOFAS) shows that only 21% of working women now wear high heels on the job, compared with 34% in 1990. And teenagers are not wearing high heels. Although daughters may be wearing lower shoes, their moms are not. Women in their 40s and 50s cling to their high heels.

The AOFAS lists what high heels do to women's feet: 1) Wearing high heels tends to shorten the Achilles tendon, causing women to lose range of motion in the foot. Women make up 75% of the 2 million Americans suffering heel pain. 2) A 3" heel creates 7 times more stress on the forefoot than a 1" heel. The average person takes thousands of strides a day. The stress contributes to bunions, hammertoes, and neuromas, or trapped nerves. 3) Women have about 90% of the nearly 800,000 annual operations for foot problems linked to shoes. The estimated cost is $2 billion a year. 4) Women are twice as likely to sprain an ankle in heels than in flats. 5) Some investigators believe that high heels are at least partly responsible for the fact that women are twice as likely as men to develop osteoarthritis in the knees. Maybe the high heels should be treated like desserts, just for occasional use. The feet would be happier.

TURNING 50

Al Neuharth, the founding editor of USA Today and a hero of mine, had a piece on turning 50, as his wife did recently (24). About 3.7 million people in the USA turned 50 this year. But 50 is not old anymore, and 100 remains a realistic goal if we keep our arteries clean. According to the Census Bureau, 64,054 centenarians are in the USA, and there will be 1.1 million centenarians by 2050. The Census Bureau projects that 41% of the women and 18% of the men who turn 50 this year will live to celebrate their 100th birthday in 2050.

GENERATIONAL TRANSFER, OR RETIREES VS WORKERS

In a piece entitled “Graying politics,” Robert Samuelson described how the federal government operates as a massive transfer mechanism between workers and retirees (25). Workers' taxes pay retirement benefits, mainly through Social Security and Medicare. Those benefits now account for a third of the federal budget and average nearly $18,000 for each person >65 years of age. This year's news is the explosion of proposals that would vastly enlarge that transfer over the next 10 years: 1) A Medicare prescription drug benefit has a 10-year cost estimated between $250 and $340 billion. 2) A reduction in income taxes paid by Social Security recipients on their benefits would cut tax revenue in 10 years by >$100 billion. 3) The gradual elimination of the estate tax (“the death tax”) yields in 10 years a projected revenue loss of $105 billion. 4) A long-term care tax credit for people in nursing homes or needing help at home costs $27 billion over the decade. Can we afford these proposals? I hope so.

TWINS

The Twins Foundation, which studies similarities and differences among twins, marked its 17th anniversary in July 2000 (26). A popular new book about twins, Entwined Lives by Nancy L. Segal (Plume Books, $16), is in stores. The world's biggest gathering of twins took place in Twinsburg, Ohio, August 4-6, 2000. The USA has 6.9 million twins. Worldwide, the estimate is 147 million. Al Neuharth, the father of adopted twins and the founder of USA Today, stresses that the problems or troubles with 2 babies are not nearly twice those of 1 baby. Most babies eat, sleep, and need their diapers changed with about the same frequency. As twin babies become toddlers, they tend to entertain and even look out for each other a bit. Twin births are increasing!

SHORTAGE OF PHARMACISTS

Pharmacists will fill at least half a billion more prescriptions this year than they did in 1992 (27). But the number of pharmacy graduates has hovered between 7000 and 8000 for almost a decade, according to the American Association of Colleges of Pharmacy. As a consequence, hospitals and independent pharmacies are forced to fight high-paying chain stores, managed care organizations, and dot.com drug companies for their share of a stagnant labor pool.

Chain-store pharmacists earned an average of $72,500 in 1999, according to a survey by the American Pharmaceutical Association. That's about $10,000 more a year than hospital pharmacists are paid. Although the hospitals offer better hours and a wider range of professional challenges than do chain stores, the lower salaries associated with hospital pharmacies make recruitment difficult. More and more pharmacies are using robotic dispensers, which can free pharmacists to work in other areas of hospitals.

Many pharmacy school graduates never fill a prescription. There are simply too many other job options for them. The doctoral programs in pharmacy schools recently were converted from 5 to 6 years. These expanded programs qualify graduates for a wide range of jobs in research, regulatory agencies, and drug development.

The drugstore chains are also having difficulty filling their pharmacy slots. Some pharmacists in drugstores fill as many as 25 to 30 prescriptions an hour, twice the number recommended. Not only are they handing out more prescriptions, they are also filling out more forms as required by managed care companies. Pharmacists now spend about 20% of their time dealing with insurance companies. At the same time, pharmacists are under increased scrutiny from courts and state boards to limit prescription errors. Texas lawmakers now are expanding enrollment at the state's 4 pharmacy schools: Texas Southern University's College of Pharmacy and Health Sciences in Houston, Texas Tech University's School of Pharmacy in Amarillo, University of Houston's College of Pharmacy, and University of Texas' College of Pharmacy in Austin.

OVER-THE-COUNTER MEVACOR AND PRAVACHOL

The FDA denied the applications of both Merck & Company, maker of Mevacor (lovastatin), and Bristol-Myers Squibb, maker of Pravachol (pravastatin), to sell these drugs over the counter as 10-mg pills. The applications were the first sent to the FDA to grant over-the-counter status for pills that treat a chronic disease. I think the FDA's decision was wrong. Any action to get more of these drugs to people who need them is advantageous in my view. There is no toxicity with a 10-mg tablet of Mevacor or a 10-mg tablet of Pravachol! Ten million people in the USA have or have had symptomatic myocardial ischemia, and only 5 million of them have ever been on a statin drug. Of those on a statin drug, only 20% reach goal (low-density lipoprotein cholesterol <100 mg/dL). The 2 companies have not given up, however, and apparently will make another application in due course.

RAT FACTS

There are 500 different species of rats (28). The US rat population is estimated to be 270 million or 1 per human. Their lifespan is 2 to 3 years, and they are sexually mature in 3 to 4 months. The number of rats per litter varies from 6 to 22, and a female rat may have 7 litters a year. The 14th-century Black Death was produced by fleas carried on rats, and it killed 25 million human beings!

GROUP DOCTORING

The doctor-patient relationship has always been considered the most fundamental encounter in medicine. That may be changing (29). Health clinics in the USA, from a Mayo Clinic affiliate in Wisconsin to Stanford University School of Medicine in California, have recently introduced programs in which as many as 2 dozen patients attend once-monthly 2-hour group sessions rather than rely on traditional individual appointments. Some physicians set up their group visits around patients with specific chronic ailments, such as diabetes, arthritis, or hypertension. Rather than saying the same thing 20 different times to 20 different patients, the physician theoretically has to say it only once. For examinations requiring disrobing, the patient and physician meet privately before or after the group session. For patients, group programs are always voluntary, and physicians say that private appointments are always available for personal or urgent medical problems.

The group visits, of course, do not provide for all patient needs. Some patients do not like to talk about their ills in front of other people. Some patients want nothing to do with groups. The emergence of group visits appears to reflect the toll taken by economic pressures on the doctor-patient encounter. Physicians complain that reduced reimbursement and managed care demands for increased productivity have led to shorter individual appointments. Proponents of group visits say they go a long way toward addressing such problems. Little evidence exists so far to gauge whether group care is better care. A 2-year study of Kaiser group-visit programs involving 790 patients provides support for the approach. The report found that while the number of hospital visits among group- and private-appointment patients was about the same, those participating in groups spent fewer days in the hospital. They also rated their quality of life higher than patients seeing the physician privately. Some of that well being may stem from the realization that others in a group have more serious complaints.

GOLDEN RULES FOR LIVING

Several years ago, my laboratory assistant Bonnie Martinez gave me the “Golden Rules for Living.” Its author is unknown. They are the following: 1) If you open it, close it. 2) If you turn it on, turn it off. 3) If you unlock it, lock it up. 4) If you break it, admit it. 5) If you can't fix it, call in someone who can. 6) If you borrow it, return it. 7) If you value it, take care of it. 8) If you make a mess, clean it up. 9) If you move it, put it back. 10) If it belongs to someone else, get permission to use it. 11) If you don't know how to operate it, leave it alone. 12) If it's none of your business, don't ask questions.

DALLASITES GETTING RICHER

Gross retail sales for businesses in Dallas County and its surrounding 6 counties totaled nearly $59 billion in 1999, up about $8.5 billion from 1998 and $14 billion from 1997 (30). Personal income in the Dallas metropolitan area increased 9.3% from 1997 to 1998, according to the most recent figures available. The number of millionaires in Dallas over the past 3 years has increased 35%, on par with San Francisco, the Silicon Valley, and Chicago. Unlike Austin and Houston, where college students and lower-paid workers in the medical industry bring down average incomes, Dallas is dominated by industries with high average wages. And we have an insatiable appetite for restaurants. More than 7000 eateries are located in the Dallas area, 4 times the number per person in New York City. In the high-end real estate market, 152 properties have sold for at least $1 million in the Dallas area since January 2000, and a handful of others have sold for >=$10 million.

JACK BE NIMBLE, JACK BE RICH

Jack Welch, the chairman of General Electric who Fortune magazine described as “the leading management revolutionary of the century,” will receive $7.1 million from Time Warner for his autobiography (31). That's nearly $4 million more than Random House gave Robert Rubin, the investment banker and former US treasury secretary, for his story. And it is $4 million more than Paula Barbieri got for describing life with O. J. Simpson, and a half a million or so more than either Colin Powell got for his heroic saga or the pope got for writing about spirituality.

Mr. Welch, who had the same agent as the pope, is the “Vince Lombardi of business” says John Huey, editor of Fortune. From the time the 64-year-old took over the company 20 years ago, the stock price of General Electric has almost been vertical-line upward and has made him the most widely studied executive in the land. Mr. Welch says he hopes his scout's-oath style of advice will be uplifting: “Be true to yourself, be honest with others, say what you think, go with your instincts, teach people that you can stretch and grow in ways you never thought possible. It's like a dinner party with 12 people. You bring as many intellects together as you can and then take the best ideas out of each. The leader who gets the most ideas from the most sources will have the most success.” Welch doesn't believe there is a new economy. “It's the same old economy with new technology. We get rid of some of the numbing, boring jobs and make society better and more creative. The young kids we are hiring today are focused and excited,” he says. “They believe in hard work and giving back to the community and in having balanced lives. I don't see more greed or less greed now. A lot of people have participated in this market. It's not confined to a narrow group of fat cats. The boats have risen everywhere.”

TIGER WOODS, KARRIE WEBB, AND LANCE ARMSTRONG

In June 2000, Tiger Woods at age 24 won the US Open by 15 strokes (12 under par); in July 2000 he won the British Open by 8 strokes (19 under par); and in August 2000 he won the Professional Golfers' Association (PGA) Championship by 1 stroke (18 under par) (32-34). The last person to win 3 majors in 1 year was Ben Hogan in 1953. In each of his major wins in 2000, Woods' 4-day score was either a record or a tie with the record, and he is the first since 1936 to win the PGA Championship twice in a row. In the 4 majors combined in 2000, Woods beat his closest competitor, Ernie Els, by 35 shots. The St. Andrew's golf course, where he won the British Open, has 112 traps, and during the entire 4 days Woods never landed a ball in a bunker. Woods has now won 5 majors, and in 14 of the 20 rounds he has shot in the 60s. His average strokes per round was 68.

In July 2000, Australian Karrie Webb won the US Women's Open, her third victory in the Ladies PGA's past 4 major tournaments--a dominance of the majors equivalent to Woods' (35).

Also in July, 28-year-old Lance Armstrong won his second Tour de France, cycling's premier race, 4 years after he was diagnosed with testicular cancer requiring chemotherapy and craniotomy (36). Winning a second consecutive Tour de France bicycle race has been done before by another American, Greg Lemond, who won in 1986 and consecutively in 1989 and 1990, but never has it been done by someone surviving advanced cancer.

1. Davis R. Blood substitute may be the breakthrough. USA Today, June 20, 2000.
2. Peterson KS. Why everyone is so short-tempered. USA Today, June 18, 2000.
3. Brasher P. Summer sends E. coli soaring among cattle herds. The Herald-Sun, July 4, 2000.
4. LeDuff C. At a slaughterhouse, some things never die. New York Times, June 16, 2000.
5. Fitsch J. A run on meat, and not by humans. New York Times, August 20, 2000.
6. Scripps Howard News Service. New meat-inspection rules allow open sores, tumors. Dallas Morning News, July 15, 2000.
7. Brooke J. Few left untouched after deadly E. coli flows through an Ontario town's water. New York Times, July 10, 2000.
8. Herbert B. Cold facts of global warming. New York Times, July 10, 2000.
9. Carr M. New evidence reported on human effect on global warming. Dallas Morning News, July 14, 2000.
10. Gonzalez A. USA Today weather focus. USA Today, June 14, 2000.
11. Halladay J. When smoke gets in your eyes and lungs: more than 1M acres scorched. USA Today, August 17, 2000.
12. Kiley D. Large drivers demand safety belts fit for all. USA Today, July 12, 2000.
13. Landers A. Squeezed too tight on overseas flight. Dallas Morning News, July 16, 2000.
14. Hellmich N. He fights a heavyweight bout. USA Today, June 15, 2000.
15. Manning A. Defeating diabetes. USA Today, June 13, 2000.
16. Associated Press. Infertility, illness cut Russian population. Dallas Morning News, July 30, 2000.
17. Larson K. Running red lights is a deadly crisis in Texas. Dallas Morning News, July 14, 2000.
18. Major jet accidents 1960-1999. USA Today, August 21, 2000.
19. Hunt AR. Politics and people: a good shot against the gun lobby. Wall Street Journal, April 13, 2000.
20. Associated Press. Doctor may face execution in deaths of 3 patients. Dallas Morning News, July 16, 2000.
21. National Institutes of Health, Funding Facts. Newsweek, May 22, 2000.
22. Goodman E. Glass half-full or half-empty for women. Dallas Morning News, June 16, 2000.
23. Peterson KS. Climbing the highest heels. USA Today, June 14, 2000.
24. Neuharth A. What's to celebrate when wife turns 50? USA Today, August 4, 2000.
25. Samuelson R. Graying politics. Dallas Morning News, August 11, 2000.
26. Neuharth A. Twins multiply joys, don't double troubles. USA Today, July 7, 2000.
27. Oldham C. Shortage gives drugstores headache. Dallas Morning News, July 9, 2000.
28. Parker S. Rats. USA Today, June 22, 2000.
29. Martinez B. Now it's mass medicine. Wall Street Journal, August 21, 2000.
30. Shah A. Land of plenty. Dallas Morning News, August 20, 2000.
31. Dowd M. The $7 million man. New York Times, July 16, 2000.
32. Saraceno J. Woods takes his place in pantheon. USA Today, July 24, 2000.
33. Blauvelt H. Major routs leaves pros awestruck. USA Today, July 25, 2000.
34. Cowlishaw T. Pause to consider Tiger's huge feats. Dallas Morning News, August 24, 2000.
35. Butler A. Pursuit of perfection. USA Today, July 25, 2000.
36. Woods BE. Armstrong tops an incredible day. USA Today, July 24, 2000.