AlterNet.org: Personal Health

Austerity Kills: Crippling Economic Policies Causing Global Health Crisis

Amy Goodman, David Stuckler, Sanjay Basu , Democracy Now! — Tue, 21 May 2013 13:26:00 -0700

Economist David Stuckler and physician Sanjay Basu examine the health impacts of austerity across the globe in their new book.

The following is reprinted from the Democracy Now! interview,"Why Austerity Kills: From Greece to U.S., Crippling Economic Policies Causing Global Health Crisis."

In their new book, "The Body Economic: Why Austerity Kills," economist David Stuckler and physician Sanjay Basu examine the health impacts of austerity across the globe. The authors estimate there have been more than 10,000 additional suicides and up to a million extra cases of depression across Europe and the United States since governments started introducing austerity programs in the aftermath of the economic crisis. For example, in Greece, where spending on public health has been slashed by 40 percent, HIV rates have jumped 200 percent, and the country has seen its first malaria outbreak since the 1970s. An economist and public health specialist, Stuckler is a senior research leader at Oxford University. Dr. Basu is a physician and epidemiologist who teaches at Stanford University. "Had austerity been organized like a clinical trial, it would’ve been discontinued given evidence of its deadly side effects," Stuckler says. "There is an alternative choice that we found in the historical data and through the present recessions: When we place people and their health at the center of economic recovery, it can help get our economy back on track faster and yield lasting dividends to our society."

Amy Goodman: "Early last month, a triple suicide was reported in the seaside town of Civitanova Marche, Italy. A married couple, Anna Maria Sopranzi, who was 68, and Romeo Dionisi, [who was] 62, had been struggling to live on her monthly pension of around 500 euros [around $650 a month], and had fallen behind on rent.

"Because the Italian government’s austerity budget had raised the retirement age, Mr. Dionisi, a former construction worker, became one of Italy’s esodati (exiled ones)—older workers plunged into poverty without a safety net. On April 5, he and his wife left a note on a neighbor’s car asking for forgiveness, then hanged themselves in a storage closet at home. When Ms. Sopranzi’s brother, Giuseppe [Sopranzi, who was] 73, heard the news, he drowned himself in the Adriatic."

Those are the opening lines to a startling recent article in The New York Times headlined "How Austerity Kills." The authors of the piece, David Stuckler and Dr. Sanjay Basu, have just published a new book looking at the health impacts of austerity across the globe. The authors estimate there have been more than 10,000 additional suicides and up to a million extra cases of depression across Europe and the United States since governments started introducing austerity programs in the aftermath of the economic crisis. In Greece, where spending on public health has been slashed by 40 percent, HIV rates have jumped 200 percent, and Greece has seen its first outbreak in malaria since the 1970s.

David Stuckler is an economist and public health specialist. He’s a senior research leader at Oxford University. Dr. Sanjay Basu is a physician and epidemiologist. He teaches at Stanford University. Together, they’ve written this new book, out today, called The Body Economic: Why Austerity Kills—Recessions, Budget Battles, and the Politics of Life and Death.

We welcome you both to Democracy Now! I’m glad you could both be together in one place, being at Stanford and being at Oxford. David, let’s begin with you. Lay out the thesis of this book.

David Stuckler: We’ve been studying how recessions affect people’s health over the past decade, looking at the Great Depression through the East Asian financial crisis, right through to the present Great Recession. And what we found is that recessions hurt. Unemployment, job loss, foreclosure, unpayable debt are risks to health. But what ultimately matters is how politicians respond. And when they make large cuts to social supports, social protections, they can turn recessions into severe epidemics.

Amy Goodman: So, explain. Give us examples in countries. I mean, this horrific story I just described of this triple suicide, the couple and then her brother. Talk about what people—what happens when policies go one way or the other.

David Stuckler: Greece is in the middle of a public health disaster, as you mentioned. To meet budget deficit reduction targets set by the so-called troika—the International Monetary Fund, the European Central Bank and European Commission—Greece has cut its health sector by more than 40 percent. At a time when homelessness is escalating and austerity has further driven up youth unemployment, we’ve seen HIV infections jump, concentrated in injection drug users. The malaria outbreak was linked to the cut in mosquito-spraying prevention programs, creating an outbreak that’s much more costly to control than the short-term money saved by reducing the budget. Healthcare access has declined substantially. The majority of people who have lost access are pensioners who have contributed to the system their entire lives. And these are just a few of the many health effects seen in Greece, mirrored in Spain, Italy and, to some extent, the U.K. and the U.S.

Amy Goodman: We were just talking before the show about one of the suicides in Spain that became very well known. I wanted to turn to a clip. At the time, we were talking to a formerDemocracy Now! producer, María Carrión, about this case that occurred in Spain. The woman, David, was named?

David Stuckler: Amaia Egaña. It was a case of Spain’s eviction suicides. Spain has a system where when people’s homes are foreclosed, even if they default on their home, they’re still liable to pay back the debt. So people are plunged into poverty and arrears at the same time, without support. We’ve seen this trigger large rises in suicides. Spain, Italy and Greece are at the high end of increases in economic suicides.

Amy Goodman: So, Amaia Egaña was 53 years old. She jumped from a balcony to her death as she was about to be evicted. María Carrión appeared on the show to talk about Amaia’s suicide.

María Carrión: Amaia is a former city council member in a town—the town of Barakaldo in the Basque Country. And her case is especially tragic because she actually didn’t share just how bad off the situation was even with her husband. So, most people had no idea that there was a whole—there had been a repossession and an eviction process. She was so desperate and so ashamed of the situation that she jumped out of her balcony, her fourth floor apartment, as court employees came to evict her. This comes two weeks after police found a man dead in his apartment as they went in to evict him from his home after repossession.

And—but, you know, the movement to stop these evictions and repossessions has been working very hard on this for almost two years, and this is just the watershed. This has been the one situation that has actually forced government and the opposition and banks to come to the table and talk about real reform. Before this, you had these evictions taking place—500 orders every single day—silently. And thanks to the 15M movement—this is—was the Occupy movement in Spain just over a year ago—the platform against evictions was incredibly energized. And so, they have been able to stop hundreds of evictions.

But those are evictions of people who come to them and who say, you know, "My home is being repossessed. I’m facing eviction. Can you help me?" There are a lot of people like Amaia who did not do this, out of perhaps a sense of guilt or embarrassment. And so, her case is really representative and emblematic of what has gone wrong in Spain with, you know, thousands of people being left homeless after repossession and eviction.

Amy Goodman: David Stuckler, you were in Spain when Amaia killed herself.

David Stuckler: I was at a conference with the Barcelona Public Health Agency. The meeting got cut short as protests erupted onto the streets of Barcelona. People were outraged at the eviction-suicide of Amaia, at the hardship perpetuated by deep budget cuts under the Rajoy government in Spain.

Amy Goodman: On April 4, 2012, a 77-year-old retired Greek pharmacist named Dimitris Christoulas shot and killed himself near the Greek Parliament after writing a note that blamed his suicide on the economic crisis. His daughter Emi spoke at his funeral and said his act had been deeply political.

Emi Christoulas: [translated] You found it unacceptable that they were killing our freedom, our democracy, our dignity. You found it unacceptable as they tightened the harsh noose of economic austerity and apartheid around us, to the unacceptable act of surrendering our independence and the keys to the country. It was unacceptable to you that Greece did not acknowledge its children and its children did not recognize their own country. You found the bestiality of capitalism unacceptable, that it infiltrated our lives and no one tried to stop it. Then, you made your decision to become the fear, the death, the memory, the sorrow of our ruined lives.

Amy Goodman: Sanjay Basu, you have found more than 10,000 additional suicides and up to a million extra cases of depression across Europe and the United States. Since when? How did you come up with these figures?

Dr. Sanjay Basu: Right. One of the major questions we asked here: Is this inevitable during a recession? Recessions are bad times. Could this just be the recession’s effects as opposed to austerity’s effects? And so, what we did is used so-called natural experiments. We compared regions and countries since the beginning of the recession, and even beforehand, to control for people’s pre-existing conditions, pre-existing mental health and alcoholism and so forth, and also compared areas that faced the same economic shock but had different policy responses. And looking at those as comparative cases, we could find that, in fact, during recessions, inevitably suicides or alcoholism didn’t increase, but rather, it was after austerity, in particular. And controlling for other factors that could statistically explain this, austerity consistently came up as a key trigger not just for suicides, but for alcohol, stress-related heart attacks and other major causes of death.

Amy Goodman: Now, this is the key point here, is the difference—I mean, people can say, "Well, hard times lead to, you know, very painful decisions that people make."

Dr. Sanjay Basu: Mm-hmm.

Amy Goodman: But that you’re saying that even in equally difficult situations, when countries opt for another solution, the public health of that community changes.

Dr. Sanjay Basu: Correct. We can look, for example, at Iceland as a contrast. Now, Greece and Iceland are very different socially, politically and economically, but Iceland serves as a nice case in point right now. They had faced a debt at 800 percent of GDP, the largest banking crisis in history compared to the size of the economy.

Amy Goodman: When their banks failed, their three top banks failed.

Dr. Sanjay Basu: Correct, all three major banks failed. And they had invested, of course, in U.S. mortgage-backed securities. After this, the Iceland politicians decided to do something truly unique as compared to the rest of Europe. They actually put the austerity plan to a public vote. And the public voted that instead of paying off bankers’ debts immediately through public cuts, they would instead do it gradually. They would still bail out their banks, but over the course of time and with great pace towards preserving their social safety net. And indeed what Iceland ended up doing was maintaining some of the healthiest standards in the world and the highest level of happiness.

Amy Goodman: We were just joined by the Icelandic Parliamentarian Birgitta Jónsdóttir onDemocracy Now! here in New York—she had just come in from Iceland—talking about how Iceland recovered from the collapse of its banking system. A part of what the country did, as you said, was to preserve its universal healthcare system.

Birgitta Jonsdottir: Actually, everybody has the same access to health and education. So even I, as an MP, ended up in a hospital in November, and I got exactly the same treatment as the woman working in the factory or in McDonald’s or Domino’s. And I like that. I love that. I think that is so important. And so, we pay just about the same amount of taxes as U.S. taxpayers. We don’t have to live in this insurance jungle. So we just, you know—and that was actually one of the first things they wanted to slash down, the IMF—no surprise.

Amy Goodman: They preserve their healthcare system.

Dr. Sanjay Basu: Mm-hmm. And indeed she highlights one of the key issues here, which is that there’s a great misunderstanding around debts and deficits. When we face a liquidities crisis, meaning that there’s a collapse in demand in the system, we actually find, quite robustly, through peer-reviewed journals and consistent with those of our colleagues, that stimulus early on does not actually produce higher, longer-term debts, but it generates the revenue and the building of the economic cycle that allows us to pay off those longer-term debts. By contrast, these short-term cuts end up so slowing the economic cycle that we find both economic and public health devastation as a result.

Amy Goodman: After break, I want to talk about the U.S., but, David Stuckler, you said you looked at the labor policies of places like Sweden and Finland in times of recession.

David Stuckler: It’s a remarkable case study. It alludes to what Sanjay mentioned earlier. Sweden faced a large banking crisis. Unemployment jumped by more than 10 percentage points. And yet suicides fell steadily. What we learned is that when politicians managed the consequences of unemployment well, they were able to prevent a mental health crisis. The specific programs we found are called active labor market programs. These help the newly unemployed link to caseworkers, develop an action plan and return into jobs. They treat unemployment like the pandemic it is. It not only saves money on healthcare bills, but even pays for itself by helping spur economic recovery.

Amy Goodman: We’re going to talk about what choices the United States is making, with David Stuckler and Sanjay Basu. Their book is called The Body Economic: Why Austerity Kills. Stay with us.

[break]

Amy Goodman: The Centers for Disease Control and Prevention recently revealed the suicide rate in people aged 35 to 64 rose by nearly 30 percent over the past decade, to 17.6 deaths per 100,000. The biggest increase was seen for men in their fifties, where the suicide rate increased 50 percent. Overall, suicides are now a greater cause of death in the United States than car accidents.CDC Director Thomas Frieden recently spoke to PBS NewsHour.

Dr. Thomas Frieden: We don’t know what specifically is causing it, but the trend has been consistent. And, if anything, our numbers would underestimate the gravity of the problem. And, of course, even one death from suicide is a terrible tragedy, and many of them are preventable. We know that in times of financial stress, there is generally an increase in suicides. We also know that this is a generation that grew up at a time when they expected more than some have been able to achieve in their lives, and also that they’re stressed with what their kids are going through and what their parents are going through. So it’s, in some ways, the sandwich generation.

Amy Goodman: That’s CDC Director Thomas Frieden on PBS. We’re joined by David Stuckler and Sanjay Basu. They are authors of The Body Economic: Why Austerity Kills. David Stuckler is a senior research leader at Oxford University, and Sanjay Basu is an assistant professor of medicine and epidemiologist at Stanford University. If you could respond, Dr. Basu, to Dr. Frieden’s comment?

Dr. Sanjay Basu:Yeah, I certainly agree with Dr. Frieden’s comment. And what we have found in our research is that these suicide rate spikes seem to correspond quite closely to state-level unemployment rates. And in particular, when we do these long-term studies that track individuals before the recession, during the recession and after, we can control for their pre-existing mental health statistically, and we find that it’s the new unemployment that seems to trigger new onset of depression and suicide, particularly among our most vulnerable, adults over 50, who, when they lose a job, are often discriminated against or have a very hard time finding new work. There’s a great deal of shame, and also it’s quite hard for our healthcare system to access those individuals, given the degree of barriers that they have, social barriers, to accessing mental healthcare.

Amy Goodman: I mean, the point for people to understand in this country is, what’s unusual for us, compared to other countries, is that when we lose our jobs, we lose our health insurance.

Dr. Sanjay Basu: Absolutely. And we do have some safety nets in the form of Medicaid, Medicare, but it’s quite true that there are some large holes in that system, as has been repeated time and time again.

Amy Goodman: During an interview on Fox News in February, Republican Senator Lindsey Graham of South Carolina suggested slashing healthcare to stop scheduled sequester cuts from, quote, "destroying the military."

Sen. Lindsey Graham: The commander-in-chief thought—came up with the idea of sequestration, destroying the military and putting a lot of good programs at risk. Here’s my belief. Let’s take "Obamacare" and put it on the table. You can make $86,000 a year in income and still get a government subsidy under "Obamacare." "Obamacare" is destroying healthcare in this country. People are leaving the private sector because their companies can’t afford to offer "Obamacare." If you want to look at ways to find $1.2 trillion in savings over the next decade, let’s look at "Obamacare." Let’s don’t destroy the military and just cut blindly across the board.

Amy Goodman: David Stuckler, can you respond to Senator Graham?

David Stuckler: Austerity in health is a false economy. The cliché, an ounce of prevention is worth a pound of cure, is really true. New York City officials learned this the hard way in the early 1990s, when they cut TB prevention programs by $120 million but ended up with a drug-resistant TB outbreak that cost more than $1.2 billion to control. What we found is that smart investments in public health can have a return on investment, for each dollar, of up to $3.

Amy Goodman: So, talk about the healthcare system, Dr. Sanjay Basu, how sequester fits in, and also just what Lindsey Graham was talking about, "Obamacare."

Dr. Sanjay Basu: So, I’m not a politician and—but I do analyze data. And I think, in looking comparatively among OECD countries, you see a lot of false claims about the U.S. health system. Why is it that we cost so much more and seem to be getting less? I think comparing our country to other OECD stations provides some sense of what—

Amy Goodman: You’re talking about European countries?

Dr. Sanjay Basu: European, as well as Japan, Australia and so forth. And you can see a lot of the myths by just looking at the data. So, what are the theories? The theory is, for example, maybe it’s just American obesity. Well, actually, the costs started well before American obesity and doesn’t seem to correspond actually statistically to obesity. Maybe it’s that we have an older population, but not so. Switzerland actually pays more in nursing home care. Japan has an older population, yet they still pay less while getting more in terms of health. Maybe it’s just technology. We do a lot of research and development. But, in fact, if you look at the Securities and Exchange Commission data, the R&D pharmaceutical industry, while making—

Amy Goodman: Research and development of the pharmaceutical companies.

Dr. Sanjay Basu: Sure. While they make a higher percent profit as a percentage of revenue than any other Fortune 500 industry at the moment, they actually spend almost double on marketing as compared to research and development. And while we do use more technology and we do tend to have some higher costs from technology, it doesn’t actually explain the majority of the bundle.

What you do see, on the other hand, if you just look at the raw data, is that we get more—we get more incentives in order to test the people who are covered, in order to bill more. And there’s a lot of companies making quite a bit of money on that margin. You can go to one hospital across town and be charged double or more of what another hospital has on a different side of town. But it’s not like a consumer market. If I’m in a car accident, I can’t say to the surgeon, "Hold my hand there for a moment before sewing it back on. I’m just going to go across town and compare prices for a minute."

So healthcare is a different kind of industry, in which we have what is classically called "market failure" by the Nobel Prize winner Kenneth Arrow back in the ’60s, but people ignored his work. I think what we really have is a system where we confuse inequality with choice. The majority of our costs come from common conditions in a small number of patients who have complications of diabetes, heart failure, hypertension. And we need more primary care prevention rather than paying for the ICU care.

Amy Goodman: I wanted to go back, and this is a theme you follow in The Body Economic, to the Depression. Going back to the Great Depression and the New Deal, this is President Franklin Delano Roosevelt speaking in 1933.

President Franklin Delano Roosevelt:It is three months, my friends, since I have talked with the people of this country about our national problems. But during this period, many things have happened. And I am glad to say that the major part of them have greatly helped the well-being of the average citizen.

In the short space of these few months, I am convinced that at least four million have been given employment, or saying it another way, 40 percent of those seeking work have found it. That does not mean, my friends, that I am satisfied or that you are satisfied that our work has ended. We have a long way to go, but we are on the way.

We come to the relief, for a moment, of those who are in danger of losing their farms or their homes. I have publicly asked that the foreclosure on farms and cattles and homes be delayed until every mortgagor in the country has had full opportunity to take advantage of federal credit. And I make the further request that if there is any family in the United States about to lose its home or its farm, that family should telegraph at once, either to the Farm Credit Administration or the Home Loan Corporation in Washington, requesting their help.

Amy Goodman: That was President Franklin Roosevelt in 1933. I think this is going to be very interesting for a lot of people listening and watching this today. David Stuckler, the choices made then and the choices being made today?

David Stuckler: Completely different. Roosevelt took bold steps, at a time when debt was 180 percent of GDP, to boost financial relief to the newly unemployed, to save Americans from homelessness. And we’ve studied the effects of his landmark program, the New Deal, on health. And what we found is that, comparing the states, the red and blue states, that pushed it to different degrees—the blue states tended to go further with the New Deal than the red states—led to a polarization in public health outcomes across the U.S. The greater relief spending implemented under the New Deal helped reduce suicides, reduced tuberculosis and pneumonias, and was in fact the biggest and one of the most effective public health programs on U.S. soil.

Amy Goodman: When you hear politicians today saying, "We’ve got to cut 'Obamacare.' We’ve got to cut healthcare in this country," talk about what you found, what it means for the economy to invest in public health.

David Stuckler: Investing in public health is a wise choice in good times and an urgent necessity in the worst of times. Had austerity been organized like a clinical trial, it would have been discontinued, given evidence of its deadly side effects. There is an alternative choice that we found in the historical data and through the present recessions, that when we place people and their health at the center of economic recovery, it can help get our economy back on track faster and yield lasting dividends to our society.

Amy Goodman: The issue of the West Nile outbreak, can you talk about that?

Dr. Sanjay Basu: Mm-hmm. Down in Bakersfield in California, there was a suspicion about why crows were dropping from the sky and people were also showing up in hospitals. A variety of theories were posited, ranging from polio to heat stroke, but in fact it amounted to a West Nile outbreak that, through a number of our colleagues’ research, it was found that the abandoned and foreclosed homes had stagnant water in old swimming pools and in other locations that were breeding mosquitoes. And this led to a rather large West Nile outbreak. Indeed, the reason why it was discovered was something called the California Encephalitis Project, a group of public system laboratories that work in concert with the CDC. And ironically, after helping to control that outbreak, they were closed due to budget cuts.

Amy Goodman: I want to turn to the issue of drug abuse. A recent film by Vice has brought renewed attention to the drug crisis in Greece, particularly the use of the new drug called sisa. This is Haralampos Poulopoulos, head of KETHEA, the main anti-drug center in Greece.

Dr. Haralampos Poulopoulos: Sisa is a form of crystal methamphetamine. They use amphetamines and some other liquids, sometimes battery liquids, to produce this drug. It’s very dangerous for the health of the users. I think the main reason for the increase of sisa is the changes of the attitudes of drug users during the crisis. They are more self-destructive. We have 27 percent unemployment, 62 percent the young people under 25. We didn’t finish yet with the crisis. We are in the middle of the crisis.

Amy Goodman: Haralampos Poulopoulos, head of the main anti-drug center in Greece. David Stuckler, talk about that, and also relate it to here, as we wrap up.

David Stuckler: This is a devastating situation we’re seeing in Greece with a drug crisis escalating at a time when drug prevention budgets are being cut. With gaping holes in social safety nets from austerity, people are becoming desperate, turning to the means of self-harm. We’ve seen drug use and infected needles spread HIV, creating rise of more than 200 percent, leading to an epicenter of HIV/AIDS spread in Europe.

What we can learn from these mistakes, and areas where we see successes in policy, is that recessions can hurt, but austerity kills. When politicians make smart choices to protect people during hard times, it doesn’t happen at expense of recovery but can help put our societies back on track to a happier, healthier future.

Amy Goodman: And here in the United States, how that translates into policy?

David Stuckler: Currently, we’re facing and implementing a large sequester in the U.S. While it’s too early to see the full health consequences, what we are seeing is the Women, Infants, Children’s health program, which provides nutritional subsidies to women, will be forced to reduce those subsidies from 600,000 pregnant women. And that program has been linked to reducing infant mortality. We’re also seeing large cuts to public housing budgets at a time when 1.4 million homes are still in foreclosure. We are concerned that, if done rapidly and indiscriminately, that budget cuts in the U.S. could create a repeat of the disasters that we’re seeing in Europe.

Amy Goodman: Final comment, what most shocked you in writing The Body [Economic], Sanjay Basu?

Dr. Sanjay Basu: You know, coming from the public health field, we have something called the "precautionary principle," which is that when a idea or policy is controversial, we should first do whatever protects people the most. And what we’re doing is entirely the opposite. We’ve essentially had a massive untested experiment. That experiment has failed, and it sounds like it’s quite deadly, given all the data through history.

Amy Goodman: I want to thank you both for being with us. Sanjay Basu is an epidemiologist at Stanford University. David Stuckler, Oxford University. Their new book, out today, The Body Economic: Why Austerity Kills—Recessions, Budget Battles, and the Politics of Life and Death.

Reprinted with permission from Democracy Now!.

How Coca-Cola's Ruthless Business Tactics Created a Despicable Global Powerhouse

Jill Richardson, AlterNet — Mon, 20 May 2013 11:27:00 -0700

Mark Pendergast's book, "For God, Country, and Coca-Cola" guides readers through decades of shrewd marketing campaigns and the company's ugly history.

For God, Country, and Coca-Cola by Mark Pendergast is the definitive history of the product so many see as a symbol of America itself. This impressive tome – recently released as a third edition with added new material – is not a critique of Coca-Cola, nor is it a fan’s tribute, as Pendergast reveals things the Coca-Cola Company doesn’t want you to know. (Yes, it used to contain cocaine.) He even reveals the drink’s original secret formula (which is less exciting than you might think).

Coca-Cola is not fascinating for what it is – colored sugar water with bubbles – but for what it represents. And that’s a point long known by the company’s marketers, with the exception of when they forgot it during the New Coke fiasco in the 1980s. Today, marketing students in business schools everywhere study that famous gaff.

Despite the decades-old slogan, “Delicious and Refreshing,” people do not drink Coca-Cola for the taste. They drink it because they associate it with positive things like friendship, fun, patriotism, and athleticism. Careful to market the drink to all people, everywhere, without alienating anyone, the ads are often vague. “Coke is It!” What is “it”? It’s whatever you want it to be, just as long as it makes you want to buy more Coke!

The book guides readers through the decades of marketing campaigns that built this image, most significantly during World War II, when Coca-Cola was made available to U.S. soldiers everywhere in the world, often at the government’s expense. When sales slumped, the answer was never changing the flagship product; it was a new ad campaign. Remind consumers that Coke = fun (or simpler times, or hope, or whatever feeling they crave) and they will drink more of it.

Because constant, never-ending growth is seen as essential, the other necessity is finding new channels to facilitate more Coke-drinking than ever before. Today, you can be 50 miles from nowhere in any country except Cuba and North Korea and if you crave an ice-cold Coca-Cola, you can get one. Even in places where few have clean drinking water or electricity, both needed to produce ice-cold Coke, some enterprising entrepreneur will have electricity and a cooler and plenty of Coke. The same cannot be said of nearly any other product.

The New Coke failure punctuates this strange phenomenon – that the world loves and guzzles an unhealthy beverage, but not for its good taste. Pepsi showed that in blind taste tests, more people prefer Pepsi over Coke. New Coke was tastier than both Coke and Pepsi in blind taste tests. Surely consumers would love it. Except, they didn’t. They wanted fun, hope, patriotism, and everything else they associated with good, old-fashioned Coca-Cola, not some new, better-tasting concoction.

Readers seeking the dirt on Coca-Cola’s sordid past with Columbian paramilitaries and Guatemalan death squads will find these episodes covered briefly in this book. But the completeness of the company’s history in this book paints a bigger picture, and Coca-Cola’s tangles with death squads fit in as just one piece.

This is a company devoted to, above all else, making as much money as possible and selling as much Coca-Cola as possible. Period. Nazis get thirsty, too, you know. In almost every case, the company tried to please everyone and sell to everyone, without taking sides, unless it had no choice.

It’s no good that Coca-Cola did business with a Guatemalan bottler who allegedly hired death squads to murder employees trying to unionize. But that is all part of a larger pattern, a larger scandal – although there’s no conspiracy at all. The drive to increase profits and sales and market share at all cost is the company’s story, plain and simple. It took us from a 6.5-ounce drink only available at soda fountains to one available everywhere in sizes as large as 64 ounces.

Coca-Cola told us it wanted to teach the world to sing, but it’s far more likely it is giving the world diabetes. Today, a small Coke at McDonalds is 16 ounces. Pendergast, ever the balanced journalist presenting both sides, fails to definitely state that Coca-Cola is unhealthy. He generously points out that Coca-Cola creates jobs and donates to charity, even though he notes the company’s policy of “strategic philanthropy” – i.e. using “charitable” donations to gain access to valuable markets, particularly children.

The book is a long and somewhat exhausting read, but it’s also a captivating history of the development of America’s consumer culture (and terrible dietary habits) and it contains fascinating profiles of the men (yes, mostly men) behind the company, making readers wonder what a psychologist might have to say about these often tyrannical, driven workaholics.

Here are some answers Pendergast gave about his book and the company he wrote about.

Jill Richardson: Why did you choose the title For God, Country, and Coca-Cola?

Mark Pendergast: Coca-Cola has been a kind of religion to many people, including the inventor, John Pemberton, who died two years after he came up with it, and Asa Candler, who took it over and used to lead the singing of "Onward Christian Soldiers" at his sales meetings.

These were days when the drink was under attack for having cocaine in it and even afterwards for its caffeine content. So they felt like early Christian martyrs in a way, fighting for a just cause. Candler called Coca-Cola "a boon to mankind." Coke employees have always joked that they have Coca-Cola syrup flowing in their veins.

The drink has also become a kind of religion for consumers, a symbol of the American way of life as well. During World War II the drink was deemed an "essential morale booster" for the troops, and it was served in lieu of communion wine during the Battle of the Bulge. When New Coke was introduced in 1985, people wrote anguished letters as if they had killed God. Here is an actual letter I quoted in the book: "There are only two things in my life: God and Coca-Cola. Now you have taken one of those things away from me." I could go on....

JR: Can you explain Coca-Cola's relationship with the two ingredients in its name, coca and kola nuts? How much cocaine was initially in the product and when was it removed?

MP: Coca-Cola was named for its two principal drug ingredients. Coca leaf from Peru contained cocaine. Kola nut from Ghana contained caffeine. Original Coca-Cola had a very small amount of cocaine in a six-ounce drink, about 4.3 milligrams. The company took out all but a minuscule amount of cocaine in 1903 and the final amount in 1928.

JR: You imply in the book that it's attempted to sugarcoat (no pun intended) this part of its past, saying at some points that the product never contained cocaine. Is that true? Can you elaborate?

MP: Every time I go to the World of Coca-Cola museum in Atlanta, I ask the guides if Coca-Cola ever contained cocaine. They assure me that it did not. The official company line seems to be that Coca-Cola never contained added cocaine -- i.e., they didn't add white powdered cocaine, which is true. But it did contain fluid extract of coca leaf, which contains cocaine. For years, the company line has also been that the name "Coca-Cola" is just a "euphonious combination of words" -- i.e., it sounds nice. True, but the drink was also named for its two principal drug sources.

JR: How did Coca-Cola use World War II to establish its dominance abroad? And what impact did its role in the war have for their market at home?

Robert Woodruff, the head of Coca-Cola, declared shortly after the attack on Pearl Harbor that, "We will see that every man in uniform gets a bottle of Coca-Cola for five cents, wherever he is and whatever it costs our company." Coke was subsequently declared an essential product and Coke men called Technical Observers were sent overseas in army uniforms at government expense to establish 64 bottling plants behind the lines. As a result, Coca-Cola was put in position for global expansion in the postwar world.

American soldiers came home with an overwhelming preference for Coca-Cola. In a 1948 poll of veterans, conducted by American Legion Magazine, 63.67 percent specified Coca-Cola as their preferred soft drink, with Pepsi receiving a lame 7.78 percent of the vote. In the same year, Coke’s gross profit on sales reached a whopping $126 million, as opposed to Pepsi’s $25 million; the contrast in net after-tax income was even more telling, with Coke’s $35.6 million towering over Pepsi’s pathetic $3.2 million.

Soon after the war, when the Army quizzed 650 recruits, 21 had never drunk milk, but only one soldier had never sampled a Coke. As the company’s unpublished history stated, the wartime program “made friends and customers for home consumption of 11,000,000 GIs [and] did [a] sampling and expansion job abroad which would [otherwise] have taken 25 years and millions of dollars.” The war was over, and it appeared, at least for the moment, that Coca-Cola had won it.

JR: The impact when Coca-Cola entered new markets was increased sales for all beverages, not just Coca-Cola -- and less consumption of water and milk. Can you explain that?

Yes. As Coca-Cola and subsequently other competing soda companies increased marketing and other campaigns to out-do one another, that's what expanded the total soda market. When the market for soft drinks expanded, it helped competitors such as Pepsi, and when people are paying attention to the cola wars, they are less focused on water or milk.

JR: Coca-Cola's history practically reads like a marketing textbook. Can you tell us about its revelation of the little girl's Pooh bear? Why do Coke-drinkers love Coke so much?

Archie Lee, who was the ad man behind "The Pause That Refreshes" slogan during the Depression, noticed during a beach vacation, that his four-year-old daughter lavished such attention on her Pooh bear that other children fought over it, though other toys appeared more attractive. Lee took the incident as a parable. “It isn’t what a product is,” he wrote to Robert Woodruff, “but what it does that interests us”—and set out to plant the proper thoughts about Coca-Cola, which he wanted to make as popular and well-loved as the Pooh bear.

Coke lovers care so much about the drink for many reasons -- not least the ubiquitous, effective advertising that associates the drink with youth, energy, happiness. But many people also really do associate the drink with some of the best times in their lives.

JR: How has soda consumption changed in the U.S. from the drink's introduction over a century ago, back when a serving was 6.5 ounces? Was there ever a "turning point" when Americans switched from more modest per capita soda consumption to the amount they drink today, or has it been a gradual change over time?

MP: Amazingly, Coca-Cola was served in 6.5 ounce bottles for a nickel until 1955, when King-Size Coke was finally introduced. (“King-Size” drinks were 10 and 12 ounces, smaller than a McDonald’s small today.) Since then, the sizes grew steadily larger, and PET bottles meant they wouldn't break and weren't too heavy. Super-size me, indeed. But over the last decade, concern over the obesity epidemic has made Coca-Cola back off a bit, and now the company has introduced smaller mini-cans, along with the huge containers.

JR: Over the years, Coca-Cola has dealt with Nazis, dictators, South Africa's apartheid government, and even allegedly Guatemalan death squads. Should consumers hold Coke accountable for this dark part of its history, or is it all water under the bridge? Do you agree with Coke's position that it doesn't play politics, it just sells soda?

MP: Of course, the company, like any other business, should be held accountable for its actions, although as you suggest, many of these episodes are safely in the past. The Guatemalan death squads were in the late 1970s. Paramilitaries in Colombia killed union employees in similar fashion in Coke bottling plants in the 1990s.

Quite recently, human rights violations have once again occurred against Guatemalan bottling employees. The Coca-Cola Company has usually attempted to distance itself from such violence, saying that it doesn't control its bottlers, but that seems disingenuous, since the bottlers rely on Coca-Cola syrup from Big Coke.

On the other hand, let me point out that while Coke did business inside South Africa during the apartheid regime, it left the country for a while and then was very instrumental in helping to ease a peaceful transition to black rule under Nelson Mandela.

JR: The past decade has ushered in an enormous change in Coca-Cola's product portfolio. How has it changed and why? Do you think the day will come when Coca-Cola's flagship product is no longer its top seller?

MP: Coca-Cola has diversified in the face of increased competition from other types of beverages and in response to concern over the obesity epidemic. It purchased Glaceau, maker of Vitaminwater, for $4.1 billion, for instance, in 2007. Today the Coca-Cola Company sells 3,500 beverages worldwide, and about a quarter of them are low- or no-calorie.

The future is hard to predict, but I don't think that Coca-Cola will lose its place as the flagship product in the foreseeable future -- but I do predict that the combined sales of Diet Coke and Coca-Cola Zero will eventually surpass sales of regular sugary Coca-Cola.

Bill Moyers: 12 Ways You Can Avoid Toxic Chemicals

Lauren Feeney, Bill Moyers — Sun, 19 May 2013 12:29:00 -0700

Lead, flame retardants, and BPA are everywhere, but you can limit your exposure.

After watching this week’s interview with Gerald Markowitz and David Rosner, you’ll probably be wondering what you can do to protect yourself and your family from toxic chemicals. Perhaps the most important thing you can do is become politically involved – join the fight against both chemicals in our environment and money in our political system. In today’s world, it’s virtually impossible to avoid dangerous chemicals, even in your own home, but here are a few simple steps you can take to limit your exposure to known toxins like lead, flame retardants and BPA.

Lead

If you think that lead poisoning is a problem of the past, or one that only affects the urban poor, think again. While it’s true that lead paint has been illegal since the 70s and leaded gasoline was phased out in the 80s, the highly toxic substance still lurks in old homes, parking lots, water pipes, and in products imported from countries that don’t have the same regulations. And while lead poisoning no longer the killer it once was, miniscule amounts of lead can cause neurological damage and behavioral problems in children. According to the CDC, there are currently half a million children with elevated levels of lead in their blood. Here’s what you can do to protect your family from lead poisoning:

1) Find out if there’s lead in your water. A good place to start is with your local government. website. At NYC.gov, for example, you can order a free testing kit. You can also try contacting your local water company, your landlord or a private lab. You may also want to install an NSF-certified water filter on your water tap. Though the EPA has mandated that water systems be tested for lead since 1991, your home’s own internal plumbing could still contain lead, particularly if you live in an older building.

2) Replace old windows. Though lead paint has been illegal since 1978 and has largely been removed from old buildings, in some cases, it was seen as too costly to replace the windows. To have your windows replaced (or to do any sort of renovation on a building that may still contain lead paint), contact an EPA-certified renovator who has been trained to follow lead safety practices. In some cases, your local government may cover the costs.

3) Throw out colorfully-painted toys that were made outside the U.S. or Europe. They may look innocent, but toys, crayons, ceramic and jewelry, particularly those manufactured in China or Mexico, may contain lead, and as any parent knows, children are likely to put these things in their mouths.

4) Dust or vacuum regularly. Even without any obvious source of lead in your home, there may still be lead in the air, particularly if you live in an industrial area or if a neighbor has been renovating an old home. Dust particles containing lead are especially dangerous to babies who crawl around on the floor. It’s also important to keep toys and hands clean.

5) Test the soil. Urban and suburban yards can still contain contaminants from the days when lead paint and gasoline were widespread. Before planting a garden or even letting your kids run around in the yard, make sure the soil is lead-free. Your local public health department may offer free testing; you can also contact a private or university-run lab.

Flame Retardants

The hazards of flame retardants have been known for some time — brominated tris was banned from children’s pajamas back in 1977. And yet, similar chemicals can still be found in everything from couch cushions to television sets. Studies have linked one group of flame retardants, polybrominated diphenyl ethers, or PBDEs, to lower IQs, behavioral problems, early puberty and fertility issues. And the fire-safety benefits of these chemicals are debatable. Here’s what you can to keep toxic flame retardants out of your home:

1) Check the labels on your furniture. The California Furniture Flammability Standard essentially requires that cushioned furniture, children’s car seats, diaper-changing tables and other products containing polyurethane foam are dipped in toxic chemicals. (Don’t breathe a sigh of relief just because you live in one of the other 49 states — because of California’s size, most mass-produced furniture is designed to meet California’s standard). Check the tags for the familiar notice: This article meets the flammability requirements of California Bureau of Home Furnishings Technical Bulletin 117. (The tag is not required though, so just because you don’t see it doesn’t mean it’s safe.) Fortunately, California has proposed changing the rule; until that happens, you can look for products made with wool, cotton or polyester filling instead of polyurethane foam. And if you can’t afford all new eco-friendly furniture, be sure to dust, vacuum and wash your hands regularly — most of the toxins enter the body by swallowing contaminated dust.

2) Check the labels on electronics, too. Flame retardants have long been used in electronic equipment like computers and television sets. Thankfully, that’s slowly changing. As of 2008, the following companies had committed to phasing out all brominated flame retardants: Acer, Apple, Eizo Nanao, LG Electronics, Lenovo, Matsushita, Microsoft, Nokia, Phillips, Samsung, Sharp, Sony-Ericsson, and Toshiba. To find flame retardant-free versions of everything from refrigerators to nose-hair clippers, check this list created by ChemSec, an environmental non-profit based in Sweden.

3) Beware of fleece pajamas. Though one flame retardant, brominated tris, was banned from children’s pajamas, some sleepwear is still treated with another flame retardant called PROBAN which has been linked to genetic abnormalities and cancer. Check the label — children’s pajamas that DO NOT contain flame retardants must have a tag that reads: “For child’s safety, garment should fit snugly” (the snug fit limits the flow of oxygen in order to prevent fire from spreading, an approved alternative to chemical flame retardants). Cotton and polyester products rarely contain flame retardants, but look out for those cozy fleece footed pajamas — they usually do.

BPA

Bisphenol A, or BPA, has been linked to cancer,asthma, obesity and reproductive issues. And yet, until recently, the chemical was found in, among other things, baby bottles. The FDA finally banned the use of BPA in baby bottles and children’s sippy cups in 2012 — three years after major manufacturers had voluntarily stopped using it. But BPA is still found in other hard plastic containers, the lining of metal cans and the paper that receipts are printed on. It’s difficult to completely avoid BPA — 90 percent of Americans have traces of the chemical in their urine. But here are some things you can do to limit your exposure:

1) When purchasing plastic products — particularly those that come into contact with your food, such as food storage containers, plastic plates and cups, look for those that are clearly marked BPA free. Thanks to vocal consumers, many companies are now manufacturing BPA-free products and marketing them as such.

2) Avoid food containers marked with recycling codes 3 or 7, which may be made with BPA. If your food does come in a container marked 3 or 7, don’t microwave it in that container – chemicals are more likely to leak into your food at high temperatures.

3) Limit your consumption of canned foods, or look for cans marked BPA free — they are rare, but do exist. Eden Organic cans have been BPA free since 1999.

4) BPA is often used in the thermal paper that receipts are printed on. Since it’s impossible to know whether or the receipt you’re being handed has contains BPA, don’t take receipts that you don’t need. If you operate a business that uses receipts, switch to a BPA-free paper manufacturer, such as Appleton Paper, which went BPA-free in 2006.

Bill Moyers: Our Media Is Polluted by Toxic Lies About the Risks Posed by Lead

Bill Moyers, David Rosner, Gerald Markowitz, BillMoyers.com — Fri, 17 May 2013 14:43:00 -0700

There’s no safe level of exposure to this dangerous toxin still lurking in millions of homes, but that truth is consistently under attack from industry-funded public relations excecutives.

From BillMoyers.com:

INTRO:Science can be a battleground — witness the politics of climate change, the teaching of evolution, the uncharted terrain of genetic modification and stem cell research, among other contentious issues. But when industries release untested chemicals into our environment — putting profits before public health — our children are the first to suffer. Nowhere is this more troubling than in the ongoing story of lead poisoning.

Bill talks with David Rosner and Gerald Markowitz, public health historians who’ve been taking on the chemical industry for years — writing about the hazards of industrial pollution and the neglect of worker safety — despite industry efforts to undermine them. Their latest book, Lead Wars: The Politics of Science and the Fate of America’s Children, is the culmination of 20 years of research. Markowitz and Rosner warn that, for young children, there’s no safe level of exposure to this dangerous toxin still lurking in millions of homes.

The authors discuss thwarted efforts to hold the lead industry accountable, failed attempts to find cheap solutions, and the cost to the future of our children. As long as the chemical industry and its powerful lobbies prevail in blocking efforts to reform outdated laws, Markowitz and Rosner say, we will continue to float in a soup of toxins — inhaling, drinking, and absorbing chemicals that we may learn, years later, have put us all in harm’s way.

***

BILL MOYERS: At the end of a week that reminded us to be ever vigilant about the dangers of government overreaching its authority, whether by the long arm of the IRS or the Justice Department, let’s pause to think about another threat, from too much private power over public policy.

All too often, instead of acting as a brake, government becomes the enabler of corporate power and greed, undermining the very rules and regulations intended to keep us safe.

Think of inadequate inspections of food and those infections which kill 3,000 Americans each year and make many millions sick. Think of the 85,000 industrial chemicals available today. Only a handful have been tested for safety. Think of the explosion of perhaps as much as half a million pounds of ammonium nitrate in that Texas fertilizer plant. People can die when government winks at bad corporate practices.

As long as there are insufficient checks and balances on big business and its powerful lobbies, you and I are at their mercy. Which is why their ability to buy off public officials is an assault on democracy and a threat to our lives and health. Keep that in mind as I introduce you to David Rosner and Gerald Markowitz.

Some years ago, their book, Deceit and Denial, told how the chemical industry tried to conceal the truth about untested and unregulated chemicals in our food, water, and air. Twenty companies responded with a vicious campaign to smear their reputations. That proved hard to do, actually, impossible.

Gerald Markowitz is a distinguished professor of history at both John Jay College of Criminal Justice and the City University of New York’s Graduate Center. David Rosner is co-director of the Center for the History and Ethics of Public Health at Columbia University where he also teaches science and history.

This is their new book, which revisits a chemical menace you might have thought was behind us, but isn’t: Lead Wars: The Politics of Science and the Fate of America’s Children.

BILL MOYERS: Gerald Markowitz, David Rosner, welcome.

DAVID ROSNER: Thank you.

GERALD MARKOWITZ: Thank you.

BILL MOYERS: Your book concludes that after all these years, lead is still a problem.

GERALD MARKOWITZ: Absolutely. You know, in some ways the story of lead is a great success. We’ve reduced the amount of lead in children's blood and we've gotten lead out of gasoline and we've gotten lead out of paint. But there are still children who have too much lead in their blood. And it is endangering their life chances, endangering their futures.

BILL MOYERS: Does it kill?

DAVID ROSNER: It doesn't kill anymore. It used to send kids into convulsions, into comas and into paroxysms and ultimately killed them up until the 1980s. But we've gotten lead levels down to the point where we're now discovering new, even in some sense, more troubling problems.

BILL MOYERS: What's the most important thing you've discovered about lead since we last talked?

DAVID ROSNER: Well, that in what we would once have considered miniscule amounts lead in children can cause neurological damage, causes behavioral problems, attention deficit disorders, dyslexia. Studies show that children who are exposed in utero can have permanent neurological changes that put them at risk later in life for learning disabilities that lead to failure in school and IQ loss. There are a whole series of problems that we never even thought about in the old days, so to speak.

GERALD MARKOWITZ: It's shocking that we know that children can be prevented from any kind of lead poisoning if they are, live in a home that is lead free. And this is no longer, you know, a priority of the country. We still have many homes millions of homes that contain lead that are endangering our children.

BILL MOYERS: Is it the cost of getting rid of the lead from homes that are already established and we're living in, is that the main barrier?

DAVID ROSNER: For some it is. But the history of public health, and that's what we are, historians, is rife with examples of decisions that are very costly that we decided are necessary for the population as a whole.

But somehow because we have in some sense accepted a definition of what the problem is and who the victims are and we've devalued their lives, we decided not to address this issue because it's quote, “too costly.”

GERALD MARKOWITZ: We really made a morally bankrupt calculation that it is less costly to endanger the health and futures of our children rather than to protect them by paying to remove lead from their homes.

DAVID ROSNER: The message really should be is we need to really think of lead as one symbol, one symptom of this much larger problem of the pollution of our children, pollution of their lives, the pollution of all of us from a whole host of toxic materials that we are, we've grown accustomed to using and tend to put out of our consciousness.

BILL MOYERS: When I first met you, people were saying, scientists were saying, that the smaller the dose of lead, the exposure to lead, the safer it would be.

GERALD MARKOWITZ: Scientists now say that it is very likely there is no safe level of lead, that any amount of lead in a child's body, in a child's blood, you know, causes a variety of neurological and intellectual problems. So this is really a sea-change in our understanding of what, the amount of a toxin that causes a problem for children.

DAVID ROSNER: We no longer have children convulsing and going into comas. In other parts of the world they still are from lead exposures. In Africa, in Nigeria, children still are exposed to huge amounts of lead from a variety of sources. And a recent article indicates that we're still selling lead paint, for example, to other countries despite the fact that we in this country no longer use it on our walls. But if you look at where lead poisoning is most prevalent, when you look at the communities that are most affected by lead they're usually communities, poor communities, working class communities, parts of the cities that are more run down because the lead that is dangerous is the lead that comes off of walls of old buildings. And walls of old buildings that are not maintained give off more lead than walls of old buildings that have been recently renovated. It's hard to believe how much lead there is in an old home. I mean, we often think of paint as just a lot of liquid with a little bit of color. But in fact, when you looked at lead paint and you lifted it in your grandfather's garage or, you know, my grandfather's garage, it was very, very heavy. And that's because about, in that can of paint there was 15 pounds of lead. And that was being painted on walls, three coats on each wall, every five to ten years, whatever the renovation took. We were putting literally hundreds and hundreds of pounds of lead, a deadly toxin at that point, that a small fingernail's worth could actually cause convulsions, into the children's environment.

BILL MOYERS: Well, there were ads actually promoting lead paint as the right paint for your home.

DAVID ROSNER: They said that lead paint was a friend of the child and that it could be spread on any surface and it could be fun to do. And they showed these ads in which children are painting their toys, painting their cabinets, painting their walls, painting their furniture with a poison. At the same time when all these cases are appearing in the medical press about lead poisoned children, at the same time when in their own internal documents they're saying, we have these examples, we have, we're being attacked because children and babies are getting poisoned by lead on their cribs.

And so you see this kind of progression of this problem from the 1930s when it once killed children and sent them into comas straight through the early 2000s and now when the CDC says there are a half million children, I mean half million children at risk, a half million children with elevated blood lead levels. This would be a national epidemic, I mean, if this were meningitis, if this were polio. I mean, could you imagine the reaction of the society?

GERALD MARKOWITZ: And the industry said over 50 years ago that this was an insoluble problem, it was a problem of, caused by slums, it was a problem caused by who they called uneducable parents. And so that they washed their hands of the problem and they have still washed their hands of the problem. Parents have played, excuse me, paid the cost of lead poisoning. Landlords have even paid the cost of lead poisoning. The government has paid the cost of lead poisoning. The industry has not paid to get that lead off the walls so future generations of children can be protected.

BILL MOYERS: What your critics say is, look, it's like gasoline in cars. We didn't intend harmful effects to come from a product that was fueling America's economy. We found out later and we're trying to cut back on emissions.

This applies as well to lead and other toxins in our environment. Nobody intended it, it proved to be a consequence of, as even you say in here, the enormous amount of material we've taken out of the earth and turned into the engine of our prosperity.

GERALD MARKOWITZ: Well, unfortunately they didn't give them the information about the dangers of lead that they had. They knew that lead was killing children in the 1930s. They knew that researchers were uncovering lead and they were fighting those, the diagnoses of lead poisoning in children. They, even into the 1970s and '80s, they went after researchers like Herbert Needleman who were uncovering the low levels of lead that were damaging children. They were not innocent purveyors of a product. They were actively involved in the political dialog attempting to increase their profits at the expense of public health.

BILL MOYERS: I interviewed Herbert Needleman some years ago for a documentary on Kids and Chemicals. Let's take a look.

BILL MOYERS in Kids and Chemicals: In the late 1970s Dr. Needleman studied the baby teeth of healthy schoolchildren in two Boston suburbs […]

DR. HERBERT NEEDLEMAN in Kids and Chemicals: When we looked at the data, we found that children who had high lead in their teeth, but who had never been identified as having any problems with lead, had lower IQ scores, poorer language function, and poorer attention.

BILL MOYERS in Kids and Chemicals: It was a stunning discovery, and no one knew it better than the lead industry. Leaded gasoline was the single greatest source of lead exposure, and as a result of Needleman’s work the Environmental Protection Agency sped up efforts to ban it. The lead industry fought back, denying Needleman’s science.

JEROME COLE in Kids and Chemicals: Lead has been used in gasoline for over 60 years. There’s simply no evidence that anyone in the general public has ever been harmed by this usage […]

DR. PHILIP LANDRIGAN in Kids and Chemicals: The lead industry attacked it viciously and they attacked Dr. Needleman himself. They accused him of scientific misconduct and they actually filed charges against him at his university and at the National Institutes of Health.

DR. HERBERT NEEDLEMAN in Kids and Chemicals: It’s like a death sentence. If you’re found guilty of scientific misconduct you’re out of business; your reputation is ruined; you’re through.[…]

BILL MOYERS in Kids and Chemicals: The assault went on for three years. For three years, Dr. Needleman stood his ground.

DR. PHILIP LANDRIGAN in Kids and Chemicals: Those were tough years in Dr. Needleman’s life. Eventually those charges were shown to be baseless and the people that brought them forward who had portrayed themselves as neutral scientists were, in fact, revealed as consultants to the lead industry. It took several years for the truth to out. But he triumphed.

DR. HERBERT NEEDLEMAN in Kids and Chemicals: I knew I was right. I mean, I knew that the work was good. I knew that my colleagues who worked with me on it were honest people. But I realized that science is not always the polite intellectual activity that it appears to be; that environmental science sometimes becomes something closer to warfare.

BILL MOYERS: So that's why you called this Lead Wars, I assume?

DAVID ROSNER: That's right.

GERALD MARKOWITZ: Yes.

DAVID ROSNER: That's where the title comes from. This is one of the, you know, tactics of this industry, of these industries to essentially control the regulators, to find ways of both undermining, in Herb Needleman's case, the integrity or the scientific integrity of the researcher by trying to attack his personality or his research, his data, but also trying to find ways of getting the regulatory agencies in government to see anyone who in any way cast doubt on their product as biased as opposed to a neutral observer. But it wasn't only lead. The more industries we look at, the more like other industries the lead story is.

BILL MOYERS: How so?

DAVID ROSNER: Well, you look at the asbestos story. Our homes are still, you know, covered with asbestos. It's on, in old homes, it's on the shingles that, you know, we use, it's in the floor coverings that, the vinyl that we use, it’s on the roofs. It's on our boil, older boilers still, but when you look at the history of asbestos the knowledge about that product goes back literally decades and decades and decades.

Then you look at the silica industry, the, when you look at the vinyl chloride industry, when you look at the PCB story. And the same unfortunate, the same unfolding of, what can you say but corporate greed.

GERALD MARKOWITZ: And in addition to the corporate greed there is their war on science. The attacks on global warming. There is a war on bisphenol A, which is in a wide variety of products, it is virtually in every human being in the United States--

BILL MOYERS: What is it?

GERALD MARKOWITZ: It is basically an ingredient in plastic that is in the linings of cans, it's even in receipts that we get every day from a clerk at a store, the credit card receipt. And we take that and that has bisphenol A on it. And we end up absorbing that.

There's been a tremendous amount of research that shows that it is an endocrine disruptor, that it causes a disruption of the endocrine system that can affect reproduction, that can affect development of the fetus. But it's also a carcinogen. And so this is a real problem that the industry has been fighting to cast doubt on really amazing science that has been done by a wide variety of people.

BILL MOYERS: Just this April California's Environmental Protection Agency put it on its toxins list. The American Chemistry Council is suing California to keep this off of that list of dangerous substances.

GERALD MARKOWITZ: And they are supporting research that, as David said creates doubt about the independent scientists who are finding these variety of subtle and not so subtle effects. And they are determined, as they did, as we talked about in tobacco, in global warming, in lead, in asbestos, to make people not be convinced. And if they're not convinced, if they have a question in their mind, then they can continue to sell their chemical.

BILL MOYERS: You two have been yourselves the subject of harassment, legal suits, attacks, efforts to discredit you, right?

GERALD MARKOWITZ: Absolutely.

DAVID ROSNER: There was an article in a legal journal that kind of warned us about what was going to happen. It talked about the title of our book--

GERALD MARKOWITZ: Which was Deadly Dust.

DAVID ROSNER: --which was called Deadly Dust. And it said, you know, we could let Rosner and Markowitz play by themselves in their own little play yard of historians, but they, their book has appeared in lawsuits against the industry. And it has become the dominant narrative or it's becoming the dominant narrative of how silicosis is understood. Therefore we have to do something about them. They didn't quite say it in those words, but that was the implication.

GERALD MARKOWITZ: Well, they said, you know, be an academic and talk only to academics. But when you talk to the public that's dangerous.

DAVID ROSNER: And then very shortly afterwards we found Deceit and Denial, the next book we did came under enormous attack. They actually subpoenaed the press, they subpoenaed the foundation that supported us, the Milbank Foundation.

GERALD MARKOWITZ: They subpoenaed the peer reviewers of the book for a university press.

DAVID ROSNER: And then they hired a historian to call us unethical, lousy historians, to attack minor footnotes in the book that weren't wrong, but he claimed were wrong. It was quite an attack. And I think the biggest thing they do, though, is try to introduce doubt. One of the issues that they constantly are raising is you don't have definitive, you don't have definitive proof that in 60 years, for example, children might develop cancer from exposure to bisphenol A, right. You don't have the long term studies that we think are really essential.

But you introduce doubt about the data and then you find other people to introduce studies that raise questions about it. So you introduce, it's really the production of uncertainty. Produce uncertainty about the issue and we as an industry have no obligation to prevent disease. And it's completely antithetical to everything that public health could, public health's supposed to be about preventing disease and you always work on imperfect data. You never have the long term 60-year study that tells you you're going to have damage 60 years from now. So that's one of the tactics, it's just to keep saying there's a question, there's a question.

GERALD MARKOWITZ: And to attack people like Herbert Needleman, and to create the kind of uncertainty that gives parents pause. Should I act or should I not act? And that is probably the, as David says, the most dangerous thing they do.

BILL MOYERS: But it's consistent with what you have learned as historians this industry and others have done over the years to whistleblowers, to truth tellers, to neutral scientists and journalists who are just simply trying to report what the public should know.

GERALD MARKOWITZ: But if you can't contest the message then you go after the messenger. But think about all the younger academics who are deciding what they're going to study, what they're going to work on. And for those people it is a real decision. Are they going to go up against powerful industries or are they going to do something safe? And our fear is that more and more younger scholars and younger scientists will end up doing something safe rather than something that could really make a difference in the public arena.

BILL MOYERS: Both of you were witnesses in that big case in Rhode Island. Can you summarize that and what happened?

GERALD MARKOWITZ: Well, this was the longest civil trial in Rhode Island history, or at least up to that point. And it was a remarkable effort by the attorney general of the state of Rhode Island to prevent future damages for lead’s harm to the children of Rhode Island. It was really a public health lawsuit, an amazing public health lawsuit.

BILL MOYERS: As I understand it Senator Whitehouse whom I have met had this problem before he was a senator. He had inadvertently exposed his own children to lead when he renovated his house. And then he became attorney general and brought this suit to try to hold the industry accountable.

GERALD MARKOWITZ: It took, unfortunately, his personal tragedy to get him to take this extraordinarily important action. And we were asked to testify in that case to provide the historical evidence of what the lead industry knew about the dangers and what did they do with that knowledge, which basically was to deny that there was a problem, to say that this was a public relations problem for them rather than a public health problem.

Our documents showed that they had been, they'd known about what they were creating, they'd known that children would be poisoned, they were discussing children dying as early as the 1920s and '30s, and yet they had created this huge environmental mess of millions and millions of pounds on the walls of Rhode Island, all of which was waiting to poison future generations.

DAVID ROSNER: And that they had done nothing about it, they continued to market. And that really, I think, enraged the jury.

GERALD MARKOWITZ And we were thrilled, just thrilled when at the end of this trial the jury came back and for the first time in lead industry lawsuits they held three lead companies responsible for cleaning up the mess, in the form of lead paint on the walls of houses throughout Rhode Island.

BILL MOYERS: So the jury said the industry has to clean up and pay for it?

GERALD MARKOWITZ: Absolutely.

BILL MOYERS: For the first time?

GERALD MARKOWITZ: First time.

DAVID ROSNER: This was the high point of our professional careers, the idea that we could use history and we could use the legal system really prevent disease for the future, not just pay back for the damages already done that were irreversible to children, but to actually prevent future generations. This was a suit that actually was going to demand somewhere between $1 billion and $4 billion from the companies to clean up the mess they had created. The low point of our lives, our professional lives, came two years later when the Supreme Court in Rhode Island overturned the decision.

BILL MOYERS: And what was the basis for them taking it back?

GERALD MARKOWITZ: Basically, they said that the lawsuit was filed under the wrong law, that it was filed under public nuisance law rather than under liability law.

DAVID ROSNER: What's interesting now is that there's another suit coming up in California. And there was fear that the California suit would not go forward because they thought the precedent of the Rhode Island Supreme Court denying the legitimacy of the suit would undermine that case. The Court in California rejected the arguments of the Supreme Court in Rhode Island. The Supreme Court of Rhode Island had said this can't go under, there is no standing in future generations to get damages from these companies because they haven't been damaged yet. Until the kids are damaged you can't actually sue. And California has said that absolutely, public health law is all based upon preventing disease. All regulations are in order to prevent future damage, therefore it can go forward in California. So we're quite excited because in June this court is, this case is going to be heard by a California jury.

BILL MOYERS: Tell me about the Baltimore case that you write about.

DAVID ROSNER: In the 1980s, researchers at Hopkins wanted to find a way of remedying the conditions of Baltimore's housing, which lead was all over the place. And they were trying to find a way of doing it cheaply. So what they did is they set up three kinds of housing, one of which has been renovated to $1,650 worth of renovation, another to $3,500 and the last to $7,000 worth of renovation.

And then they recruited mothers, young mothers with children between the ages of six months to five years to live in these different houses, knowing that each house had lead exposures, but that if they could find which was the cheapest and which was the most effective way of lowering the blood lead level, not actually eliminating lead but lowering it a little bit.

GERALD MARKOWITZ: And perhaps the most troubling part of the experiment was that we've seen the consent forms and the consent forms do not tell parents that living in these homes may cause their children to be lead poisoned.

And as a result they ended up exposing 100 kids to less than fully abated homes expecting that most of those blood lead levels of those children would go down. And in fact, for most of the children their blood lead levels did go down. But some of the children, their blood lead levels went up.

DAVID ROSNER: What the court says is they were using children as human guinea pigs, as canaries in the mine so to speak, they were using them to measure the effectiveness of each one of their methods of abating lead. You know, this is young women, single mothers by and large with children, young children. And--

GERALD MARKOWITZ: Overwhelmingly African American.

DAVID ROSNER: And this is the, one of the most prestigious medical institutions in the country, Johns Hopkins.

BILL MOYERS: Weren't they trying to figure out how little could be spent to protect children in the short term? And wasn't that the wrong question altogether, don’t we need to solve these problem for the long run?

GERALD MARKOWITZ: Absolutely. And the lead researchers understood that the only way to solve the problem of lead poisoning in children was to get rid of all the lead from the walls. But they didn't think that there would be the political will to do that.

BILL MOYERS: Why don't we have that political will?

GERALD MARKOWITZ: Basically the industry has bought that political system.

DAVID ROSNER: For the past 40 years really we've been living under this set of assumptions about the scarcity in our society, how we can't afford anything and how government can't do anything. Government is the problem, not the answer. That's diametrically opposed to virtually all principles of course of public health which sees government as something that really could do something good. And but we've been taught over and over again that it's too expensive and government is the problem. And therefore we're incapacitated.

BILL MOYERS: With millions, billions of dollars at stake in profits aren't they following a kind of logic of capitalism?

GERALD MARKOWITZ: They absolutely are following the logic of capitalism. But we are all research subjects in a grand experiment where we are being exposed to literally thousands of chemicals that we have no data about. And do we want to know in ten, 20, 30 years that these are going to be either making us gravely ill or killing us?

Do we want our grandchildren to be exposed to this toxic soup of chemicals and only to find out when they're in their 30s and 40s that this is endangering their lives? And there really is a way that we can handle that problem. There is legislation in Congress now, the “Safe Chemicals Act,” which would require the EPA to test all existing and, existing chemicals and the 700 chemicals that are introduced every year and to not allow those that are dangerous to continue.

BILL MOYERS: But Jerry, you know that, as you write in here about the politics of science, that the industry went to Congress in 2005 and got fracking, even before it had come to full blossom, got fracking exempted from the Safe Drinking Water Act. And you think, and you have hope for any kind of legislation such as you just described?

GERALD MARKOWITZ: Well, I have hope that there were actually 29 senators who were willing to cosponsor this piece of legislation, but no, I don't have hope that it's going to pass. I think only if environmental groups all around the country, and there are hundreds of environmental groups around the country, really mobilize a mass movement to demand that Congress protect our health, we really care about our health, but we are not doing the political mobilizing that is necessary in order to put that caring about health into legislative action.

BILL MOYERS: So how is the politics of science affecting the fate of America's children?

GERALD MARKOWITZ: You know, in our lifetime we have seen the abandonment of the commitment to try to help those who are most vulnerable in our society. And instead of that commitment today we ask how much does it cost. And by that we mean how many dollars does it cost. We don't ask what does it cost in terms of the health of our children, what does it cost in terms of the futures of our children and of our society.

Hospitals Should be Care Providers not Loan Sharks

Deborah Burger, AlterNet — Fri, 17 May 2013 10:38:00 -0700

Predatory pricing practices can be found nearly everywhere in healthcare.

If there is one problem that symbolizes the ongoing national healthcare emergency, it is the rampant price gouging in the healthcare industry that continues to price too many Americans out of access to care and into financial ruin. Not only is the problem not solved by the Affordable Care Act, but it is a likely reason many will continue to demand more effective reform, as in expanding and extending Medicare to cover everyone.

Predatory pricing practices can be found nearly everywhere in healthcare, by the drug companies, insurance companies, medical suppliers, outpatient clinics, boutique medical services, and many others as chronicled this spring in Time magazine.

U.S. hospitals are among the biggest abusers, as illuminated in recent datareleased by Medicare on hospital charges for a variety of common procedures as well as brand new findings by the Institute for Health and Socio-Economic Policy, the research arm of the National Nurses United, based on Medicare cost reports.

The nurses’ data augments the Medicare findings, and goes the next step, illustrating a trend of rising high hospital charges while providing context to a very ugly picture and the deplorable impact on anyone who needs healthcare.

Here’s the sobering numbers:

· U.S. hospitals charge on average $331 dollars for every $100 of their total costs, in statistical terms a 331 percent charge to cost ratio.
· While hospital charges over costs have been climbing steadily over the past 15 years – the charges took their biggest leap ever in 2011– a 22 point vault.
· From 2009 to 2011 (the most recent year for which the data is available), hospital charges lunged upward by 16 percent, while hospital costs only increased by 2 percent.
· U.S. hospital profits, pushed upward by the high charges, hit a record $53.2 billion, while nurses see more and more hospitals cutting patient services and limiting access to care.
· One case study is California where hospitals soared past the national average with a charge to cost ratio of 451 percent, or $451 for every $100 of costs.

That similar pricing practices occur elsewhere in the healthcare industry is hardly an excuse for the private hospitals to act more like Wall Street corporations than responsible, community based institutions. It should be no shock that the lowest charges are by government-run hospitals that operate in public, not in secret, and have far more accountability and transparency.

Hospitals ought to act as responsible providers of needed medical care, not loan sharks. Piling up profits in large part by jacking up prices is at sharp odds with the glossy feel good ads from hospitals we see so often on our TV screens, newspaper pullouts, sponsorship of sports teams, and on mass transit placards.

Hospital lobbyists have tried for years to convince us all that predatory pricing policies don’t matter. These are just “list” prices that few people actually pay, they claim, and it is a random phenomenon that two hospitals in the same city, or even on the same block, might have widely varying prices for similar patient services.

But the grotesque reality tells a different story.

We’re not the only ones who think so. As Glenn Melnick, a USC health economist, told a reporter, "If (hospital prices are) meaningless how come hospitals spend all this money on consultants to raise them? Why haven't they stayed flat for the past 15 years? Why do hospitals keep raising them if they have no impact?"

While it is true that major payers seldom pay the list price, hospitals typically bargain with insurance companies over reimbursements. Anyone who has ever bought a car knows that the higher the list price, the more you end up paying. That’s true with hospital charges as well.

The inevitable result is insurance companies respond by ratcheting up their charges to employers and individuals. In California, for example, since 2002, premiums have risen 170% -- more than five times the inflation rate, as noted in a California Healthcare Foundation survey last month.

An alarming, if predictable ripple effect follows. As the CHF survey noted, in the past decade, the percentage of California employers providing health coverage dropped from 71 to 60 percent; 21 percent said they’d increased workers’ co-insurance premiums while 17 percent said they had reduced benefits or increased other out of pocket costs. More than one-fourth of workers in small firms have deductibles of $1,000 or more on their health plan.

Then there’s the uninsured who do not have the collective clout to bargain down the list price. Hospitals say they write off a lot of those bills, but clearly not all of them. How many distressing stories have we all heard about patients staggered by $50,000 or $100,000 un-payable medical bills while being hounded by the hospitals or bill collection agencies to pay up?

Patients and families, even those paying for insurance, have a stark choice. Use your health coverage and get socked with huge out of pocket costs that may mean choosing between medical bills, housing costs, food, or other necessities, or facing financial calamity, or forgo needed care.

As the Washington Post recently noted, the Affordable Care Act has not ended the deplorable story of medical bills accounting for more than half of all personal bankruptcies in the U.S.

Even many of those now paying for health insurance either through their employer or as individuals, or who will be required to buy insurance under the ACA, choose not to use it because of the high co-insurance, deductibles, co-pays, and all the add ins that get thrown in by the hospitals, such as professional fees, facility fees, pathology fees, anesthesia fees, and so on.

A 2011 Commonwealth Fund study found that the U.S. stands out among high income countries with as many 42 percent of Americans skipping doctors’ visits, recommended care, or not filling prescriptions due to cost.

Consequently, people end up in emergency rooms for medical problems that should have been resolved earlier at far less cost and pain. It is also why two recent reports disclosed that the U.S. has the lowest life expectancies and the highest first day infant death rate among major industrial countries.

It’s long past time to fix this nightmare, and sadly the ACA won’t meet that test. At a minimum we need to crack down on price gouging by all the corporations that control our health, with real penalties for lack of compliance.

But a longer vision is needed. Replace our profit focused health care system with one based on patient need and quality care as all those other countries with national or single payer systems that surpass us in access, quality, and cost, have long figured out.

Why You Can't Sleep: The Science of Insomnia

Joseph Bennington-Castro, io9 — Thu, 16 May 2013 11:35:00 -0700

Is your anxiety about falling asleep keeping you awake? Or are your neurons to blame?

We've all experienced a sleepless night or two, and for some people that's actually the norm. But why do we experience insomnia at all? What is going on in our minds and bodies, to cause this awful condition? Here's what scientists know so far.

The prevalence of insomnia in adults varies widely, depending on how the condition is defined. Most broadly, someone has insomnia if he or she simply suffers from difficulty falling asleep, waking up over and over during the night, or nonrestorative sleep — and according to that definition, up to 50 percent of adults experience insomnia. But only around 20 percent of the population deals with insomnia, if we're going by the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, where insomnia is considered a sleeping disorder (pdf) that lasts at least a month and causes daytime distress.

In any case, our understanding of insomnia is constantly evolving. For many years, insomnia was considered just a symptom of other issues, including depression, anxiety and schizophrenia. The prevailing thought was that if you treated the dominant condition, insomnia would subside as well. Insomnia is now known to be a syndrome in its own right, one that occurs alongside (is comorbid with) other disorders. So if you suffer from depression and insomnia, both issues should be treated at the same time — rather than just treating your depression alone.

To doctors, this type of insomnia, which is not caused by other medical issues or medicines, is called primary insomnia (as opposed to its sibling, secondary insomnia). They further describe the condition by how long it lasts — acute insomnia occurs for days or weeks, while chronic insomnia goes on for a month or more.

The basic models

In the past few decades, scientists have proposed a number of models to describe how chronic primary insomnia arises. One of the foundational paradigms was the "3-P model," referring to the supposed Predisposing, Precipitating and Perpetuating factors of the condition.

The model says that certain attributes, including being highly anxious or a perfectionist, may first make you more susceptible to insomnia. Then, some precipitating event, such as a death in the family or a new job, throws your sleep out of balance, causing acute insomnia. Finally, poor attitudes and perceptions perpetuate insomnia — these can include heightened uneasiness and tension regarding sleep, or poor sleep hygiene.

Over the years, other models have come along, some of which adapted concepts of the 3-P model. For example, the cognitive model, proposed a little over a decade ago, explains that insomniacs are overly worried about sleep and about what happens if they don't get enough of it. These negative thoughts trigger arousal and emotional distress, which essentially plunges people into an anxious state, causing them to actively monitor themselves and the environment for sleep-related threats (noises, body sensations and the like). Of course, this only exacerbates sleeplessness.

But insomnia (and the models to explain it) isn't limited to the psychological realm. Theneurocognitive model explains that people with insomnia show more high-frequency electrical activity in the brain (EEG) when they're going to sleep compared with normal sleepers. This cortical arousal suggests that insomniacs have enhanced sensory or information processing and long-term memory formation during a time when normal sleepers do not, which could ultimately affect sleep. For example, the enhanced sensory processing may make insomniacs more sensitive to and aware of what's going on in the environment.

Hyperarousal?

A common theme in these models and others is this idea of arousal. In fact, many researchers now consider insomnia to be a state of 24-hour hyperarousal, brought on by the interplay between psychological and physiological factors.

Current models suggest insomnia is caused by an interaction between behavioral and neurobiological factors. Courtesy of Elsevier.

On the psychological side of things, we have some of what we've already discussed. One useful cognitive model called the AIE (attention–intention-effort) pathway says that people with insomnia focus their attention on sleep, which leads to an active intention and effort to fall asleep.

The idea here is that normal sleep is automatic and involuntary — it's the result of a de-arousal process that allows homeostatic and circadian factors to engage sleep. But by actively trying to engage sleep themselves, insomniacs are impeding these natural processes and actually maintaining a state of arousal.

Interestingly, scientists have seen evidence of AIE even in the daytime naps of insomniacs. Numerous studies have looked at the Multiple Sleep Latency Test, which involves four or five 20-minute nap opportunities set two hours apart. If someone has gotten poor sleep because of insomnia, it stands to reason that they would be able to fall asleep quicker than someone who slept well the night before — but test after test has shown just the opposite. Some researchers are now speculating that the increased nap latency of insomniacs is due to the demands of the test, which directly asks participants to attempt to sleep at that very moment (insomniacs have basically conditioned themselves to enter a state of arousal when they make a conscious effort to sleep).

This induced arousal, at night and during naptime, has several lines of supporting physiological evidence. For example, studies have shown that insomniacs have higher whole-body metabolic rates — measured by looking at oxygen consumption at periodic intervals throughout the day — than normal sleepers.

Using PET scans, researchers have also investigated brain metabolism differences between insomniacs and normal sleepers. They saw similar results: insomnia patients had elevated global brain metabolism, both asleep and awake. Moreover, the study showed that insomniacs had smaller metabolism declines in wake-promoting regions of the brain when going from waking to non-REM sleep. In addition to this, a recent study found that insomnia patients have increased waking EEG.

Scientists have also examined the body temperatures, galvanic skin responses and heart rates of insomniac patients (all of which are physiological indicators of arousal). The results are not entirely conclusive, but suggest insomniacs have elevated electrodermal activity during the day, and may have elevated heart rates and altered heart rate variability during sleep; also, elderly insomnia patients have elevated core body temperatures at night (given the inconsistencies in the research, we can't say much else about other insomniacs).

Studies on hormone levels have also yielded interesting results, supporting the hyperarousal theory. Patients with primary insomnia apparently secrete less nighttime melatonin, which is known to regulate sleep and wake cycles. On the other hand, norepinephrine, which helps mediate wakefulness, is increased in insomnia patients, even at night. Stress hormones, including cortisol and ACTH (adrenocorticotropic hormone) may also be elevated in insomniacswhen compared with controls.

Flip-flopping

Scientists' understanding of insomnia points to the condition being a state of hyperarousal, which is mediated by cognitive and physiological factors. But the exact mechanisms behind the arousal are not clear.

Some research suggests that the neurobiology of sleep-wake regulation may provide some answers. To put it simply, the tendency to sleep is regulated by a balance between sleep-promoting neurotransmitter systems and wake-promoting neurotransmitter systems. To facilitate sleep, a group of neurons in the hypothalamus called the ventrolateral preoptic nucleus (VLPO) release the inhibitory neurotransmitters galanin and GABA to shut off the arousal (wake) system. So a faulty VLPO flip-flop switch may prevent the brain from de-arousing.

At the same time, however, other evidence suggests that sleep arises from bottom-up processes. In this sense, sleep may be a local process, an intrinsic property of individual neurons or group of neurons. This concept of local sleep would suggest that hyperarousal is not something that happens globally in the brain — it may instead be a "use-dependent dysfunction" in specific neural circuits.

Future research will no doubt tease out these finer details. And other work may elucidate the role that genetics play in chronic primary insomnia. But the ultimate goal of insomnia research, of course, is to find an effective way to stop the condition in its tracks. Given that insomnia apparently costs us billions of dollars each year, curing the syndrome could have a huge positive impact in a lot of areas.

Meet the Senate's Powerful and Progressive Policy Wonk, Ron Wyden

Joe Conason, AlterNet — Thu, 16 May 2013 11:00:00 -0700

His habitual reaching across the partisan chasm has generated controversy, notably when he floated a Medicare reform plan with House Budget chair Paul Ryan.

Having served in Congress for more than three decades -- and in the upper chamber since 1996 -- Oregon Democrat Ron Wyden has established a reputation as one of the Senate's more serious and diligent members. Over the years on Capitol Hill, he has watched the Republican Party veer constantly further rightward, and yet he continues to believe against all evidence that bipartisan legislative cooperation is possible -- even likely. His habitual reaching across the partisan chasm has generated much controversy, notably when he floated a Medicare reform plan with House Budget chair Paul Ryan.

Meanwhile, Wyden has also accumulated considerable seniority, despite his youthful demeanor (and a new baby at home). With the announced retirement of Democratic Senator of Montana Max Baucus, Wyden is set to replace him as chair of the powerful Senate Finance Committee in the next Congress (assuming that Democrats retain control of the Senate). Recently he spoke with The National Memo about the budget, tax reform, health care and other matters of concern to the Finance committee.

Among Wyden's enduring charms is his political optimism. Dismal as Washington's budget debate may be, he perceives an opportunity in the sequester. "At a time when people are talking about hammering (programs like) Meals on Wheels, this critically important program for the most vulnerable seniors as a part of this sequestration process, I think this highlights how important it is to start looking at our real priorities ... Before you cut Meals on Wheels, you ought to be looking at rolling back some of these really offensive, outlandish, special interest tax perks.

"What I and others are hoping is that we can shift the debate away from ... sequestration and talk about what are really core values and particularly core progressive values. ... This is the time when we ought to put values front and center in terms of making sure people understand what our real priorities are, and whether it's tax breaks for shipping jobs overseas or kind of special interest goodies tucked into the tax code. I think that's something you're going to finally see emerge as the heart of this budget debate."

Wyden now says he would like to take the budget fight to the House, whose Republican leaders long complained that the Senate hadn't passed a budget. "The House has passed a budget, the Senate has passed a budget," he noted. "We think our values are much more in line with the American people than what the House is talking about. And the House, after having insisted for literally years on what's called regular order, and passing bills, and having conference committees, now they don't want to do it. ... It's time to have an actual budget conference where people can see in broad daylight some of the differences that are so important to the country."

Asked how he maintains his faith in bipartisanship, Wyden mentions more than once his Republican colleague from Alaska, Senator Lisa Murkowski, with whom he seeks common ground on issues ranging from clean energy to campaign finance. "She and I produced the first bipartisan campaign finance reform bill in the Senate in a decade. ... What it's about is making sure that before an election, in real time, the American voter knows where money is being raised, and where it is going to; and particularly we blow the whistle on the so-called social welfare organizations, which are really kind of political operations masquerading as social welfare organizations that get tax breaks -- and make it clear that that kind of approach is not going to get in, effect, subsidized by the tax code." But he acknowledges that he and Murkowski cannot currently persuade enough Republicans to vote for a bill to bring transparency and honesty to outfits like Karl Rove's American Crossroads.

Wyden has studied and proposed tax reform for years -- and if Baucus fails to pass a reform bill before retiring, he will face that daunting objective as Finance chair. He says that his model is the 1986 Reagan tax reform bill. "We're spending more than a trillion dollars on these special interest tax breaks, these tax expenditures, and what you ought to do is get rid of them in order to broaden the tax base, and keep progressivity. ... You know, we Democrats really look at these special interest tax breaks, hotwired by these very powerful lobbies. We want to get rid of them. Republicans say, 'Look, we want to have a tax code that is more efficient, we want to encourage growth.' That kind of approach was advanced in 1986 by a big group of liberals and a conservative Republican president.

In the 1986 bill, Wyden says, "there should have been a provision to make it tougher for lobbyists to try to unravel (the reforms) after they got enacted. And frankly this time ... once we really do have tax reform that helps to grow the economy and create more opportunities for the middle class, let's make sure that we do what wasn't done in 1986, and that's make it tougher for the lobbyists to unravel it." He promises to protect the "middle-class deductions" for mortgage payments, health insurance, savings and charitable contributions -- and he says that rather than being "revenue neutral," as Republicans insist, progressive tax reform will inevitably raise revenues.

Wyden's version of tax reform will grow the economy "because it puts more money into the hands of middle-class people." Among other benefits for average taxpayers, he would triple the standard deduction.

Of his abortive Medicare initiative with Ryan, he says that it "provided a way to protect the Medicare guarantee" while holding costs down. But the right wing in the House scuttled that plan, and Wyden dropped his brief partnership with Wisconsin's famed Ayn Rand disciple. Now he intends to focus on chronic care for the elderly, which consumes roughly 70 percent of the Medicare budget and drives higher costs even though treatment is often ineffective.

"So many seniors have these multiple health care conditions, and what we're doing now is so fragmented, and so poorly focused, that we ought to really step back and try to think through what's the best way to efficiently get good quality care to those who need it most. Right now those are the individuals who are the sickest, they are the most expensive to care for, and they arguably get some of the worst care, and that's going to be the reform area that I focus on next."

What he vows, despite constant threats from his Republican colleagues, is to defend Obamacare, despite their concerns about its implementation. "But the bottom line here is, and this needs to be said loud and clear to the far right that wants to repeal the Affordable Care Act and allow the insurance companies to go out and clobber the people with pre-existing conditions ... I don't want to turn back the clock and go back to the days when the health care system in America was just for the healthy and the wealthy."

One Company Has Enormous Power in the Breast Cancer 'Market'—and Their Pricey Test Could Be Costing Lives

Irin Carmon, Salon — Tue, 14 May 2013 14:55:00 -0700

Angelina Jolie's op-ed about her approach to mitigating breast cancer risk helped a company's stock value rise 4%. Is that what medicine is really about?

So far, much of the heated discussion about Angelina Jolie’s brave Op-Ed in the New York Times today has focused on her decision to undergo a double mastectomy after learning she carried the BRCA1 gene. As Salon noted here, that’s not the only option. But for those who do want to consider following Jolie’s path, there are structural barriers to even gaining the information to make those choices, something she mentions but doesn’t explain. It’s because one company, Myriad Genetics, owns the patent to the two genes that indicate an increased risk of breast or ovarian cancer. You read that right: The genes themselves, not the procedure to test for them. And the Supreme Court will decide in a matter of weeks whether that should continue.

Jolie wrote, “It has got to be a priority to ensure that more women can access gene testing and lifesaving preventive treatment, whatever their means and background, wherever they live. The cost of testing for BRCA1 and BRCA2, at more than $3,000 in the United States, remains an obstacle for many women.” According to the ACLU, which brought the lawsuit heard recently by the Supreme Court, Myriad actually recently raised the price to over $4,000, despite the fact that “genetic testing technologies have advanced to the point where all 23,000 human genes can be sequenced for $1000.” The test is often covered by insurance, but policies vary, and of course, not everyone is insured.

Myriad’s monopoly over BRCA1 and BRCA2 not only means showing that it can charge whatever it wants for the test; it also means that further research on the genes is restricted, and that women who take the test and get an ambiguous result can’t get a second opinion, only take the test again. An ambiguous result can mean the difference between removing breasts or ovaries or leaving them intact.

The economic and racial implications of all this are major, both for how the research has been done and who gets access to it. In a video on the case, the ACLU points out, “Initial gene studies focused on white women. And now the patents make it more difficult to learn what some mutations mean in women of color, because Myriad has total control over researchers’ access to those mutations.” And information that allows some women to choose prophylactic surgery likely contributes to the massive disparities in who dies of breast cancer. Black women are the likeliest to die of breast cancer, even as they are less likely than white women to be diagnosed with it. A 2005 study in the Journal of American Medicine found that “African American women with a family history of breast or ovarian cancer were significantly less likely to undergo genetic counseling for BRCA1/2 testing than were white women with a family history of breast or ovarian cancer.” That was true even when controlling for socioeconomic factors, suggesting cost was not the only barrier.)

Myriad has argued that its patent was valid because it had innovated in the process of extracting the gene, and that patent protection was needed to incentivize more such research. It lost at the district court level, which threw out its patents, but prevailed at the circuit court. The Supreme Court heard oral arguments in the case a month ago. According to Lyle Denniston at SCOTUSBlog, the ACLU’s “Hansen wanted a flat declaration that human genes are not patentable – period. The Justices who pressed him closely left the impression that the suggestion was both too simple, and possibly too inhibiting for inventors and their financial backers.” Meanwhile, the Obama administration took a middle route, with Solicitor General Donald B. Verrilli saying that only synthetic DNA molecules should be patented.

Myriad’s patent on the genes expires in two years, but the Supreme Court’s ruling will set the broader principle going forward. For now, Jolie’s Op-Ed has apparently made Myriad’s stock price rise 4 percent, its best level in years.

Metal Shards and Much Worse In Your Food? What Happens When the Food Industry Regulates Itself

Martha Rosenberg, AlterNet — Mon, 13 May 2013 17:13:00 -0700

In a move that may prove deadly for workers and consumers, the federal government is washing its hands of slaughterhouse inspection and encouraging industry self-regulation.

Was Jose Navarro, a federal poultry inspector who died two years ago at the age of 37, a victim of increasingly noxious chemicals used in poultry and meat production? Chemicals like ammonia, chlorine and peracetic acid that are frequently employed to kill aggressive bacteria in meat and poultry?

Navarro coughed up blood several months before his death, the Washington Post reported last week, and he died in November 2011 of lung and kidney failure, according to the autopsy report. An OSHA inspector during a subsequent investigation said “the combination of disinfectants and other chemicals” in addition to pathogens such as salmonella “could be causing significant health problems for processing-plant occupants,” reports the Post. The plant where Navarro worked and the chicken industry defend the chemicals as safe.

It is no secret that new methods are being used in the war against bacteria because of the antibiotic resistance the meat industry's widespread reliance on antibiotics has helped cause. Antibiotics save money for livestock operations in two ways: they keep the animals alive in filthy, packed conditions in which they might otherwise die; and they make animals gain weight with less food because of their metabolic effects.

Despite the routine use of antibiotics in livestock operations, bacteria and resistant bacteria are rampant in the food supply. Almost half of US beef, chicken, pork and turkey contained staph bacteria when they were tested, reported the Los Angeles Times in 2011--including the resistant MRSA bacterium (methicillin-resistant S. aureus). Two serious strains of antibiotic-resistant salmonella, Salmonella Heidelberg and Salmonella Hadar, forced recalls in recent years of turkey products from Jennie-O Turkey and Cargill. The resistant salmonella strains were so deadly, officials warned that disposed meat should be placed in sealed garbage cans to protect wildlife.

But there is another reason that stronger and more volatile chemicals are being used. The federal government is increasingly washing its hands, pun intended, of slaughterhouse inspection and encouraging industry "self-regulation," which is cheaper for both sides. Thanks to the new era of food industry laissez-faire, assembly lines are moving even more quickly--if that's possible--and more aggressive chemicals are being employed. "Pink Slime" treated with puffs of ammonia to kill E. coli, was only one example of extreme chemicals routinely used to kill germs, often under the public's radar.

There is also an ongoing battle between US trade officials and the European Union and Russia over US poultry because it is dipped in chlorine bleach to kill germs. Who knew? And conventional US poultry is often grown on feed that contains arsenic, which the FDA says is used to control parasites, promote weight gain and feed efficiency and improve “pigmentation.” In 2011, Pﬁzer announced it would stop selling arsenic-treated chicken feed after the FDA found residues in chicken livers and most people assumed the substance had been retired from poultry farms. Guess again. Histostat, or nitarsone, another arsenic-based feed additive, is still on the market, reports the New York Times.

Inspectors Add Their Voices To Agribusiness Critics

Over the years, reports about the deleterious effects of self-regulating agribusinesses on animals, workers, the environment and consumers who eat the products have made headlines. But increasingly, federal meat inspectors are speaking out about the broken system.

“My plant in Pennsylvania processed 1,800 cows a day, 220 per hour,” and veterinarians were pressured “to look the other way” when violations happened," Lester Friedlander, a federal meat inspector told the Winnipeg Free Press. The reason? Stopping "the line" cost the plant about $5,000 a minute. Friedlander was a USDA veterinarian for 10 years and trained other federal veterinarians.

When mad cow disease was first a US threat in 1991, Friedlander says a USDA ofﬁcial told him not to say anything if he ever discovered a case and said he knew of cows who had tested positive at private laboratories but were ruled negative by the USDA. Friedlander told United Press International that the USDA attempted to force him out after he alleged, on national TV, that meat from downer cows supplied the national school lunch program. His charge proved true, and led to the biggest meat recall in US history.

National Joint Council of Food Inspection Locals, the union that represents meat and poultry inspectors in federally regulated slaughterhouses, also spoke out about mad cow disease risks. In a letter to the USDA in 2004, the union said that cattle parts that could give humans the disease were “being allowed into the production chain.” Heads and carcasses of cattle over 30 months old sailed through slaughter and processing lines, said the whistle-blowing inspectors. “We couldn’t determine that every part out of there was from a cow under 30 months,” said Stan Painter, the union’s chairman, to MSNBC. “There was no way to determine which one was which.” Inspectors were “told not to intervene” when kidneys from older animals were sent down the line to be packed for the Mexican market, which prohibited cows over 30 months, the union charged. Cows younger than 30 months were considered to pose less mad cow disease risk to humans.

Food Safety and Inspection Service (FSIS) inspectors in the Department of Agriculture have traditionally been responsible for a plant’s compliance with the Federal Meat Inspection Act (or Poultry Products Inspection Act or the Egg Products Inspection Acts) and the Humane Methods of Slaughter Act but the balance of power is switching to self-regulation. A turning point was the implementation of the Hazard Analysis and Critical Control Points (HACCP) inspection system in 2000 which replaced inspectors' visual examination of carcasses with inspectors simply ratifying that companies are following their own self-created systems--as in "trust me."

The HACCP system was developed by former Monsanto lobbyist Michael Taylor, which is no surprise in light of his pro-industry initiatives while working at the government. Taylor facilitated the approval of unlabeled GMO crops and recombinant bovine growth hormone (rBGH), both spearheaded by Monsanto, and has even lobbied against the Delaney Clause, which prohibits cancer-causing chemicals in food.

Food activists, animal activists, consumers and even industry insiders called HACCP "Have a Cup of Coffee and Pray" and an unvarnished a gift to industry. It's a “politically based policy masquerading as a science-based measure” that privatizes the meat inspection process for large plants while regulating smaller plants out of business. It allows contaminated meat to leave the plant with “smaller downstream processors . . .left accountable for problems caused by the original slaughterhouses,” writes Nicole Johnson.

Soon after HACCP was implemented, a study by the Government Accountability Project and Public Citizen found that 62 percent of inspectors surveyed allowed contamination like feces, vomit and metal shards in food under HACCP on a daily or weekly basis, which had never happened before. Almost 20 percent of inspectors said they’d been instructed not to document violations. In fact, a full 80 percent of 451 inspectors surveyed said that HACCP attenuated their ability to enforce the law and the public’s right to know about food safety.

Another federal meat inspector who spoke out about the broken system was veterinarian Dean Wyatt. The Food Safety and Inspection Service supervisory public health veterinarian from Williston, VT testified at congressional hearings in 2010 about federal inspectors' shocking lack of authority in slaughter plants. Plant managers openly defied the federal inspectors he said, and workers followed suit, actually ridiculing them.

Both Wyatt and public health veterinarian Deena Gregory reported that they witnessed a Seaboard employee hit an, "animal hard in the face and nose 8-12 times," but David Ganzel, the District Veterinary Medical Specialist, deemed the acts was not "egregious," hence not a violation, said Wyatt in his congressional testimony. Seaboard employees began to snicker when Wyatt walked past.

Food Safety and Inspection Service officials overtly served plant managers not the government, food consumers, employees or the animals. Wyatt was instructed not to file violation reports--not to do his job--and official reports were sanitized and deleted. In one report of an employee abusively throwing an animal, the word “threw” was changed to “dropped” he testified.

Shortly after testifying to Congress in 2010, Dean Wyatt died of brain cancer at the age of 59. He was a second-generation federal meat inspector and told Congress that, “Public service is in my blood.” His father died in the “line of duty,” he said, contracting a lethal pathogen at a turkey slaughter plant he inspected.

Welcome to the Brave New World of Corporatized Medicine: Just Hope You Don't Get Sick!

Yves Smith, Naked Capitalism — Mon, 13 May 2013 14:02:00 -0700

"Business freedom" in America increasingly means the God-given right to exploit the vulnerability of the public.

One of the most effective scare techniques employed to preserve our grotesquely inefficient, overpriced health care system has been to invoke the red peril of “socialized medicine”. Never mind that foreigners in advanced economies fail to recognize the caricatures scaremongers supply, or that Americans who need emergency care while overseas are almost without exception impressed with the caliber of care and astonished by the low (sometimes no) cost to them. After all, Americans live in the best of all possible worlds, and consumer and business freedom are always better.

In fact, business freedom here increasingly means the God-given right to exploit the vulnerability of the public. The example slouching into view is more corporate control over the practice of medicine. And based on the previews, it will make the horrors falsely attributed to socialized medicine look pale.

Two accounts last week bring the issue home. The first came in the Health Care Renewal blog (hat tip Lysa). It’s a reminder of how the current institutional efforts to regiment doctors undermine the caliber of medical care. It has become distressingly common for HMOs and other medical enterprises to have business-school trained managers putting factory-style production parameters on doctor visits. Outside of foreclosure mills, it’s hard to find similar approaches in other professions.

The post describes how a pediatrician, Pauline, who has developed a reputation for treating chronic conditions is at loggerheads with her for-profit practice. The suits don’t like her patient mix. She gets too many tough cases, when they’d rather have basically healthy kids who are there for a cold or ear infection. Mind you, this is only partly a money issue. These visits can be “up coded” so as to get larger insurance/patient payments, but she gets a higher level of patients in less-generous state insurance programs. But some of the pushback is that her practice is perceived as disruptive, since she uses what is perceived as too much of her and staff time, separate and apart from the economics. She’s constantly breaking management’s precious guidelines. One of her turf struggles:

She had set up a visit to see a new medically complex patient and had blocked off 40 minutes, the amount of time she felt she needed to do a good job. The child had a complex genetic disorder, cerebral palsy, and heart, lung, and kidney problems. Both the cardiologist and the nephrologist had called asking her to take this patient. She agreed. After she had scheduled the visit, a manager called her and told her that she was being allowed only 15 minutes to see that patient. After some fruitless discussion with him, Pauline finally said, “Okay, I guess that means that you’ll be seeing the patient instead of me, right?” The shocked voice at the other end of the phone line replied, “What do you mean? I don’t know how to take care of patients.” “That’s exactly my point,” Pauline put in.
Pauline explained that this manager assigned to her office is not even a college graduate. Physicians cannot access the schedule electronically and have no control over scheduling. These functions are controlled by the office manager and (amazingly) by some of the medical assistants who have received some “leadership” training. These medical assistants are even allowed to evaluate the clinical competency and skills of the physicians.

And to add insult to injury, how long did this discussion take? All those minutes the doctor spent fighting with a petty bureaucrat come at the expense of patient care.

As an aside, it’s hard to stress enough that this sort of demoralizing micromanagement and unwillingness to listen to and learn from workers, is a widespread shortcoming of management American-style. And it has weirdly been airbrushed out of the media. When I was a kid in business school, US manufacturers were having their clocks cleaned by Germans and the Japanese. There was a good deal of critical self examination back then. One source of foreign ascendancy was that they had newer factories, so you couldn’t really blame American management for that one. But the second was that it was widely acknowledged that US managers were generally poor at dealing with labor. And this wasn’t “labor” in the union sense, but at having productive relationships with factory workers (note that there has been massive revisionist history since then. When I was in Bschool, none of my classmates, nearly half of whom had worked in major manufacturing companies, had bad things to say about unions.) Now you’ll often see the decline of American manufacturing attributed to unions in an “everybody knows that” tone.

Now before you come running to the defense of management against the doctor, think twice:

So let me add a further nugget about Pauline’s background. In one of her previous jobs, she was made the manager of a pediatric outpatient center within a county hospital caring for a largely indigent population. This center had been running in the red for a good while. Pauline took over and within 28 months she’d streamlined the place and had them running well in the black, while still administering a quality of care that Pauline and her colleagues could be proud of. In short, Pauline could probably tell the managers of her current practice a thing or two about how to optimize patient scheduling without compromising care or cost —if they’d listen.

As bad as that is, most patients are unware of how much their care has been fitted to a Procrustean bed. The deliberate degradation in the name of profits is going to become more obvious, at least if the health care industry has its way.

I strongly encourage you to read this post from Whole Health Chicago (hat tip Lambert) in full. It shows how the future of American medicine is to fire the ones who are unhealthy. No, I am not making that up. The writer, Dr. David Edelberg, describes a recent presentation by a large insurance company. They’ve apparently been hosting similar sessions with physicians in the Chicago area in large medical practices. Here are the key bits (emphasis original):

The speaker at these evenings is always a physician employed by the insurance company. His/her title is medical director (I begin to think there must be dozens and dozens on their payroll) and he always begins by reassuring the audience that he was in clinical practice himself so he understands something of what physicians–especially primary care physicians–are facing. I view this physician more as a “Judas steer,” the animal that leads an innocent but doomed herd of cattle through the slaughterhouse corridors to the killing floor.
• The health industry hopes that individual medical practices and small medical groups will ultimately disappear from the landscape by being financially absorbed into larger groups owned by hospital systems.

And why do the powers that be regard this as desirable? Although the article does not stress this point, doctors have an established revenue stream. So the acquirers buy them out and impose discipline on those artistic, freewheeling doctors. The “practice style,” which used to mean the independence that doctors once enjoyed, is now an Orwellianism and includes hewing to corporate guidelines as to how to operate.

And here’s what to expect:

Physicians are expected to spend a limited amount of time with each patient, and are encouraged to see as many patients as possible during a workday. The insurance companies, sometimes with the token cooperation of a few physician-employees, create vast books of patient-care guidelines to which they believe their physicians must be “accountable” (remember this word, it will crop up again). These guidelines might mean documented Pap smear and mammogram frequency, weight management and exercise, colonoscopies for patients over 50, and getting that evil LDL (bad cholesterol) below 99 by any means possible…
If the chart audit system discovers that a physician, for whatever reason, is an “outlier”–that she’s either not following the guidelines exactly or not getting the results anticipated for her patient population—she’ll be financially penalized. A quick example of what might occur: if your LDL is 115, you may be on the receiving end of a statin sales pitch from your doctor, not because bringing it down to 99 will improve your longevity, but because your refusal to do so will impact her financial bottom line.

Now of course, you might say, “Well, in fairness, medicine is too much of a cottage industry. Look at how many doctors give unnecessary annual EKGs to patients in low risk groups. How else are we going to get to evidence-based medicine?” The problem is that what we as patients will get isn’t driven by best outcomes, it’s driven by profits. Edelberg explains:

…the subtext of “standardized” always includes the unspoken “spend less money on the patient.” Thus, a doctor might be financially penalized for recommending nutritional counseling to lower cholesterol (“counseling is expensive”) instead of writing a generic statin drug (cheap). Or recommending psychotherapy (“therapy is very expensive”) instead of generic Prozac (cheaper than M&M’s). Or referring patients for massage, acupuncture, or even chiropractic (“expensive, expensive, expensive!”) instead of pushing an over-the-counter antiinflammatory (free to the insurance company, as it’s OTC).

And I shudder to think what becomes of patients who don’t hew to standard templates: the person who had a high body mass but not due to dangerous abdominal fat (which is what creates the health risk) who is pushed to take the latest, greatest diet drug. What about people who don’t buy into the religion of getting your LDL down to below 100 (one reader argued that while it may lower your risk of heart disease, it increases your all-factor death risk by reducing your ability to fight MRSA)? Will they face penalties if they fail to comply?

No, you just will find it nearly impossible to get a doctor to take you:

• Let me close with a best-as-I-recall quote from an insurance company medical director. “We can no longer afford to pay for health care under the PPO model. Our plan is to phase out all fee-for-service care during the next few years. We’ll pay you doctors a finite amount of money to take care of a defined population. We tell doctors, ‘Don’t spend much money and you can keep the difference. Period. Don’t follow guidelines, and you’ll be leaving behind some serious money on the table and we’ll just take it back.’”

In case you think I overstated the implications, Edelberg recapped the discussion that ensued:

One physician piped up…. “But what about the non-compliant patients who won’t take the meds, don’t eat well, don’t have mammograms, continue to smoke? And what about super-health-conscious patients who want their vitamin levels measured and want referrals to acupuncturists?”
Another physician answered wearily for the medical director (who didn’t disagree): “You’ve got to fire patients like that. Get the non-compliant and the super-demanding out of your system. They’ll drag your numbers down. Hit your personal bottom line.”
Hey you, patient. Yes, I mean YOU. Pink slip time! Canned! Take your medical records and don’t let the frosted glass door hit you in the…on the way out.

In other words, if you are high maintenance because you don’t do what your doctor says (and remember, “non-compliant” includes people who don’t follow orders because they think the cookie-cutter approach isn’t right for them) or want higher service or per the example of the pediatrician Patricia’s 40 minute case, have a complicated set of ailments, you’ll be shunted. The brave new world of corporate medicine will eject you.

The rich are unlikely even to know that this change is occurring. There will be a tier of doctors on the high end to cater to patients who want more personalized, cutting edge treatment and might need some prodding. And they can always go abroad if they can’t find what they need here. But for ordinary schlubs, expect to find the doctor’s office become more hostile as the brave new world of corporatized medicine becomes entrenched.

Merchant of Death Steps Down: A Look at the Deadly Work of Philip Morris International's Outgoing CEO Louis Camilleri

Michele Simon, John Stewart, AlterNet — Mon, 13 May 2013 11:13:00 -0700

During his tenure, nearly 30 million people died from tobacco-related causes globally.

This week, when tobacco giant Philip Morris International hosts its annual shareholders’ meeting in New York, the company will honor outgoing CEO Louis Camilleri for his years of service. But a look back at Camilleri’s tenure shows a trail of death and destruction unworthy of celebration.

In 2008, parent company Altria Group spun off the international division of Philip Morris to focus more on “emerging markets,” the euphemism corporations use to describe the exploitation of Global South nations. For decades, as the regulatory environment and public sentiment has turned against smoking in the U.S., tobacco corporations have set their sights overseas. As a result, Philip Morris International now derives more revenue from Asia than from the European Union, and nearly 80 percent of tobacco-related deaths occur in the Global South.

While the Marlboro man has been retired in the United States, he is alive and well as a marketing icon in several countries around the world. Sales of Philip Morris International’s brands grew in other nations last year, with shipments of 927 billion cigarettes and revenue of more than $31 billion -- an accomplishment for which the CEO is well compensated. Also in 2012, Camilleri received an astonishing $24.7 million, up 23 percent from the previous year.

Second in size only to state-controlled China National Tobacco Corp., Philip Morris International is the biggest bully of the tobacco industry globally. On Camilleri’s watch, the corporation has engaged in numerous aggressive marketing tactics and legal maneuvers to ensure increased sales in nations that are trying to stem the rising tide of smoking deaths. Here are just a few recent examples:

In 2010, Philip Morris International filed a lawsuit against Norway challenging that country’s ban on point-of-sale tobacco advertising displays. Last year, the Oslo District Court ruled in favor of Norway’s landmark law. How many lives were lost during the policy’s delay?
In 2012 in the Philippines, Philip Morris International circumvented that nation’s ban on advertising by paying for an article in a popular magazine that praised the corporation’s efforts on disaster aid and relief. The NGO HealthJustice Philippines filed a legal complaint against the company.
Also in the Philippines, Philip Morris International sued to stop that country from banning deceptive words such as “light” and “low tar” on tobacco packaging. In 2010, the courts rejected the company’s challenge.
In 2009, Uruguay issued an executive order demanding graphic health warnings cover 80 percent of cigarette packaging. It also required a single design, preventing corporations from using colors to indicate allegedly less-harmful varieties. In response, Philip Morris International sued the country for $2 billion through an obscure World Bank Court. Although tobacco control philanthropist Michael Bloomberg stepped up to help the small country fend off this legal bullying, the case will be tied up in international courts for years.
In 2010, the company filed a lawsuit against Brazil, arguing that images the government requires on cigarette packages do not accurately depict the health effects of smoking and “vilify” tobacco companies.

On this page on the Philip Morris International website, the company makes clear that it has little patience for such inconveniences as the World Health Organization’s global tobacco treaty, adopted in 2003. Formally known as the Framework Convention on Tobacco Control, the treaty specifically prevents industry interference in public health policy, thanks to the active work of civil society, such as organizations like Corporate Accountability International. All of the above challenged policies are included in the treaty, which has been ratified by 175 countries and prohibits advertising, promotion and sponsorship. As a result, more than 60 percent of countries have some form of ad ban already in place. But that’s just a nuisance to Philip Morris International.

Calling such policies as point-of-sale display bans and plain packaging “extreme,” the company invokes familiar rhetoric about “communication with adult smokers” and whines about bans on charitable contributions, “use of journalistic expression or political commentary” and “restrictions on the rights of the tobacco industry to participate in the democratic process.” This is rich coming from a company whose modus operandi is to upend the democratic process in every nation it does business with.

But it’s also no surprise given Philip Morris International’s leadership. Hardly a class act, CEO Louis Camilleri remarked at the 2011 shareholder’s meeting that it wasn’t really “that hard to quit” smoking. Also, in this Michael Moore style 20/20 segment on ABC, Camilleri attempted to dodge hard questions about why his company was targeting children in Indonesia. (Included is the infamous and startling video of the “smoking baby.”)

Will Philip Morris International change its destructive ways with Camilleri stepping down as CEO? (He remains as board chair.) During his tenure, nearly 30 million people died from tobacco-related causes globally. When will the tobacco industry’s largest player stop obstructing public policy in nations that are trying to save lives and reduce suffering among their citizens? With this change in leadership, Philip Morris International has the opportunity to stop being the world’s bully.

Michele Simon is a public health lawyer specializing in industry marketing and lobbying tactics. She is the author of Appetite for Profit: How the Food Industry Undermines Our Health and How to Fight Back and on Corporate Accountability International's advisory board. You can follow her on Twitter.

John Stewart is the director of Corporate Accountability International's Challenge Big Tobacco campaign. You can follow him on Twitter @JMS255.

How the Economic Slowdown Has Drastically Affected How Much America Spends on Health Care

Laura Tyson, Al Jazeera English — Sun, 12 May 2013 16:14:00 -0700

The weak economy has caused people to postpone consumption of health care services and has encouraged states and employers to restrain their spending on health.

Over the last five years, the growth of health care spending in the US has slowed dramatically - to the lowest rate in the past 50 years. The slowdown is not a surprise. It is a predictable result of the recession and slow recovery that have left millions of Americans without health insurance and dampened household spending.

But the size of the slowdown is surprising, as is the fact that it started several years before the 2008 recession - and not only in the private insurance system, but also in Medicare and Medicaid, the two major government health programmes. (Medicare provides health coverage for retirees, and Medicaid provides coverage for low-income Americans and their children and those with disabilities.)

What explains this slowdown in health care spending? How much of it is attributable to the weak economy, and how much is the result of changes in provider and consumer behaviour?

Slowdown

Two recent studies offer different answers, but both predict that at least some of the slowdown will persist even after the economy recovers. That would be good news for the US economy, which currently devotes nearly 18 percent of GDP to health care, by far the largest share among developed countries. It would also be good news for America's fiscal position, because Medicare and Medicaid are the two largest contributors to the long-term federal budget deficit.

The growth of health care spending declined or remained unchanged in real (inflation-adjusted) terms each year between 2002 and 2011, falling to 3-3.1 percent in 2009-2011, the lowest rates on record since reporting began in 1960. Recent data indicate that after a slight acceleration in 2012, the growth of real health-care spending in 2013 has fallen back to its 2009-2011 average.

As a result of the recession and lagging recovery, health care spending has also slowed significantly since 2009 throughout the OECD. Indeed, for the first time on record, real health-care spending stalled on average in the OECD in 2010, as developed countries, reeling from budgetary constraints, clamped down on health programmes. Growth in health care spending was slower in every OECD country in that year, with the exception of Germany.

A new study by Drew Altman, a respected health care expert and President of the Henry J Kaiser Family Foundation, concludes that slower growth in real GDP, along with a lower inflation rate, accounts for more than three-quarters of the slowdown in health care spending in the US after 2001. The weak economy has caused people to postpone consumption of health care services and has encouraged states and employers to restrain their spending on health.

But important cost-containing changes in the private health care system, including more cost-sharing in private insurance plans and tighter controls in managed care, have also contributed to the slowdown. Altman conjectures that, overall, the growth in health care spending between 2008 and 2012 was about one percentage point lower than predicted by deteriorating macroeconomic conditions alone.

If this reduction continues after the economy recovers - as seems likely, given the cost-containment incentives in the Affordable Care Act (commonly known as Obamacare) - the US stands to spend $2 trillion less on health care over the coming decade.

Based on the relationship between changes in real per capita health care spending and changes in unemployment rates at the state level, the recent Economic Report of the President concludes that the recession and lacklustre recovery account for less than 20 percent of the slowdown in health care spending since 2007 - and for an even smaller share of the slowdown that began in 2002. And difficult macroeconomic conditions explain little (if any) of the slowdown in Medicare spending per enrollee since 2001.

Who are vulnerable?

That is not unexpected, because the largely retired Medicare population is less vulnerable to macroeconomic fluctuations than is the working-age population. The Council of Economic Advisers, whose members write the president's report, surmise that structural changes - including stronger incentives for efficiency by hospitals and providers, more cost-sharing in insurance policies, and the substitution of generic drugs for branded drugs - explain most of the deceleration in per capita spending growth.

They also suggest that payment reforms contributed to the slowdown in Medicare's spending growth after 2001, and that early responses to new Medicare regulations in the Affordable Care Act may have caused a further decline after 2010.

The long-term effect on the federal budget implied by a sustained reduction in the growth of Medicare and Medicaid spending to the rates of the last several years would be profound. These programmes currently claim 21 percent of the budget, with Medicare accounting for two-thirds of that amount.

Even a small reduction in the growth of these programmes would save billions of dollars. Based on the unexpected slowdown in spending growth during the last few years, the Congressional Budget Office recently cut its 10-year projections for these programmes by 3.5 percent, reducing the 10-year deficit by $382bn.

In 2011, Medicare spending accounted for 3.7 percent of GDP. Based on current policies, the government forecasts that Medicare spending per beneficiary will grow at an average annual rate of 4.3 percent and will rise to 6.7 percent of GDP over the next 75 years. If, instead, Medicare spending per beneficiary grew by only 3.6 percent a year, the average rate of the last five years, Medicare's share of GDP would remain unchanged. This would narrow the fiscal gap, a widely used measure of long-term budgetary imbalance, by almost one-third.

Trends in the US budget reflect an inconvenient truth: If the growth of spending on health care programmes cannot be slowed, stabilising the federal debt at a sustainable level will require deep cuts in spending on other priorities and increases in taxes on the middle class. The recent slowdown in the growth of health care spending is a promising sign that America's budgetary tradeoffs may turn out to be less difficult than expected.

Laura Tyson, a former chair of the US President's Council of Economic Advisers, is a professor at the Haas School of Business at the University of California, Berkeley.

My First Baby Was Born with a Rare Syndrome -- I'm Pregnant Again, and Worried About What Could Happen

Heather Kirn Lanier, Salon — Fri, 10 May 2013 16:20:00 -0700

My first baby was born with a rare syndrome. Now pregnant with my second, I wonder: What could happen this time?

The technician pushed the plastic wand onto my belly, and there on the TV screen were white blobs and filaments in a black cone.

“There’s the cervix,” she said, as though I’d driven two hours to get the inside scoop on my cervix. “And there’s the placenta.” She ran a computer curser over a fuzzy white mass.

But I wanted a profile or a full-body shot, some image that would tell my brain, Yes, there’s a person in there, which would tell my heart, Yes, you can risk loving this person.

Right now it was still an it, and I still called it “Baby X.” Right now I still imagined a giant mathematical variable in my pelvis, offering a host of faceless unknowns.

But the tech held off on the print-worthy images and dwelled instead on organs. A flapping, four-chambered heart. A black marble of a spleen. Look, there’s the brain: two hemispheres inside a globe.

Finally, the face. “There,” she said.

Except it was not the usual ultrasound profile of sloping forehead, dainty nose, and chin. It was a square shot, and I saw deep and ghostly eyeball cavities. The angular bone structure of the cheeks. A black opening for a mouth, gaping wide. It was a skull in my uterus. A Halloween icon floating in my womb.

The tech almost sounded apologetic. “They look pretty skeletal at this stage,” she said.

I would have to remain patient, and it was hard. My first child already required regular trips to a children’s hospital. She will probably never live on her own. Could I love yet another child whose life is not necessarily the typical promise of a sunshiny future but a gray, worrying question mark?

* * *

A life, by definition, possesses the end of itself. This was what I’d thought 18 weeks back, when my husband and I started trying for our second kid. And this was what I’d thought two years before, when we’d tried for our first. But with my first, I was only thinking about the coexistence of life and death in some abstract way. O Life. O Death. The nouns could be capitalized and personified as in some shoddy poem.

Then, two and a half months into my first child’s life, a doctor suggested we get her chromosomes studied.

And three months into her life, the nurse explained what she was missing.

And four months into her life — into my life as her parent — I had the courage to Google her diagnosis, Wolf-Hirschhorn syndrome. I learned what that missing bit of her fourth chromosome could mean. Developmental delays and cognitive disabilities, yes. But also life-threatening seizures. Potential kidney failure. And a 1-in-3 chance of dying before age 2.

So with my second child, when I say I thought about how a life also possessed its end, I was not just waxing philosophical. I was holding everything I knew to be true about parenting — that it seemed as crazy as standing at the edge of a precipice and jumping off — and I was baffled by my urge to do it again.

Now here was my second baby. Not a plump, cooing thing, but a skull staring back at me, sending a message I’d hoped the ultrasound would erase: You are right to fear. Beneath life — beneath flesh and dew and blood — is always bone, is always death.

Shortly after the ultrasound, I bought Emily Rapp’s book, “The Still Point of the Turning World,” which had just come out. It was an odd choice for an anxious parent. Rapp’s memoir tells the story of mothering a child with Tay-Sachs disease. When I carted the book to my midwife’s office, with its cover image of a sweet baby’s face, I hoped nobody would ask what it was about. But I was spending nights sleepless and fretting about all the terrors and unknowns that faced my second child. I needed camaraderie, and I chose that of a mother who walked an even tougher road than mine.

* * *

My first daughter’s chromosomal deletion was not hereditary, so some think I shouldn’t worry, but the randomness of her syndrome has made the world all the wackier, all the less trustworthy. There are 22 other chromosomes that could have deletions, or additions, or extra copies. There are single genes that could wreak havoc on a body. There are too many ways to get sick, to die.

Since having Fiona, I’ve learned about not only genetic syndromes but also babies born with cords around their necks, babies born too early, babies with intestines on the outsides of their bodies. Babies and babies and babies who live nothing like most of the babies I see posted on friends’ Facebook walls, who are fat and smiley and cooing and/or babbling and/or doing what I’m told statistically most babies do.

I could have gotten an amnio, which at the very least would have told me if my unborn child has any chromosomal deletions or additions. But that would have put me in a 1-in-300 risk for miscarriage, and my daughter already has a syndrome that only 1-in-50,000 babies has. I see myself in the big, fat “1” on top of any fraction, no matter how large the denominator.

Besides, science can’t offer certainty. An amnio only reveals so much. As a geneticist once told my friend whose results came back normal, “Some things we can test for. Some things we can’t. But that’s what you sign up for when you sign up to be a parent.”

“I didn’t sign up for this,” I cried into a cellphone just a few weeks after learning about Fiona’s diagnosis. I was pumping gas, and the world, including the gas station, was filled with able-bodied people, and my child was not one of them, was now slated for a swallow-study to see if she could even handle her own spit without slowly killing herself.

But I was wrong — I had signed up for it. Or at least the possibility of it. I just didn’t know.

You, Aspiring Parent, thought you were signing up for burping and night feedings and fingerprints on your windows, for Little League and pubescent door slams and an eventual first day of college. You weren’t. You signed up for uncertainty. You signed up to stand at the edge of a cliff and jump off. You signed up for love, too, but whenever you sign up for love, you’re also signing up for the risk of loss, for the possibility of heartbreak.

And maybe that’s the reason why I carted Emily Rapp’s memoir to my midwife’s appointments. I needed to hear from a woman who intimately knew this risk, this heartbreak, a woman who understood the real contract a person signs when she or he looks at another and says, “Yes, let’s become parents.”

In one essay, Rapp talks about one of the most isolating sentences she hears as a mother to a Tay-Sachs kid: I cannot imagine. Within three years of life, a child with Tay-Sachs will die. She challenges people to imagine this kind of parenting. “In the end there are no limits to what one can imagine. It’s how humans are built; it’s how we survive. You could care for a dying child if you had to, because that’s what love would require.”

I cannot imagine having one of those babies I see posted on Facebook. A baby who does not raise alarms with her very first breath. Maybe because my first baby has a neurologist and a cardiologist and an orthopedist and a nephrologist and an early interventionist, a geneticist and a homeopath and a naturopath and a speech pathologist and an occupational therapist and a physical therapist. Maybe because my baby, while delightful and happy, will never reside in any realm of typical. Will always put those of us who love her in a precarious spot of worry, hovering over her bed at night to see if that strange breathing is a seizure, monitoring her kidneys with ultrasounds to see if there’s a warning of failure, scanning the workings of her heart to see if the hole closes or widens or just holds still.

I cannot imagine mothering a child who looks and feels and behaves as most babies do, who is dewy and fat with the promise of the future. A child who I can expect will outlive me, will drive cars away from me, will write her own bills for a house without me. Instead, as my belly button pops out and as my tent-shaped maternity T-shirts become too short, it seems more important to imagine a child whose days are not just unknown but clearly numbered, a child who challenges his mother to reinterpret much of what she knows about being human.

* * *

This year, at least three children with my daughter’s syndrome have died. One died just last week. A friend wrote that her thoughts went to all the families who parent kids with this syndrome because we “appreciate these fragile lives and know the importance of embracing every moment.”

To which I thought of all the times I did not embrace the moment. The times I checked my email while Fiona whined for me to play with her. The times I prayed she’d just go down for a nap so I could get this or that done.

Because my daughter’s syndrome doesn’t come with an absolute life end — because while some die at birth, others live on to middle age — I can forget how fragile she is. I can sometimes pretend I don’t live with zero ground beneath me.

Can you really hold the preciousness of a life every day, every minute? Is it possible to carry the true weight of our lives — which is the fragility of them — if we aren’t intimately reminded?

For my second child, the first ultrasound came back “normal.” No red flags. All systems go.

Still, I’ve worried.

“You’re afraid to let yourself love this baby,” an intuitive friend said after I described my sleepless nights.

“Yes,” I said, and teared up. The thought hadn’t occurred to me.

I love my daughter with a hugeness I’ve never known before, but it is a hard love. She is a clapping, music-loving joy, and at almost 2 years old, she is also a floppy, willowy creature who cannot make most vowels or consonants and is nowhere near crawling, much less walking. And loving her breaks my heart open. It can hurt almost as often as it heals. That I’m afraid to love again seems cold and cruel to the little one in my middle, whose nails are growing and whose organs are all present and whose eyes are just starting to open.

I crave the illusion of certainty, the pat on the shoulder and the words, “Everything will be OK,” and the courage, no, the naiveté to believe them.

About two months after the first ultrasound, I told the midwife that I couldn’t shake my worry. She thought she was being kind when she ordered a second ultrasound, which she called “therapeutic.” It would put my mind at ease.

The universe is a tricky bastard. It bit my quest for certainty and spit it back at me. The results indicated, not just a “too-big” baby, but a baby with a larger-than-expected abdomen. There were now health concerns. It took several versions of the question to get the midwife to answer, but eventually she told me the worst-case scenarios. A gastrointestinal issue, maybe. Microcephaly, maybe. The latter diagnosis, I knew, could be a marker for a host of other problems.

“Well, now I’m terrified,” I said.

To which the midwife said, “Yeah, it’s terrifying.”

* * *

Rapp makes clear that any lesson she learns as a result of mothering her son is not the reason he exists. “The meaning of Ronan’s life was not to teach me; we often say this about people who defy our notions of normal and I find it pathetic, patronizing … Ronan would have his own path that had nothing to do with me, and I would try to understand it in my limited way.”

Yes, yes, yes, I thought, and furiously underlined. Though my heart has repeatedly broken open as a result of mothering my daughter, she does not exist to transform me. She has her own purpose. Still, the experience of loving Ronan teaches Rapp lessons, many of which I’m slowly learning myself. For example: “It took this experience to help me see clearly, to understand that the bulk of the popular parenting advice champions an approach to living that completely complies with achieving bogus standards of success.” More furious underlining.

Rapp mentions the mothers who make “products” of their kids, the moms for whom parenting becomes yet another venture at which to succeed. In such a case, the child is not a person but a measurement of one’s success. But the limits of Ronan’s body refuse to offer Rapp the back-patting moments of typical modern parenting. Walked before age 1! Started signing at 9 months! Breast-fed immediately after delivery, that’s how smart he is! Instead, Rapp’s son played with his toys in reverse.

At 0 days old, my daughter already came out delayed. She was born at 41 weeks gestation, and some exam of her body’s natural movements had her pegged at 37. She was so small she didn’t even land on the growth curve — she fell somewhere off the bottom margin of the page.

Before Fiona’s diagnosis, I was susceptible to this achievement style of parenting. I’d read birth stories, for instance, from women who forewent the epidural and bragged that their children were consequently “so aware” and scored “perfect 10′s” on the Apgar. A perfect 10? That was like an A-plus. I was hell-bent on a natural birth from then on.

But my daughter never measured up to doctors’ expectations.

“Did you smoke?” a nurse asked within an hour of Fiona’s life? “Were you on any drugs?”

“It’s either bad seed or bad soil,” one of the hospital pediatricians said, meaning either I was the bad soil or my daughter was the bad seed.

Just as parents were asking me, “So is she sitting up yet? Eating solid food yet?” and on and on, I was learning that my child might never do these things, that to do even one of these things would be, not a given of development, not an aspiration to do “early” so that I could brag and say, “Look how smart,” but a major achievement that, if she’d do them at all, she’d do them far later than expected.

And the only way to survive this, at least with any joy, was to see what Rapp also had to see: that the desire to approach parenting as a race, as a series of achievements measured by the output of one’s kid, is a cultural sickness. That there is a deeper, more transformative way to parent.

I’ve found no greater teacher of this transformative way of parenting than Rapp. And maybe I’m reading her book while pregnant to highlight the real power of parenting. It is not to raise children who outlive us (Rapp: “My son was being destroyed, every minute of every day, by the lack of one stupid enzyme”), not to raise children who will eventually become the future as long as we teach them well à la Whitney Houston.

I think it’s to be brought to our knees with a love we have no choice over. To surrender to that love. To say, Yes, yes, yes, I will love whomever we find ourselves holding. Nothing seems to underscore this love more than the possibility of its loss.

Rapp: “What makes the situation with my son so horrible is that one can imagine such a loss; if you allow yourself to feel great love (which is not an option when you are rocketed by love for a child, a connection that allows for no option but to be all-in), then you must imagine gutting loss. You cannot have one without the other. To fully live is to tremble, always, on the lip of losing everything, which is why true love — of a child, of a parent, of a partner, of a friend, of a pet — is so terrifying, and why many people never allow themselves to feel it fully.”

Yeah, it’s terrifying, the midwife had said after my second ultrasound, and that was about all she could say, other than, Come back in three weeks for another measurement.

* * *

Today, at my third and hopefully final ultrasound, the first image I see surprises me. It’s not a scary skull, not a sweet profile, not even an indifferent blob of organ. As I crane my neck toward the computer screen, I immediately catch the intricate, long ripple of vertebrae up my child’s back. Her spine. It’s a tightly knit totem. A series of stepping stones. It seems holy. Evidence of my child’s life force. Each intricate bump is crucial, guarding the nerves as they weave through the spaces in the vertebrae to find the organs, to communicate to the brain.

I often feel crazy for doing this. I often shake my head at myself, amazed and baffled that I’ve asked to do this a second time: to stand at the precipice and jump.

But here I am. Seven-plus months pregnant. Having no DNA test to tell me who lurks behind the stretched skin of my abdomen. Having only one “normal” ultrasound and one “big-belly” ultrasound and no other clue, really, as to what this life holds, the life that will now become my responsibility.

My new daughter has shown me a skull beneath her face, and she has shown me a dazzling spine. She’s shown me that she possesses the inevitability of death, yes. But she is also living. And she is mine.

And as I stare at that third ultrasound while the technician clicks and measures her femur bone, her head circumference, her supposedly giant abdomen, I think this without even consciously meaning to: “Are you OK, my love? Are you OK in there?”

The white blobs and filaments in the black cone do not answer me. And yes, that is terrifying. But I notice she is no longer Baby X. She is “my love.” Whatever loving her entails.

Heather Kirn Lanier is the author of the memoir, "Teaching in the Terrordome: Two Years in West Baltimore with Teach For America." She blogs about her daughter, Fiona, at starinhereye.wordpress.com.

AlterNet.org: Personal Health

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