Facts and ideas from anywhere

MIDDLE EAST MEDICINE

William C. Roberts, MD

According to The Lancet, the Middle East is the most neglected health arena in the world today (1). That, of course, has not always been the case. Many early medical discoveries were made by physicians from the Middle East in the first millennium. Avicenna, whose real name was Ibn Sina, wrote The Canon, the 10th-century textbook hailed as the “medical bible,” was the first to describe the contagious nature of pulmonary tuberculosis, and emphasized the importance of diet, climate, and the environment to health. The Persian-born Al-Razi, more commonly referred to as Rhazes, advocated an ethical framework for medical practice and provided the first accurate account of smallpox. Ibn Al-Nafis, born in Damascus in 1213, was the pioneer of scientific peer review and the first to describe the pulmonary circulation, although his work remained largely unknown until the later dissections of William Harvey. These early achievements serve as a reminder of the intelligence and innovation of health professionals in the Middle East. Unfortunately, the status of health and medicine in the region today is often compromised by political unrest, poor public health, poor infection control, and inadequate educational opportunities. A recent report from the United Nations focused on “the three deficits of the Arab world”: knowledge, women's empowerment, and freedom. There are now large numbers of illiterates in the Middle East. Half of the Arab women cannot read or write.

The countries forming the Middle East are hugely diverse and have many inequalities (2). The gross domestic product per person in Yemen is US $800, but in Qatar, $26,000. Only 36% of Yemenis have access to safe drinking water compared with all people who live in Kuwait and the United Arab Emirates. Malaria, pulmonary tuberculosis, and measles kill many in the region, and qualified doctors are few in number (3). Iraq has 6.2 physicians per 10,000 people, compared with 217 per 10,000 in the United Kingdom.

Bernard Lewis' book What Went Wrong? describes the long, slow, and sad decline of this region of the world (4).

CONSANGUINITY

Consanguinity or close-kin marriage has become a source of major scientific and public interest worldwide with the remarkable advances in genetics over the past 50 years (5). The World Health Organization defines a consanguineous marriage as one between individuals who are second cousins or more closely related. Consanguinity is common in the Middle East. Improvements in childhood nutritional status and efforts to combat infectious disease in some countries have resulted in more focus on the genetic disorders. The Arabs and Muslims traditionally favor close-kin marriage. Excluding Israel and Cyprus, the consanguinity rates range from 20% to 70% in most Middle Eastern countries.

Although not a religious prescription, the practice of consanguinity is certainly affected by religion. It is deeply rooted in the Arab culture and has been practiced over many generations, not only by Muslims, who generally prefer marriages between first cousins, but also by Christian Arabs, albeit with lower rates and with a tendency towards second-cousin marriages. Factors that promote consanguinity in these societies include economics, involving the preservation of wealth (land in particular), psychosocial advantages, and geographical and tribal traditions.

Consanguineous marriages, of course, are associated with a higher frequency of autosomal recessive disorders and multifactorial defects than are marriages between unrelated individuals. These disadvantages translate into higher prenatal, perinatal, and postnatal mortality. A first-cousin couple has a twofold higher risk of having a child with a major birth defect than an unrelated couple. Although some studies have shown an adverse effect on cognitive performance, there is no clear association between parental consanguinity and the frequency of common diseases such as diabetes mellitus, asthma, or adult-onset behavioral and psychiatric disorders. The effect of consanguinity on reproductive potential is controversial. However, it is clear that rates of miscarriage and stillbirth are higher in consanguineous marriages. One scientifically useful feature of consanguinity is that it facilitates homozygosity mapping of disease-related genes, a practical strategy for mapping the genes of rare autosomal recessive disorders.

PERSONAL HYGIENE IN ISLAM

Hand hygiene is the cornerstone of prevention of health care–associated infection. Topical alcohol-based solutions are better than detergent-based cleansers for improving compliance and effectiveness of hand hygiene in health care settings (6). Some Muslim health care workers believe that they are unable to comply with these new recommendations because of religious objections. In Islam, consumption of alcohol, called haram in the Qur'an, is expressly forbidden.

Personal hygiene has been a major tenet of Islam for centuries. Of the 5 basic tenets of Islam, observing prayer 5 times daily is one of the most important. Personal cleanliness is mandatory to worship in Islam. Muslims must complete methodical ablutions before praying, and explicit instruction is given in the Qur'an as to precisely how Muslims should wash. Ablutions must be made in freely running, not stagnant, water and involve washing of the hands, face, forearms, ears, nose, mouth, and feet, 3 times each. Additionally, hair must be dampened with water. Thus, every observant Muslim is required to maintain scrupulous personal hygiene 5 times a day, aside from his or her usual routine of bathing. These habits are observed by Muslims of all races, cultures, and ages.

Apart from the Qur'an, other written sources also exist to guide Muslims. The ways in which the prophet Mohammed lived are documented in the Hadith and the Sunna and provide additional observations on personal hygiene with specific focus on hand hygiene. The prophet Mohammed always urged Muslims to wash their hands frequently and after clearly delineated tasks: before and after meals; after visiting the lavatory; after touching a dog, a cadaver, or one's shoes; and after handling anything soiled. Hence, from the dawn of Islam, strict observation of hand hygiene with running water has been advocated for all Muslims.

There are an estimated 1.2 billion Muslims worldwide, and Muslims now represent 4% of the total European population. The yearly growth rate of Muslims is estimated at 3% to 6%, faster than that of the total world population, which increases by about 2% yearly. With the Muslim population growing so rapidly, there is a need for all health care workers to be better informed of beliefs and cultural practices that affect Muslims.

Islam is the religion revealed to the prophet Mohammed in 610 am over a 23-year period. These revelations are recorded in the Qur'an, which encompasses an entire code of life for all Muslims and provides divine guidance on the most important aspects of life. The word Islam is derived from the Arabic root Salaam, meaning peace, purity, submission, and obedience; in the religious sense, it means submission to the will of Allah (God) and obedience to his law. For Muslims, the Qur'an provides pertinent guidance and counsel that remain relevant 1400 years later.

GERMAN INGENUITY

The nursing home sector in Germany is seriously understaffed, with about 6500 vacancies nationwide, despite a national unemployment rate of 12% (7). The solution: retrain prostitutes to become care workers for elderly people. The director of a Protestant welfare program that runs nursing homes across the country is leading the movement. She believes that prostitutes make excellent caregivers, as they have “good people skills, aren't easily disgusted, and have zero fear of physical contact. These characteristics can set former prostitutes apart from trainee nurses.” She plans to offer 30 prostitutes aged 20 to 40 the chance to train for a new career, with 2 years of courses and vocational training. A former prostitute is also helping to get the project started. She indicated that “thejob situation is miserable. No one can make money anymore, and the prostitution market is flooded.” She went on, “When I started looking after old men instead of young men, I found there were many similarities. Most men just wanted a nanny; all I really had to change was the outfit.” And she found that looking after women was just as natural. “Prostitution taught me to listen and to convey a feeling of safety. Isn't that exactly what's missing so much in care for elderly people?”

SUICIDES IN JAPAN

In 2004, a record 32,325 Japanese killed themselves, >3 times the number in Britain and >2 times the number in the USA, whose population is >2 times the size (8). In 2003, suicide was the leading cause of death among Japanese men aged 20 to 44 years and among women aged 15 to 34 years. In today's Japan, the world's second-biggest economy, people are 5 times more likely to kill themselves than to be murdered. Japan is now expanding its counseling services in schools and in businesses. It is also introducing more automatic barriers on subway platforms to deter the “jumpers” who end their lives in full view of their colleagues. The number of suicides in Japan spiked to over 30,000 for the first time in 1998 as the recession took its toll in the form of bankruptcies and layoffs. In 2004, more than 70% of victims were middle-aged men—the age group most likely to suffer from the economic downturn. Among men aged 30 to 60 years who left suicide notes, most cited money troubles. In Japan, suicide is considered an act of selfless devotion—as with the kamikaze pilots of World War II or the samurai retainers working for feudal warlords—and no strong religious taboos against suicide exist in this strongly secular society. Instead, suicide in Japan is seen as a way out of what can seem like an irredeemable personal crisis.

SAN FRANCISCO, APRIL 18, 1906

The Great San Francisco Earthquake, now thought to have been a magnitude of 7.8 or 7.9 on the Richter scale, was over in a minute (9–11). Much of San Francisco was in rubble, and what was still standing burned in the fire that followed. The death toll was estimated to range from 480 to 6000. In addition, 28,000 of San Francisco's 53,000 buildings were destroyed; 225,000 of San Francisco's nearly 400,000 residents were left homeless; and estimates of property damage were the equivalent of $8.2 billion in today's dollars. The devastation spurred California to appoint a team of scientists and engineers to study what happened when nearly 300 miles of the San Andreas fault moved as much as 21 feet. Thus, the 1906 earthquake was the beginning of earthquake science.

In 2002, the US Geological Survey estimated a 62% chance that an earthquake with a magnitude of 6.7 or higher would hit the Bay Area before 2032 along one of the 7 major earthquake faults in the region. Along the San Andreas fault, large earthquakes occur once every 220 years on average, and a giant earthquake only once every 400 years, so maybe San Francisco can be at peace for a while. If a quake hit San Francisco today at the same magnitude as occurred in 1906, it would cause up to an estimated $34 billion of building-related losses in San Francisco and approximately $70 billion in nearby counties. Sometimes a single minute can be devastating.

THE SOUTH ASIAN EARTHQUAKE OF OCTOBER 8, 2005

It was the world's third-deadliest natural disaster of the past 25 years, surpassed only by the 2004 Asian tsunami and the 1991 cyclone in Bangladesh (12). An estimated 75,000 people lost their lives—a higher death toll than the average annual loss for all natural and manmade disasters combined during the 1990s, excluding armed conflict. In addition to those who died, >76,000 people were injured, 2.8 million were left homeless, and 2.3 million had poor access to food and other essentials 6 months later. The affected population was spread over 30,000 square kilometers in impoverished, mountainous, and difficult-to-reach areas. Once the bitterly cold winter set in, it became clear that the earthquake would continue taking its toll for months to come.

Although the world's initial response was encouraging, later response has been lackluster at best. Pakistani authorities estimated that of 564 health facilities in the affected area, 291 (52%) were totally destroyed, and an additional 74 (13%) were seriously damaged. To accommodate the survivors, 144 relief camps were established, housing nearly 140,000 residents. Infectious diseases were common in these camps and accounted for at least 65% of all illnesses. Mass vaccination against measles was undertaken, and water and sanitation facilities were reestablished. Provision of health care services to the affected continues to be a challenge. Much of the quake-affected area is home to a conservative Muslim society in which many men refuse to allow their wives and daughters to be examined by male clinicians. Early on, numerous severely injured women were denied medical care by their families. We can all do better in response to these natural disasters, wherever they may occur.

CHERNOBYL 20 YEARS LATER

The worst nuclear power plant disaster in history occurred on April 26, 1986, involving reactor 4 at the Chernobyl Nuclear Power Plant (13–15). The explosion was attributed to a combination of operator error and peculiarities in the design of the reactor, a type used only in the Soviet Union. Despite the design flaws, the 3 other reactors at Chernobyl stayed in operation until 2000. Twelve other Chernobyl-type reactors still function, 11 in Russia and 1 in Lithuania. The remaining Chernobyl-type reactors have been modified in ways that supposedly will reduce the threat of a similar explosion. Some experts are not so sure. The April 1986 disaster forced the evacuations of large swaths of some of the Soviet Union's best farmland and forests. The radiation spread far enough to be detected in reindeer meat in Norway and in rain in the US Pacific Northwest. The explosion in a way exposed the failings of the communist system and may even have hastened the collapse of the Soviet Union 5 years later.

The health consequences of Chernobyl have been less than predicted. Fewer than 50 deaths have been directly linked to radiation exposure as of 2005. A total of 4000 of the “liquidators”—workers who were hastily mobilized to clean up the accident site—are likely to die from radiation-related cancers and leukemia, far below the tens of thousands many claimed would be fatally stricken. Thyroid cancer rates have skyrocketed, however, among people who were younger than 18 at the time of the accident, even though more than 99% have survived therapy. It is estimated that between 4000 and 5000 people who were children when the explosion happened have been diagnosed with thyroid cancer in Ukraine and Belarus—making it the single biggest Chernobyl-related medical problem. At least 9 have died. Before the accident, thyroid cancer was so rare that in most years only about 10 children were diagnosed with it. The numbers appear to keep growing. Breast cancer has also increased 2-fold to 3-fold in the areas most contaminated by radiation after the explosion at Chernobyl (16). The risk has been higher among women who were younger at the time of the disaster; the increase began 10 years after the explosion.

FALLING CIGARETTE SALES

Cigarette sales in the USA are presently at their lowest point in half a century (17). In 2005, 378 billion cigarettes were sold, the lowest number since 1951, although the population has doubled over the same time period. Sales have slumped by 21% since 1998, including a 4% decline in the last 12 months. The Master Settlement Agreement introduced in 1998 was designed to protect the public and reduce cigarette consumption, and it has done just that. That ruling greatly restricts cigarette marketing. Worldwide sales, however, are still climbing and reached a record 5500 billion cigarettes a year in 2005. In contrast, in 1940 the number of cigarettes sold was 1000 billion. A third of cigarettes smoked worldwide are now consumed in China.

INCREASING LIFE SPAN

In 1900, the average man in the USA lived 46 years and the average woman, 48 years (18). By 1950, those numbers were up to 66 and 71 years, respectively, and by 2000, they were up to 74 and 80 years, respectively. Nearly 50,000 fewer Americans died in 2004 than in 2003, the sharpest 1-year decline since World War II (19). In 2004, the number of deaths in the USA was 2,398,343. It is not clear why there was such a big drop in 2004. The age-adjusted death rate declined for 10 of the 15 leading causes of death. The heart disease death rate declined 6%, and heart disease is the biggest killer.

HEALTH INSURANCE OR A FINANCIAL PENALTY

Massachusetts has recently mandated that its citizens carry a health insurance policy or pay a financial penalty(20, 21). States have long required drivers to carry liability insurance, but this is the first time any state has imposed a health insurance mandate. Presently, very few of the 46 million Americans without health insurance go entirely without medical care. When they get sick, they typically show up at emergency rooms, where they can get very expensive care without paying. By forcing all residents to assume responsibility for their own health coverage, Massachusetts may largely solve this “free rider” problem and tilt treatments back toward routine and preventive care and away from emergency care. A lot of details must be worked out, and there are already concerns that the financial underpinnings of the plan are shaky. But Massachusetts deserves credit for attacking the problem that Washington has been unable to solve.

FOOD BUYING BY BEER BUYERS VERSUS WINE BUYERS

Johansen and colleagues (22) from Copenhagen, Denmark, investigated whether people who buy wine buy healthier food items than those who buy beer. The authors obtained information on number, type of item, and total charge from 3.5 million transactions over a 6-month period. Wine buyers bought more olives, fruit, vegetables, poultry, cooking oil, low-fat cheese, milk, and meat than did beer buyers, who bought more ready-cooked dishes, sugar, cold cuts, chips, pork, butter or margarine, sausages, lamb, and soft drinks. Good for wine buyers.

UNPLANNED PREGNANCIES AND INCOME

The National Center for Health Statistics reported that from 1994 through 2001, the rate of unplanned pregnancies increased by almost 30% for women below the federal poverty line (now $16,000 annually for a family of 3) (23). In contrast, for women in families comfortably above poverty, the rate of unplanned pregnancies fell by 20% during the same period. Thus, increasing income decreases unplanned pregnancies.

LEVEL OF EDUCATION AND AMOUNT OF CORONARY CALCIUM

Many studies have documented that education is inversely associated with a wide array of diseases. Its effect on cardiovascular disease and coronary heart disease, in particular, is among the most consistent and pronounced. In recent years, coronary artery calcium has attracted much attention as an indicator of subclinical coronary artery disease. Yan and associates (24) from 4 US metropolitan areas measured coronary artery calcium by computed tomography (CT) in 2913 participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study. The first CT scan was done in 1985–1986 when the subjects ranged in age from 18 to 30 years, and the scan was repeated 15 years later, in 2000–2001, when the subjects were 33 to 45 years of age. Overall, 9.3% of the subjects had coronary artery calcium. After adjusting for age, race, and sex, those with less than a high school education had an odds ratio of 4.14; high school graduates, 1.89; those having some college, 1.47; and college graduates, 1.24 compared with those who had more than a college education, 1.0. Thus, education was strongly inversely associated with the prevalence of coronary artery calcium. The more we know, the cleaner our arteries! Or the less we know, the more fast food we eat, and fast food means quick plaques.

PRAYER AND CORONARY BYPASS

Although intercessory prayer is widely believed to influence recovery from illness, the claims of benefits are not supported by well-controlled clinical trials. Prayer studies have not addressed whether prayer itself or knowledge/certainty that prayer is being provided may influence outcome. Benson and colleagues (25) from 5 US medical centers evaluated whether receiving intercessory prayer or being certain of receiving intercessory prayer was associated with uncomplicated recovery after coronary artery bypass surgery. Patients at 6 US hospitals were randomly assigned to 1 of 3 groups: 604 received intercessory prayer after being informed that they may or may not receive prayer; 597 did not receive intercessory prayer, also after being informed that they may or may not receive prayer; and 601 received intercessory prayer after being informed that they would receive prayer. Intercessory prayer was provided for 14 days, starting the night before coronary artery bypass surgery. The primary outcome was presence of any complication within 30 days after surgery. Secondary outcomes were any major event and death.

In the 2 groups uncertain about receiving intercessory prayer, complications occurred in 52% of patients who received intercessory prayer and in 51% of those who did not. Complications occurred in 59% of patients certain of receiving intercessory prayer compared with 52% of those uncertain of receiving intercessory prayer. Major events and 30-day mortality were similar in all 3 groups. The authors concluded that intercessory prayer itself had no effect on complication-free recovery from coronary artery bypass surgery, but certainty of receiving intercessory prayer was associated with a higher incidence of complications.

GREEN TEA, CAFFEINE, AND DIABETES MELLITUS

The prevalence of type 2 diabetes mellitus has increased worldwide, particularly in Asian countries, where it was previously low. Several studies done in Europe and in the USA have reported an association between coffee consumption, a major source of caffeine, and reduced risk of diabetes mellitus. Although these studies did not show any association between consumption of black tea and the risk of diabetes, they did not examine the effect of green or oolong teas, major sources of caffeine in Asian countries. In Japan, 80% of the population drinks green tea, and the average consumption per capita is 2 cups per day.

Iso and colleagues (26) from Osaka, Japan, examined 17,413 persons aged 40 to 65 years who had no history of diabetes mellitus, cardiovascular disease, or cancer at baseline, and they completed a 5-year follow-up questionnaire. During the 5-year follow-up, there were 444 new cases of diabetes. Consumption of green tea and coffee was inversely associated with development of diabetes after adjustment for age, sex, body mass index, and other risk factors. Thus, green tea, as well as coffee, appears to decrease the chance of developing diabetes. (With the amount of coffee I drink daily, I should never develop diabetes mellitus.)

HIGH SERUM BILIRUBIN LEVELS IN NEWBORNS

My first 2 offspring had serum bilirubin levels of about 50 mg/dL shortly after birth. Newman and colleagues (27) from 3 institutions in California studied 140 neonates with total serum bilirubin levels ≥25 mg/dL and 419 randomly selected controls from a cohort of nearly 107,000 term and near-term infants born from 1985 through 1998 in California. Peak bilirubin levels were between 25 and 29.9 mg/dL in 130 and ≥30 mg/dL in 10 newborns. Treatment involved phototherapy in 136 and exchange transfusion in 5. Follow-up data to the age of at least 2 years were available in 132 of the 140 children. There were no cases of kernicterus. Neither crude nor adjusted scores on cognitive tests differed significantly between the 2 groups. Thus, when treated with phototherapy or exchange transfusion, total serum bilirubin levels in the range included in these studies were not associated with adverse neurodevelopment outcomes in infants born at or near term. (Neither of my 2 children had either phototherapy or exchange transfusions, and both have done well as observed several decades later.)

MUMPS

More than 1000 cases of mumps have been reported recently in 8 states, mainly in the Midwest, and suspected cases are being investigated in 7 other states according to the Centers for Disease Control and Prevention (28, 29). Most cases have been in Iowa, where the outbreak appears to have begun late last year at a university. Since 2001, the average number of mumps cases reported annually in the USA has been 265; the number of mumps cases in Iowa since January 2006 numbers 815, and in 7 nearby states, 350. Twenty people have been hospitalized in the outbreak, but no one has died. The Iowa Department of Public Health reported that 64% of the state's cases have been in people who got 2 doses of a measles-mumps-rubella vaccine. Mumps has become an uncommon disease since 1967 when this vaccine was licensed, and some physicians have never seen it. The last previous major outbreak was in Kansas in 1986, with 269 cases.

MOTIVATIONAL DEFICIENCY DISORDER

Extreme laziness may have a medical basis according to a group of high-profile Australian scientists. They described a new condition called motivational deficiency disorder (30), which may affect 1 in 5 Australians and is characterized by overwhelming and debilitating apathy. Diagnosis is made by a combination of positron emission tomography and low scores on a motivation rating scale. The condition may be costing the Australian economy an estimated US $1.7 billion a year in lost productivity. Some might call this syndrome laziness.

UNITEDHEALTH AND WILLIAM MCGUIRE, MD

In 1986, William McGuire, a pulmonologist, quit his private practice and took a $70,000-a-year job as an HMO manager (31). Today, the 58-year-old Dr. McGuire is chief executive officer of UnitedHealth Group, Inc., one of the nation's largest health care companies. He draws $8 million a year in salary plus bonus and enjoys perks such as personal use of the company jet. He has amassed one of the largest stock option fortunes of all time, with unrealized gains on the options now totaling $1.6 billion. While patients and practicing physicians are feeling the pinch, this chief executive officer may be worth nearly $2 billion. Something is wrong here.

SIXTH-LARGEST EMPLOYER

Baylor Health Care System is the sixth-largest employer in the Dallas–Fort Worth area, having approximately 14,150 employees(32). Wal-Mart stores is number one with nearly 27,000; AMR Corporation is second with nearly 24,300; AT&T is third with 19,200; Verizon Communications is fourth with nearly 16,000; and Lockheed Martin Aeronautics is fifth with 15,000 employees.

CHANGING FACE OF DALLAS

In 1980, the population of the city of Dallas comprised the following ethnic categories: white, 57%; black, 29%; Hispanic, 12%; and other, 2% (33). By 2000, the white population was 35%; black, 26%; Hispanic, 36%; and other, 4%. Just 4 years later, the estimates in the city of Dallas include 30% white, 23% black, 42% Hispanic, and 4% other. The total US population now is 298 million, and 41 million are Hispanic.

$3 GASOLINE IN THE USA

The Europeans have been used to it for many years. For a gallon of unleaded gasoline, the English pay about $6.50; the French, just over $6.00; and the Dutch, $7.00 (34). The 25-member European Union ranks first in the world in oil imports at about 16 million barrels a day (each barrel contains 44 gallons of oil). The USA is number 2 with about 14 million barrels imported daily. The major reason that many British and European motorists are unsympathetic to Americans now is that they have been paying more than $3 per gallon for more than a decade. Despite the high fuel prices, Europeans, in general, show no sign of giving up their love affairs with cars, and similarly, there is no apparent decrease in driving in the USA with the recent increase in gasoline prices. However, $3 gasoline means that many families will have less to spend on medical care and other necessities. The lower the family income, the greater the percentage of it that will be spent on $3 gasoline (35). Families with a pretax annual household income of $20,000 would spend $2400, or 12%, for gasoline at $3 a gallon; those with a pretax annual household income of $75,000 would spend $4650, or 6%, for the year. Thus, expensive oil harms the poor more than anyone else.

DRESSMAKERS COMBATING INCREASING WEIGHT IN WOMEN

Dressmakers have found the answer: just change the label. In the 1950s, a dress for women measuring 34-24-34 inches was labeled size 8; by the 1970s, size 4; by the 1990s, size 0; and by 2006, size 00 (36). Problem solved. If vanity sizes continue, it will only be a matter of time before dress sizes are available in negative integers.

“CHEESE”

It's not what you think it is. Cheese is a new heroin-laced powder making its way into middle schools and high schools in Texas, particularly Dallas, where dozens of youths have been caught with the drug. The Drug Enforcement Administration calls the addictive concoction “starter heroin” (37). As of April 27, 2006, police in Dallas have registered 78 incidents involving “cheese” in 11 middle and high schools. Cheese is a tan powder made mostly from acetaminophen and diphenhydramine HCl—the ingredients in Tylenol PM—with a little heroin mixed in. According to an investigator with the Dallas Independent School District Police Department, the drugs are crushed together and typically folded into notebook paper. A quarter gram sells for $5, and a single hit usually sells for $2. Users feel euphoric and then sleepy, lethargic, and hungry. The powder typically has been sold by 18 and 19-year-olds near school campuses and by older students in the schools. The heroin has been brought in from Mexico and then mixed with other drugs in the USA. This “cheese” appears to be gaining in popularity.

WHAT IS A BILLION?

A college friend, Frank McCollum of Houston, sent me the following (38). A billion is a difficult number to comprehend, but one advertising agency did a good job of putting that figure into some perspective in one of its releases: a) a billion seconds ago it was 1959; b) a billion minutes ago Jesus was alive; c) a billion hours ago our ancestors were living in the Stone Age; d) a billion days ago no one walked on the earth on 2 feet, and e) a billion dollars is spent by our federal government every 8 hours and 20 minutes.

Louisiana Senator Mary Landrieu asked Congress for $250 billion to rebuild New Orleans. What does it mean? If you are one of 484,674 residents of New Orleans (every man, woman, child), you each get $516,528. Or, if you have one of the 188,251 homes in New Orleans, your home gets $1,329,787. Or, if you are a family of 4, your family gets $2,066,012.

WHAT WE REMEMBER

A high school friend, Frank Taylor, sent me the following. Although it is attributed to Charles Schulz, the creator of the “Peanuts” comic strip, he is not the author. The real author of this quiz is unknown, and it has been circulating since at least 2000(39). Here are the first questions. 1) Name the 5 wealthiest people in the world. 2) Name the last 5 Heisman trophy winners. 3) Name the last 5 winners of the Miss America contest. 4) Name 10 people who have won the Nobel or Pulitzer Prize. 5) Name the 6 Academy Award winners for best actor and actress. 6) Name the last decade's World Series winners. How did you do? The point is none of us remember the headliners of yesterday. These are no second-rate achievers. They are the best in their fields. But the applause dies. Awards tarnish. Achievements are forgotten. Accolades and certificates are buried with their owners.

Here's another quiz. 1) List at least 2 teachers who aided your journey through school. 2) Name 3 friends who have helped you through a difficult time. 3)Name 4 people who have taught you something worthwhile. 4) Think of a few people who have made you feel appreciated and special. 5) Name 5 people you enjoy spending time with. The people who make a difference in our lives are not the ones with the most credentials, the most money, or the most awards.

—William Clifford Roberts, MD

23 May 2006