Facts and ideas from anywhere

William C. Roberts, MD

THE COST OF IRAQ

According to Nicholas Kristof, the Iraq war costs the USA $380,000 per minute (1). Former Secretary of Defense Donald Rumsfeld estimated before the war started that the total cost would be $50 billion. It more likely will be $2000 billion ($2 trillion); that's $6600 per American. The cost of this war already appears to be four times the amount needed to provide health insurance for all uninsured Americans for the next decade!

Many of the costs are hidden and will occur in the future. For example, 20,000 soldiers have been injured in Iraq, including 3000 who have suffered severe head injuries, and the US government will have to pay for around-the-clock care for many of them for decades at a cost ranging from $600,000 to $5 million per person. (Some military experts say the number of wounded is a more accurate gauge of the fierceness of the fighting than is the death toll [now 3000] because advances in armor and medical care allow many service members to survive who would have perished in past wars (2). The ratio of wounded to killed among US forces in Iraq is about 8:1, compared with 3:1 in Vietnam.) The disability payments will continue for half a century. Among veterans of the First Gulf War—in which ground combat lasted only 100 hours—40% ended up receiving disability payments, still costing $2 billion per year. The number of today's veterans who will claim such benefits is uncertain, but more veterans sought care through the Department of Veterans Affairs in the first quarter of 2006 than had been budgeted for the entire four quarters. The war has forced the military to offer re-enlistment bonuses in exceptional circumstances that reach $150,000. Likewise, tanks, helicopters, and other battlefield equipment will have to be replaced early since they are being worn out at up to six times the peacetime rate.

The war, of course, is being financed by “loans” from China and other countries. These borrowing costs are estimated to range from $265 billion to $300 billion in interest annually. The increase in the price of oil from about $20 per barrel to over $60 per barrel is in part the result of the Iraqi war and the marked drop in Iraq's oil exports. Every additional year we keep our troops in Iraq will add $200 billion to our tax bills. That kind of money could pay a lot of our health bills and also help update our nation's deteriorating infrastructure.

SQUIGGLY BORDERS: IRAQ VS SWITZERLAND

Two authors, one from Harvard and one from New York University, divided countries into two categories: natural and artificial (3). They defined the natural state as one defined by ethnicity and geographic features such as mountain ranges. Mountains reinforce ethnic communities if only by isolating them. Natural borders tend to be bumpy. The map of an artificial state, in contrast, looks like it was drawn with a ruler, which it often was (Figure). Its straight borders sometimes partition ethnic communities, placing them in two separate countries. Other times, they place tribes that are hostile to one another in the same nation. Most nations have borders that are a combination of lines and bumps. Eliminating the borders with oceans and focusing only on the squiggliness of natural borders with other nations, these authors concluded that it is better to be natural than artificial and that squiggliness is good for growth and stability.

Figure.

Comparison of Switzerland's irregular natural border (left) with Iraq's largely artificial border (right).

The squiggliest country of 144 studied was Luxembourg, Slovenia was third, and Switzerland fourth. The least squiggly nation was Papua, New Guinea, the site of chronic and violent feuds. Saudi Arabia was 143rd, Somalia and Libya were 142nd and 141st, and Iraq was 110th. Iran was 86th and Afghanistan 62nd. These authors found that less-squiggly countries generally had lower incomes, worse public services, higher infant mortality rates, and social unrest that often led to wars. In other words, the straighter the border, the greater the problems. There were exceptions including Lebanon, which is very squiggly, so that the recent wars there seem like an anomaly. The USA and Canada have long, straight borders and low rankings, but these borders were put in place long before so many people lived near them. The great powers of 50 and 100 years ago drew the lines that created the colonies or satellite countries (4). Britain arbitrarily constructed Iraq and arbitrarily decided its size, which is a bit less than twice that of the state of Idaho. As one of the authors stated, “The worst thing that ever happened to Iraq was the invention of the straight line. They took Mesopotamia and combined mutually antagonistic groups into one nation.” It's an interesting concept that makes a lot of sense.

AFGHANISTAN'S OPIUM

Afghanistan's opium harvest in 2006 has reached the highest level ever recorded, an increase of almost 50% from 2005 despite the fact that the Afghan government and international donors have poured millions of dollars into programs since 2001 to reduce the poppy supply (5). The increase in cultivation was fueled by the resurgence of Taliban rebels in the south, the country's prime opium-growing region. As the insurgents have stepped up their attacks, they have also encouraged and profited from the drug trade, promising protection to growers if they worked to expand their opium operations. The 2006 harvest will be around 6100 metric tons of opium, 92% of the total world's supply. The harvest exceeds global consumption by 30%. The previous record was 4600 metric tons, recorded in 1999 when the Taliban governed the country. Also, the area of land cultivated increased by 59%, with 165,000 hectares planted with poppy in 2006 compared with 104,000 in 2005.

The Bush administration has made poppy eradication a major facet of its aid to Afghanistan, but that effort has not been successful. About 35% of Afghanistan's gross domestic product is estimated to come from its narcotics trade. Most of the heroin made from Afghan poppies is sold in Europe and Asia. The place to treat opiate addiction is not in those who take it but in those who grow it, but we appear not to be able to stop either group. We are battling both production (which provides the income needed for survival) and addiction, both incredibly difficult to conquer.

THE FEMALE BRAIN

Louann Brizendine, a neuropsychiatrist at the University of California, San Francisco, wrote The Female Brain in an effort to dispel what she calls the myth of the “unisex brain” (6). I tend to agree with her. She describes the female brain as having “tremendous unique aptitudes—outstanding verbal agility, the ability to connect deeply in friendship, a nearly psychic capacity to read faces and tone of voice for emotions and states of mind, and the ability to diffuse conflict.” She believes that these traits are hard-wired into the brains of women during fetal development when brains are exposed to either male or female hormones beginning about the eighth week of pregnancy. She believes that testosterone prunes away the connections in the communication centers of the brain whereas estrogen enhances these connections as well as the regions of the brain responsible for language and for expressing emotion and observing it in others. These differences make women better negotiators and conciliators and make men better fighters and lone wolves. They also account for some of the author's favorite facts, including that men use about 7000 words per day and women use about 20,000. Some, of course, may chafe at these ideas as politically incorrect, and indeed Brizendine presents relatively little scientific evidence for her arguments. I like her thoughts.

MORNING-AFTER PILL (PLAN B)

Beginning in January 2007, American women will be able to purchase emergency contraceptive pills without a prescription; they will not have to go to a physician as long as they can prove they are age 18 or older (7). Young teens will still need a prescription. The pills will be kept behind a counter, to be given to the customer by a pharmacist or health care professional; they will not be sold at gas stations, convenience stores, or other outlets that do not have pharmacists. The approval marks the first time a hormonal contraceptive will be broadly available in the USA without a prescription. The pills, available under the trade name Plan B, will probably cost about $25 to $40 per dose. Men will also be able to purchase them. This contraceptive pill taken within 72 hours after intercourse contains a high dose of the synthetic hormone found in many birth control pills. It generally prevents ovulation or fertilization. It cuts the risk of pregnancy by up to 90%. The sooner it is taken, the more effective it is. It has no effect on a woman who is already pregnant.

A NEW MINORITY

In October 2006, the Census Bureau released the results of the 2005 American Community Survey, and it showed that married couples made up 49.7% of US households, a decrease of 2% since 2000. For the first time in American history, married couples represent a minority of households (8). For the subgroup of Americans aged 35 to 64, married couples still made up the majority of households. Marriage is still a priority for most Americans—more than 90% of American adults eventually marry—but now people are not marrying immediately after high school or college.

Christine Whelan, writing in The Wall Street Journal, opined that although we are marrying later we are marrying smarter (9). According to the census data, 32% of men and 24% of women aged 30 to 34 have never married, nearly a fourfold increase since 1970. Yet surveys since the middle of the 20th century consistently reveal that 75% of men and women report that a good marriage is “extremely important” to them, and an even higher percentage report positive feelings about being married.

Women's educational attainment is a major reason for this later-marriage trend. In recent years, female college graduates have outnumbered male graduates, and the percentage of women in professional schools is now about the same as that of men. If current trends continue, by 2010, 151 master's degrees will be awarded to women for every 100 awarded to men. A record high 28% of the US population now has at least a bachelor's degree, and among 30- to 34-year-olds—the group that is delaying marriage—59% have completed at least some college and nearly one third have completed a bachelor's degree or more. According to the 2006 Current Population Survey data, among 35-to 39-year-old women, 88% with advanced degrees have married compared with 81% without college degrees. And once they are married, these smart, successful women are just as likely to have children.

It appears that increased education leads to better marriages and stronger families. College graduates are less likely to divorce, and families with highly educated mothers are half as likely to split. A study at the University of Maryland looking at marriages that began between 1990 and 1994 found that of marriages in which the wife had a college education or more, only 17% dissolved in the first 10 years compared with 38% in which the wife had only a high school diploma. In a Harris Interactive Poll commissioned by Christine Whelan in early 2006, 71% of men who earned in the top 10% of their age group or who had a graduate degree said that a woman's career or educational success made her more desirable as a wife, and 68% believed that smart women made better mothers. Also, 90% of high-achieving men said that they want to marry or have already married a woman who is at least as intelligent as they are.

Nevertheless, the social norms of marriage are changing. Young people no longer have to marry to have sex, cohabitation is more socially acceptable, and women no longer need to marry for financial security. Now, real love may be what brings couples together, something not always the case 50 years ago.

URBAN SUCCESS AND BRAIN POWER

Richard Florida in the October 2006 issue of The Atlantic wrote about a demographic realignment now occurring in the USA, one as large in magnitude as the pioneers moving westward, as immigrants and farmers moving to industrial cities, as African Americans moving from the rural South to the urban North, and as families moving outward from cities to suburbs and exurbs (10). Now it's the mass relocation of highly skilled, highly educated, and highly paid Americans to a relatively small number of metropolitan regions and a corresponding exodus of the traditional lower and middle classes from the same places.

In 1970, human capital was distributed relatively evenly throughout the USA. Nationally, 11% of the population over age 25 had a college degree, and that figure ranged from 9% to 13% in half of the USA's 318 metropolitan regions. In Washington, DC, 18% of the residents had finished college; in Cleveland, only 4% had finished. Over the past 3 decades, the percentage of Americans holding a college degree has more than doubled, reaching 27% by 2004, but those gains have not been evenly spread. Now about half of the residents of Washington, DC, and San Francisco have college degrees versus 14% and 11% in Cleveland and Detroit, respectively. The trends for graduate degrees have a similar pattern. In Washington, DC, and Seattle, more than 20% of the adult population had an advanced degree in 2004, compared with 5% in Cleveland, 4% in Detroit, and 2% in Newark. In the downtown neighborhoods of high-powered cities, the concentration of well-educated people is even greater. In 2000, about 70% of the residents of downtown Chicago and of midtown Manhattan had college degrees. Most rural and suburban areas, meanwhile, are being left behind.

Mr. Florida also determined the number of college graduates per 100 people relative to the national average in 1970 and again in 2000. San Jose, San Francisco-Oakland, Seattle, Boston, Denver, and Atlanta were +12 to +16, and all had nearly doubled the number of college graduates since 1970. Dallas, on the other hand, was +6 in both 1970 and 2000. These six cities with the most college graduates also had the highest mean housing values'an increase varying from 179% to 513% during the 30 years from 1970 to 2000. The Dallas–Fort Worth area ranks 22 in the number of college graduates among metropolitan areas in the USA with >1 million people, and Dallas is 33rd in terms of advanced degrees. Dallas is in a league with Milwaukee, Indianapolis, St. Louis, Cincinnati, Memphis, Pittsburgh, and Buffalo as opposed to San Francisco, Denver, and Washington, DC. Dallas can do better.

COMBUSTIBLE TOBACCO VS SMOKELESS TOBACCO

The number of Americans who still smoke cigarettes is about 45 million. More than 400,000 Americans die each year of smoking-related diseases, making cigarettes the number-one cause of preventable death in the USA. Surveys show that most smokers want to quit, and about 40% each year make a serious effort to do so. But even with the help of counseling or nicotine-replacement products, most quitting attempts fail. Of those who fail, half go on to die of smoking-related disease.

According to Kevin Helliker (11), many believe that smokeless tobacco could serve as a last-ditch alternative for those who cannot quit otherwise. The risks of smokeless tobacco appear to be considerably less than those from smoking cigarettes. Helliker summarized a piece in Addictive Behaviors that analyzed the likely outcome of an official policy offering a regulated low-nitrosamine smokeless product to smokers. It concluded that such a policy would increase the use of smokeless tobacco but would reduce the number of persons smoking cigarettes. The type of smokeless tobacco used by baseball players, a thick wad of snuff called chewing tobacco, accounts for a small percentage of smokeless sales. Most smokeless tobacco sales come from so-called moist snuff, which users place between their lip and gum. Switching from cigarettes to virtually any moist snuff in the US market would decrease the frequency of cancer and heart disease by eliminating the dangers of smoke. But smokeless brands vary widely in the amount of nitrosamines they contain, and those with the lowest levels are the least available. The kind used in Sweden, where the rate of cigarette smoking has plummeted to the lowest in Europe, is low in nitrosamines; that brand can be purchased online but is offered in only a few retail stores in the USA.

The lung cancer mortality rate for men is 70 per 100,000 in Belgium, the European country with the highest percentage of male smokers, and just over 22 per 100,000 in Sweden, the European country with the lowest percentage of male smokers. All-cancer incidence rates among European men are highest in Switzerland, at 9.0 per 100,000, and next to lowest in Sweden, at 4.5 per 100,000. Interestingly, Swedish women smoke cigarettes at rates nearly commensurate with the rest of Europe, and they have one of the continent's highest lung cancer rates. Sweden is the only country in Europe where smokeless tobacco can be purchased. In the early 1990s, the European Union banned the product, seeking to avoid the creation of another tobacco problem.

A century ago, smokeless tobacco was the dominant form of tobacco consumption, as evidenced by the antique spittoons that can still be found in taverns and government buildings. Then manufactured cigarettes emerged and became a fashion among celebrities and the well-to-do. As smoking flourished, smokeless tobacco languished (now 2% compared with 22% for smoking tobacco in the USA). The US public health community's campaign against smokeless tobacco beginning in the 1980s started with a landmark New England Journal of Medicine study showing that women who used snuff had a risk of oral cancer four times as great as that of nonusers. That risk, however, is less than the risk from cigarettes. Subjects of that study primarily consumed powdered snuff, a rarely used variety. In 1986, health officials persuaded Congress to require that one of three warnings be placed on each smokeless tobacco package sold in the USA: that the product may cause mouth cancer, that it may cause gum disease or tooth loss, or that the product isn't a safe alternative to cigarettes. Subsequent research, however, has shown that moist snuff, the more popular kind, poses a lower risk of cancer than powdered snuff and that it is safer than cigarettes. Nevertheless, surveys have consistently shown that about 90% of smokers wrongly believe that smokeless tobacco is just as likely as cigarettes to cause cancer. Smokeless tobacco can raise blood pressure, is addictive, and can contribute to development of cardiovascular disease and cancer, and kicking this habit is no easier than quitting cigarettes.

An advocate of smokeless tobacco as a means of discontinuing cigarette smoking is Dr. Brad Rodu, a dentist and board-certified oral pathologist at the University of Louisville. He states, according to Helliker, that smokeless tobacco is 98% safer than combustible tobacco and is a healthy option for smokers who cannot quit. The State of California, in contrast, without any help from smokeless tobacco, has lowered its smoking rate to nearly the same low rate as in Swedish men simply by using public health initiatives. The Californians worry that declaring smokeless tobacco safer than combustible tobacco could encourage teenagers and others to start using it. It's good for both health and the pocketbook to stay away from both the smokeless and the smoking tobacco.

FOOD OVERSIGHT

The recent Escherichia coli contamination of spinach called attention to the inadequate US governmental oversight of our food supply. As Meyerhoff and Schultz (12) describe, a half-dozen federal agencies haphazardly administer the outdated standards and statutes and perform inadequate inspections that allow pollution in the fields, filth in the packing houses, and contaminated food on the supermarket shelves. Millions are sickened by contaminated food each year, and about 9000 die annually from food poisoning in the USA.

Today, American food is more manufactured than grown. Hogs grow in closed facilities several stories high. Tomatoes are picked green, gassed, and then canned. Our food factories generate some 1.4 billion tons per year, 10,000 pounds for each American. Since 1995, there have been 20 other E. coli poisonings of spinach and lettuce, eight of them in the Salinas Valley—the nation's “salad bowl” in California, where the Salinas River and its tributaries form a system of virtual sewers from agricultural runoff and flooding, violating nearly every national clean water requirement. Pathogens, animal waste, agrichemicals, and fertilizers routinely enter our food supply, either from environmental pollution, as with E. coli, or intentionally, as in the case of pesticides. Infected animals confined in feedlots are dosed with antibiotics. The lots themselves produce lagoons of urine and feces that contaminate the land, water, and the food itself.

Three agencies within the Department of Agriculture and two within the Department of Health and Human Services, plus the Environmental Protection Agency, have overlapping jurisdiction over the food supply. None really has authority or responsibility for the quality of food. Contaminants are not even subject to a single standard. From the field to the table, different rules apply. Probably most rules are decades old. The environmental contaminants that get into food indirectly from the soil or from surface or irrigation water, including everything from insect fragments and fly eggs to mercury and lead, are typically subject only to “action levels”: informal, discretionary limits that lack the clout of regulations and are set without sufficient data.

Unlike prescription drugs, food does not go through an approval process. The integrity of the system depends heavily on the agency's inspection force. The Food and Drug Administration (FDA), which has responsibility for all processed food products except meat and poultry, has <2000 inspectors for >100,000 facilities. Today, field processing plants are inspected on average once every 10 years. Imported food is almost never inspected. The Department of Agriculture has about 6000 employees to inspect meat and poultry plants, but the use of the inspectors is not based on the food safety risks of particular products. Obviously, all food safety functions (development of standards, inspection, risk assessment, research), as suggested by Meyerhoff and Schultz, should be consolidated under a single independent agency. This approach is supported by scientists and consumer advocates but has been consistently blocked by agency turf wars and agribusiness interests.

DEPLETED OCEANS

Every year it is estimated that human beings remove 150 million metric tons of life from the seas (13, 14). A report in the November 3, 2006, issue of Science predicted that 90% of the fish and shellfish species that are hauled from the ocean today to feed people worldwide may be gone in another 40 years. Even now, 29% of fish have “collapsed,” meaning a 90% decline in the amount being fished from the sea. And overfishing is not the only problem. The destruction of coastal areas, estuaries, and reefs by dredging, building, and pollution destroys nursery habitats for young fish. A decline in marine biodiversity can increase coastal flooding because of the loss of flood plains and erosion control provided by the wetlands, reefs, and underwater vegetation that are a cornerstone of marine life. Also, the fish declines reduce water quality by destroying the plants because shellfish and fish are the oceans' biological filtering apparatus. Additionally, the fish declines increase beach closure because of harmful algae blooms, such as red tide, facilitated by diminished filtering.

FORESKIN

The incidence of female genital mutilation, removal of the clitoris with or without the labia in young girls, apparently is decreasing in Africa (15). We all deplore this procedure, and fortunately the world is mobilizing against its practice. More than 50 African nations have signed a protocol against female genital mutilation. Women who have undergone this procedure are 70% more likely than other women to hemorrhage during childbirth and are 60% more likely to deliver a dead or dying baby. Additionally, the World Health Organization has estimated that for every 100 deliveries, female genital mutilation kills one or two more newborns.

Now to male genital mutilation, which means circumcision. Fewer boys are being circumcised today in the USA than in 1970. A number of anticircumcision groups including Mothers Against Circumcision, Jews Against Circumcision, and Catholics Against Circumcision are flooding the Internet. Seven years ago the American Academy of Pediatrics concluded that evidence of potential benefits of male circumcision was “not sufficient to recommend routine neonatal circumcision,” and the American Medical Association agreed. The anticircumcision activists are pushing federal legislation to impose jail sentences on anyone who “cuts or mutilates the whole or any part” of the foreskin of a boy younger than 18 years. They are also fighting to end public funding of circumcisions. They are planning lawsuits to intimidate physicians and ban infant circumcision through the courts.

But what about circumcision as a prevention of HIV? In 2002, an analysis of 38 studies, mostly in Africa, by the Agency for International Development concluded that circumcised men were less than half as likely as uncircumcised men to get HIV, apparently because of the susceptibility of the foreskin. A study in South Africa in 2005 found that circumcision reduced female-to-male transmission of HIV by 60%. Using these data, it has been estimated that over the next 20 years circumcision in sub-Saharan Africa could prevent 6 million HIV infections and 3 million deaths. At clinics across southern Africa, men apparently are lining up, pleading and nearly rioting to be circumcised. They want protection. The strongest argument against circumcising babies to prevent HIV is that they are too young to consent and they won't be at risk for the virus until they are grown. But of course we vaccinate babies all the time. Our customs continually change.

SOME CHANGES IN THE USA IN THE LAST 80 YEARS

Several changes that have occurred in the past 80 years are summarized in the Table (16). Medical care was much less expensive, of course, in 1915 and in 1967, but it is much better to be ill in 2006 than in the earlier times.

Table.

Demographic and economic variables in the USA: 1915, 1967, and 2006

Variable	1915	1967	2006
Population (millions)	100	200	300
Foreign born	15%∗	5%	12%†
Average number of persons per household	2.6	3.3	4.5
“Homeownership”‡	46%	64%	69%
Life expectancy (years) at birth	54	71	78
Women in labor force	23%	41%	59%
High-school diplomas	14%	51%	85%
Motor vehicles (millions)	2	99	237
Farms (millions)	6.5	3.2	2.1
Cost,§ gallon regular gasoline	$5	$2	$2
Cost,§ gallon of milk	$7	$6	$3
Cost,§ first-class stamp	40¢	30¢	39¢

∗Mainly European

†Mainly Latino

‡Few actually own the home; most have sizable mortgages.

§Costs are presented in 2006 dollars.

SHORT STATURE

Idiopathic short stature (ISS) is defined as a predicted adult height of <59 inches for girls and <63 inches for boys. Dr. Joyce Lee, a pediatric endocrinologist at the University of Michigan, estimated that 400,000 children in the USA have ISS and that treating just 10% of them would cost $4 billion, given that the average cost of treatment for each child is $100,000 (17, 18). According to Lee, that works out to about $50,000 per inch gained. In the only trial in ISS children that compared a growth hormone group with a placebo group, the treatment group's final adult height was on average 1.5 inches higher than that of the placebo group. Growth hormone is fairly safe to take, but is it worth that huge expense to gain 1.5 inches? There is no evidence, according to Lee, that short children have poorer psychosocial function or poorer quality of friendships than do taller children. Three of the four top-selling human growth hormone brands used to treat short stature (Genotropin, Norditropin, and Saizen) have shown steady increases in US sales. When I got my driver's license at age 16, I weighed 110 pounds and was 65 inches tall. After the first year of college, I was 72 inches tall. Predicting adult height in childhood may be fraught with a bit of difficulty.

BODY MASS INDEX IN UNION ARMY VETERANS AND WHITE MALE AMERICANS 80 YEARS LATER

Dejun Su in 2005 compared body mass index (BMI) (kg/ m²) in 1238 white Union Army survivors aged 50 to 59 when examined in 1891 to that of white American men aged 50 to 59 when examined in 1971 to 1975 (19). The mean BMI of the Union Army survivors was 23.2 and that of men in the 1970s group, 26.2. The mean height of the Union Army survivors was 67.8 inches and that of the later Americans, 68.5. Only 2% in each group were underweight (BMI <18.5); 74% of the Union Army survivors and 36% of the 1970s American men had a normal BMI (18.5 to <25); only 19% of the Union veterans were overweight (BMI 25 to <30) compared with 45% of the 1970s men; and 2% of the Union veterans and 17% of the 1970s American men were obese (BMI ≥30).

The author followed both groups for the next 18 years. He found a U-shaped association between BMI and age at death: the Union survivors with an optimal BMI had a 9% lower average mortality rate than their heavier colleagues, and the men in the 1970s with an optimal BMI had at least a 15% lower mortality rate than the average in their group. The optimal BMI for men in this age group had a substantial upwards shift: from 20.6 to 23.6 in 1891 to 22.7 to 27.3 in the early 1970s. We all need to know our BMI. Each 1-point increase in it represents 7 or 8 additional pounds in most adults.

LOSE WEIGHT—SAVE FUEL

A new study has implied that Americans are burning nearly 1 billion more gallons of gasoline each year than they did in 1960 because of their expanding waistlines (20). More weight means lower gas mileage. Using recent gas pricing of $2.20 a gallon, that translates to about $2.2 billion more spent on gas each year. Our hunger for food and our hunger for oil are not independent of each other! If we reduce the total weight of cars, either by removing excess baggage or by carrying lighter drivers and/or passengers, fuel consumption drops. For a driver who loses 100 pounds and drives 12,000 miles annually, that translates into 18 fewer gallons of gas used in the year. At $2.20 per gallon, that would be a savings of nearly $40. The obesity rate among US adults doubled from 1987 to 2003, from about 15% to more than 30%. In 2002, the average weight of American men was 191 pounds and of women, 164 pounds—about 25 pounds heavier than in 1960. Eating less, driving less, and exercising more all reduce gas consumption.

COMMUTING

An August 2006 article from the Associated Press is hard for me to believe. It indicates that the average daily commute for Americans is 25 minutes each way and that commuting time has not changed in the last 6 years (21). The longest commute in the USA is 39 minutes for people living in Vineland, New Jersey, about 40 miles south of Philadelphia. The second-longest is in the New York City area, which is 34 minutes, and next, Washington, DC, 33 minutes. Cities in the North Texas region do not rate in the top 25. Among the findings from the Census Bureau in 2005 was that 77% of workers driving to work drive alone, 11% carpool, 5% use mass transit, and nearly 4% work at home. My commute, fortunately, is about 10 minutes each way, and when I was at the National Institutes of Health, it was only 15 minutes. I have always been a blessed man from a transportation standpoint. Many individuals spend an entire day a week just getting back and forth to work. In addition, many people spend far more time commuting than vacationing.

The greater the income, the shorter the commute as a rule. I tell my grandchildren to study hard because that will more likely assure them of a parking place and a shorter commute. When I was considering another position 3 decades ago, a wise man advised me not to leave unless I had the authority to carry out the responsibilities I was to be given and unless I had a parking place. I never forgot that advice.

INCREASING ADHERENCE TO PRESCRIPTIONS

Allan J. Taylor, chief of cardiology at Walter Reed Army Medical Center in Washington, DC, studied medication compliance in 200 patients >65 years of age taking at least four medicines daily (22). For 6 months they were assigned to a program that included consultations with pharmacists who dispensed the daily pills in single so-called blister packs rather than in individual bottles. Then the patients were randomly selected to either continue on the same blister-pack program or return to a conventional approach that included getting monthly supplies of each drug in separate pill bottles. In the initial phase of the study, compliance with medications, based on the number of pills patients took, increased from 61% at the start to 97%. In the second phase, compliance after 6 months among those who continued with the program was 96%, while it dropped to 69% among those who went back to the usual way of getting medicines. This intervention is a good idea, but the blister packs cost money and the additional work for pharmacy employees would of course add additional costs.

PERMANENT ARTIFICIAL HEART APPROVED

The first fully implantable permanent artificial heart won limited FDA approval in September 2006 (23). The scientific advisors voted 7 to 6 against approving the device, but the FDA nevertheless ruled that the AbioCor heart can be used but only in patients who are too old or too sick for a cardiac transplant. This approval comes nearly 25 years after replacement of Barney Clark's heart with the Jarvik-7 in 1982. Clark survived just 12 days. Approval of the new artificial heart was based on its implantation in 12 patients, none of whom left the hospital and all of whom have died. Six had strokes due to clotting in the device. The titanium and plastic AbioCor is the size of a grapefruit. Its external power unit sends current through the skin without use of penetrating wires. By March 2007, six medical centers in the USA will have this device for implantation. I think that I would rather die peacefully.

SPECIALTY HOSPITALS

In August 2006, the Bush administration released the ban on physician-owned specialty hospitals (24), which tend to focus on the most lucrative specialty areas. The sharp focus usually results in quality care but at the same time usually makes successful operation of local nonprofit community hospitals, which must offer a wider array of services, more difficult. Emergency department services and maternity wards are costly to provide. Of the 130 operating specialty hospitals in the USA, 35 (27%) are in Texas, by far the largest number in any state. The next closest is Louisiana with 15. Critics of these doctor-owned hospitals say that they drive up health care costs because they increase the number of procedures performed in their specialty areas. Supporters, in contrast, say these hospitals are more efficient and provide care equal to or better than that provided by general hospitals. A federal law bars physicians from referring patients to businesses they have a financial interest in, but that law contains loopholes. One of them allows physicians to invest in hospitals where they practice. Surveys indicate that patients at the Baylor Heart and Vascular Hospital are very pleased with the care they receive at this facility.

GIVING PRESENTATIONS

My mother told me that if I was ever going to make something of myself, I needed to learn how to give a talk. The trouble, she said, was that you had to have something to say. When I was in high school, those speaking opportunities arose in the evening Sunday School service at the First Presbyterian Church in Atlanta. The speaking thereafter did not resume until house officership, and it has been progressive since then. I have read some books on speaking and they—just like books on how to play tennis or golf—have been helpful to me.

In 1982, I was boarding a plane and noticed Jack Valenti in a seat. Mr. Valenti, now retired, was the longtime president of the Motion Picture Association of America and former aide to President Lyndon Johnson. I quickly glanced at my seat stub again and to my surprise and delight saw that I was to sit next to Mr. Valenti, a magnificent public speaker who had just published his wonderful book on the topic called Conscience of a Speaker (25). As I sat down I commented to Mr. Valenti that I had enjoyed his book immensely—and I did. He said to me: “You could have said almost anything to me, but nothing you could have said would have pleased me more than what you did say.” He was and is a charming man. He knows how to give a talk and how to teach others to do it too.

I heard Dorothy Leeds speak on the topic about 15 years ago, and her book, Power Speak, was useful to me (26). I then encountered Reid Buckley's Strictly Speaking (27). Reid is one of several brothers of William F. Buckley, Jr., who probably wrote more words in the last half of the 20th century than anyone else. (Probably H. L. Mencken wrote the most in the first half.) At any rate, Reid Buckley's book is outstanding and also most entertaining (all the Buckleys have a splendid sense of humor).

And on November 21, 2006, the physicians at Baylor University Medical Center were treated with a splendid lecture entitled “Presentation Skills for Physicians: Making Your Next Teaching Presentation Go Better Than Your Last!” This superb presentation was the first Drs. Gordon and Mary Moore Hosford Lectureship at Baylor's medical grand rounds. The visiting professor was Dr. Scott C. Litin, professor of medicine at the Mayo Clinic in Rochester, Minnesota.

Dr. Litin's presentation concerned essentially the art and science of speaking, whether to individual patients and their families or to groups of physicians or nonphysicians. He suggested putting one's e-mail address on the first slide: members of the audience can contact the presenter if desired, and that gesture might indicate an openness of the speaker. He suggested that the presenter write his or her own introduction. He summarized the most annoying uses of PowerPoint: the speaker reads the slides; the font size is too small (there should be no more than six or seven lines per slide and no more than six or seven words per line); complete sentences are used; red or green backgrounds are used, both of which are too difficult to read (he suggested blue backgrounds); and totally unreadable slides are shown, for which the speaker has to apologize (if an apology is needed for a slide, don't show it, he advised).

He provided 10 tips to improve presentations:

1. Practice, practice, practice.

2. Use appropriate humor. The best is probably self-deprecating humor. Use video clips. Most of us know what inappropriate humor consists of.

3. Take the edge off of nervousness. Have a comfortable posture. Do not have a “fig leaf ” or “firing squad” posture. Either let your hands fall by your side comfortably (it helps to put the thumb and index finger together) or hold your hands like they are on a table. Most anxiety, fortunately, does not show. Make eye contact with the audience. Move your eyes from one side to the other, but move slowly. Do not try to awaken those who are sleeping. Drink tea or hot water before talking to soothe the voice. The most important way to prevent nervousness is to be well prepared.

4. Make it a performance. Smile, be enthusiastic, have passion, use hand gestures, tell stories, show pictures. The presentation should be “edu-tainment.”

5. Concentrate on delivery. Face the audience, avoid the monotone, slow down, and use more pauses. Use the pointer infrequently; when you use it, focus on a single bullet on the slide.

6. Do not go past the scheduled time. To be on time, most speakers need to practice extensively and practice out loud, not silently.

7. Eliminate unnecessary information.

8. Organize the presentation. Make the opening statement a hook to grab the audience's attention, limit the number of points to present, and have a strong closing. He suggested using the phrase, “In summary, the points I made …” Thank the audience for their attention during the presentation. If there are no questions from the audience, he suggested saying, “A question I am often asked …” Always repeat any questions. Exit gracefully.

9. Have a clear purpose. Make clear the goals you want to accomplish.

10. Meet the needs of the audience. Most people in the audience ask themselves, “What is in it for me?” (WIIIFM).

After each presentation evaluate what went well. Was there an opening hook? Were you enthusiastic? Evaluate the areas needing improvement, such as talking too fast or not smiling. Dr. Litin gave a splendid presentation, and the Hosfords deserve much thanks for sponsoring his visit.

POWERPOINT

According to Jared Sandberg, an estimated 30 million Power-Point presentations are given every day around the world (28). Why are there so many if audiences dread them? Sandberg's answer is that PowerPoint presentations are a lot easier for presenters than for the audiences they are allegedly intended for. Edward Tufte, the preeminent designer of visual information, argues that PowerPoint sacrifices thought and analysis for convenience to the speaker, hurting both content and the audience: “PowerPoint allows presenters to pretend they are giving a pre-sentation—its cognitive style profoundly corrupts serious communications.” Dave Paradi, who cowrote a book on PowerPoint, adds that executives “seem to be surprised that they should think about the audience before they think about what they are saying.” Mr. Paradi estimates that bad PowerPoint presentations cost companies over $250 million a day in wasted time. For those who freeze in front of an audience, PowerPoint helps keep the presenter on message, another reason for PowerPoint's popularity. “Fear of public speaking ranks slightly below night landing a plane on an aircraft carrier during a storm,” says John Faick. I think PowerPoint is a wonderful Microsoft invention. Personally, I prefer “weak point”—the flip chart.

TEXAS AND GREENHOUSE GASES

According to a piece in the September 3, 2006, Dallas Morning News, Texas leads all other states in the amount of carbon dioxide emissions from fossil fuel burning (29). In millions of tons per year, Texas exudes 723; California, 422; Pennsylvania, 289; and New York, 233. Worldwide, of course, the USA is number one at 6517, China follows at 5189, then Russia at 1857, Japan at 1391, India at 1228, and Germany at 950. (The most recent figures available for the USA are from 2001 and for the other countries, 2004.)

Texas has no formal strategy on global warming and no plans to require reductions in the carbon dioxide that the state's industries, vehicles, and farms release into the atmosphere. California, by contrast, approved a bill in 2006 to slash emissions by 2020 back to 1990 levels. Power companies plan to build 16 new coal plants in Texas over the next 6 years if they get state permits. TXU, which plans to build 11 of the new coal plants, would account for 78 million tons of the new emissions—the same amount that would result if TXU gave each of its 2.4 million retail customers four Cadillac Escalades. Of all the ways to generate electricity, coal puts out the most carbon dioxide, about 2.86 tons for each ton of coal that is burned. The large amount of carbon in coal combines with oxygen in the air to make carbon dioxide. Of all the emissions that come out of a coal-burning power plant, only carbon dioxide is not subject to any limits or controls! Texas, like other states and the federal government, does not regulate carbon dioxide as a pollutant and has no current plans to do so. Our lives will probably be better than those of our grandchildren.

A CARBON-NEUTRAL LIFESTYLE

Al Gore in his film, An Inconvenient Truth, as Peter Schweizer summarized, recommends switching to compact fluorescent light bulbs, using clothes lines, driving hybrids, using renewable energy, and dramatically cutting back on consumption (30). But if Al Gore is the world's role model for ecology, the planet is in trouble. Although Mr. Gore indicates that he recycles and drives a hybrid and uses renewable energy credits to offset the pollution he produces when using a private jet to promote his film, he and his wife, Tipper, live on two properties: a 10,000-square-foot, 20-room, 8-bathroom home in Nashville and a 4000-square-foot home in Arlington, Virginia, and they also own a third home in Carthage, Tennessee. There is no evidence that Gore has signed up to use green energy in either of his large residences, although it is available for both. Gore and his family also own hundreds of thousands of dollars of Occidental Petroleum stock and also receive thousands of dollars in royalties from Pasminco Zinc, which operates a zinc concession on his property in Carthage. Both of these companies apparently are major polluters. Schweizer suggests the issue here is not hypocrisy but credibility. If Gore wants radical changes in the way other people live, he needs to set the example in his own life.

SEX OFFENDERS

The number of sex offenders in the USA is 566,000; in Texas, 46,000; and in Dallas, 3300 (31). The residence of Texas offenders is unknown for 19,000 of the 46,000 (41%), despite the law requiring all sex offenders in Texas to be registered. Of the remaining 59%, 12% (5620) are considered high risk; 32% (14,700), moderate risk; and 14% (6400), low risk. Although sex offenders are supposed to register with the state, a Dallas Morning News investigation found that one in six is hiding behind phony or outdated information.

BURGLARIES IN DALLAS

In 2005, Dallas ranked number one in burglaries among cities with a population of at least 1 million (32). There were roughly 22,400 burglaries, and only 8% of them were solved. Lock your doors!

SECURITY ALARM SYSTEM

Frank McCollum, my college classmate, sent me via e-mail a suggestion he apparently saw on the Internet: when you go to bed keep your car keys on your nightstand. If you think someone is trying to get into your house or if you hear a noise outside your house, just press the panic alarm on your car keychain. It will go off from most anywhere inside your house and the car will keep honking until your battery runs down or until you reset it with the button on the keychain. It works if you park your car in a garage or in your driveway. If the car alarm goes off when someone is trying to break into your house, odds are that the burglar or rapist will not stick around. It is also a good idea to carry your keys while walking to your car in a parking lot. The alarm can work the same way there.

HEALTH INSURANCE PREMIUMS

Health care premiums rose 7.7% in 2006, more than twice as fast as inflation (33). Health insurance premiums have surged 87% since 2000. Intel's chief executive officer warned that rising health care costs will spur more US employers to move jobs offshore. Intel spends $6000 on average per worker on health care, Chrysler an average of $1400 per four-wheeled vehicle built (34).

TRAVEL MEDICAL INSURANCE

According to many surveys what most haunts the American traveler today, aside from terrorism, is the prospect of being injured or seriously ill away from home (35). Fortunately, most travel medical insurance plans cover patient transport worldwide. Generally, insurance policies are priced based on client age and length or cost of the trip. Not all policies cover preexisting conditions. Most insurers offer a variety of plan options. Some of the most inclusive are the following: 1) HTH Worldwide, www.hthtravelinsurance.com; 2) M.H. Ross, www.tripinsurance.com; 3) MultiNational Underwriters, www.mnui.com; 4) On Call International, www.oncallinternational.com; and 5) Travel Guard International, www.travelguard.com. Insuremytrip.com compares quotes from 16 companies offering >100 policies.

MEDICAL LIABILITY

In its September/October 2006 newsletter, the Texas Liability Trust described 10 common errors that increase the risk of a malpractice suit (36): 1) Failing to listen to patients, spending inadequate time with them, and communicating emphatically with them. 2) Writing illegibly and not documenting reasons for procedures or therapies adequately. 3) Allowing staff to treat patients poorly. 4) Being inaccessible to patients. 5) Failing to order or follow up on indicated tests or delaying these tasks. 6) Failing to refer appropriately, to track referrals appropriately, and to communicate properly with referring physicians. 7) Prescribing medications inappropriately. 8) Caring improperly for patients during emergency situations. 9)Failing to obtain informed consent. 10) Allowing noncompliant patients to take charge.

ABE LINCOLN AND BILLING

One of my favorite writers is Paul Johnson, the eminent British historian and author who writes a column entitled “Current Events” in Forbes magazine. A recent piece concerned lawyers (37). He discussed Lincoln and the compensation culture. He mentioned that it is often said that the USA has more lawyers than the rest of the world put together. He recalled pundits arguing decades ago that one reason Japan was going to overtake the USA was that it had only one tenth the number of lawyers per capita that the USA had. One reason the USA has so many lawyers is that it has always been easier to become one in the USA than anywhere else. He mentioned some outstanding examples of individuals with little social standing—such as Abraham Lincoln and Andrew Jackson—who used the law as their first step on the road to noteworthy careers. With his impoverished background, Lincoln would not have qualified to become a lawyer in England, Germany, or France of his day. And Lincoln was a good lawyer—not only professionally but also morally. A letter Lincoln wrote on February 21, 1856, from his office in Springfield, Illinois, to a George P. Floyd of Quincy, Illinois, is instructive:

Dear Sir,

I have just received yours of 16th, with check on Flagg & Savage for twenty-five dollars. You must think I am a high-priced man. You are too liberal with your money.

Fifteen dollars is enough for the job. I send you a receipt for fifteen dollars, and return to you a ten-dollar bill.

Yours truly,

A. Lincoln

As Mr. Johnson indicated, this is a beautiful letter—brief, simple, and practical. Lincoln doesn't argue the point; he just returns $10. A copy of this letter should hang over the desk of every partner of every law firm in the USA. As Johnson indicates, it was not that Lincoln underpriced himself;quite the reverse. At one point he took on a troublesome and time-consuming case for the Illinois Central Railroad Company. He eventually won the case, saving the railroad (by his calculation) $500,000. Lincoln thought his services worth $5000; when the company tried to pay him only $250, he took them to court and won.

Lincoln's view of the law has direct relevance to today's compensation-culture debate. In the 1850s he wrote to a young man contemplating the law as a profession. The paper is entitled, “Notes on the Practice of Law.” In it Lincoln advises:

Never stir up litigation. A worse man can scarcely be found than one who does this. A lawyer should always discourage litigation. Persuade your neighbors to compromise whenever you can. Point out to them how the nominal winner is often a real loser—in fees, in expenses, and waste of time. As a peacemaker, the lawyer has a superior opportunity of being a good man. There will still be business enough.

Lincoln believed the great virtue of the law was that it provided the best means—often the only means—of obtaining justice without violence. Lincoln continued: “Resolve to be honest at all events; and if, in your own judgment, you can not be an honest lawyer, resolve to be honest without being a lawyer.”

THE FORBES 400

To make the Forbes 400 richest Americans list in 2006, at least $1 billion is needed (38). The collective net worth of our nation's wealthiest 400 has now climbed to $1,250 billion. William H. Gates III is first with $53 billion and Warren Buffet second with $47 billion. Those in third and fourth place each have $20 billion. The Walton families of Wal-Mart fame together have $60 billion, so if there was only one of them, they would be first. There are no practicing physicians on this list.

THE CHINESE WAY: ONE CHILD, ONE DOG

China is already famous for its one-child policy. Now, in the Year of the Dog, Beijing is enforcing a one-dog policy (39). The goal is to curb a pet boom among people whose bourgeois lifestyles would shock Chairman Mao, the communist leader who banned pets entirely for decades. Recent regulations limit each Beijing household to one dog, prohibit owners from taking them to parks or other public areas, and reinforce the ban on large dogs—any animal with a shoulder height above 14 inches. The official reasons are public safety and disease control.

Rabies fatalities increased 30% in the first 9 months of 2006. Rabies became the nation's top infectious disease killer, ahead of tuberculosis and AIDS, according to the Ministry of Health. The owners of the 550,000 registered dogs and the estimated 450,000 unregistered dogs in Beijing fear that their animals will be detained or killed before their eyes. The police started house-to-house searches in November 2006. On November 11, 2006, 200 young Chinese, fearful that their animals would be killed, gathered for a noisy but peaceful demonstration that attracted at least 200 police officers, some in riot gear. The police detained and later released at least 15 people. They spread word about the demonstration through the Internet even though the government has blocked some pet websites in recent days. It's better to live in the USA.

TRUST

Alex Guinness, the beer mogul of the United Kingdom and producer of the Book of World Records, stated on one or more occasions that all he wanted to know about another person was whether or not he could trust him or her. Charles S. Bryan, whose recent book is reviewed by the Warrens in the book review section of this issue, places trust as one of the major character traits and a part of faith or transcendence. In 2006, Stephen M. R. Covey, the son of Stephen R. Covey, the bestselling author of The Seven Habits of Highly Effective People, has himself written a book entitled The Speed of Trust: The One Thing that Changes Everything (40). The young Covey breaks out 13 behaviors that build trust. Eight of these are as follows. Talk straight. Be honest and tell the truth. Demonstrate respect. Treat everyone with respect, especially those who cannot do anything for you. Create transparency. Operate on the premise of “what you see is what you get.” Right wrongs. Apologize quickly. Don't let pride get in the way of doing the right thing. Show loyalty. Acknowledge others' contributions. Speak about others as if they were present. Deliver results. Accomplish what you are hired to do on time and within budget. Practice accountability. Don't blame others when things go wrong. Keep commitments. When you make a commitment, you build hope, and when you keep it you build trust. Covey states: “Trust brings out the best in people and literally changes the dynamics of interaction.”

US DOMINANCE IN SPORTS DISAPPEARING

In September 2006, the USA lost the Ryder Cup again, the fifth time in the past 6 years (41). That cup pits the 12 best American golfers against the 12 best European golfers. The US basketball team fell in the 2002 and 2006 World Basketball Championships and in the 2004 Olympics. US baseball's best professionals lost badly in 2006 in Bud Selig's made-for-TV World Baseball Classic. Our team lost to South Korea, Canada, and Mexico in a sport we have dominated for 100 years. All of this, of course, does not mean our best athletes are in a decline; it simply means that the rest of the world has caught up. And, of course, now other countries make the best automobiles, TV sets, computers, and steel, among other things. We still make the best military weapons, political talk shows, TV sitcoms, and airplanes. Our edge in medicine may also be slipping. In 2006, over 50% of manuscripts submitted to the four major cardiology journals in the USA were from non-US countries.

“LORD BYRON” (1912–2006)

John Byron Nelson, Jr., in the 1930s and 1940s won 51 professional golf tournaments including 11 straight wins in 1945 and a total of 18 in 1945 (42–46). He was only 34 when he quit after 52 wins. He had raised enough money by 1946 to buy a ranch in Roanoke, Texas, and he moved there to live as a gentleman rancher. His influence on golf and the professional golfers who came after him, however, was enormous. He surely was the most loved of all the professional golfers. His last 60 years were characterized as a beautiful, simple, and humble life. Why he quit at his peak intrigues me. Bobby Jones quit at an even younger age, but he had to earn a living (he was an amateur). Byron Nelson, of course, was a professional. Jack Nicklaus said, “No one could consistently hit the ball as straight as Byron Nelson.”

GOLFING

Golf used to be good exercise, but now most courses require golfers to use carts. The Japanese love golf but have relatively few courses, drive many miles to play, and pay enormous fees (over $500 per round). The USA has just over 16,000 golf courses; about 125 new ones open each year, and about 95 close each year (47). A golf course is a real estate developer's dream: about 150 acres of undeveloped land. The newer courses are being built where land is cheaper, meaning more rural, so golfers now often have to drive further to play.

I haven't played golf in several decades, but when I did, I remember being unable to think of anything else but the next shot. Today, I am told, golfers talk on their cell phones while putting. Certainly Tiger Woods has reestablished enormous interest in this sport. During Tiger's five tournament wins in a row in 2006, he earned just over $5,700,000, almost as much as Jack Nicklaus earned from tournaments during his entire professional golf career (48).

PRO FOOTBALL MYTHS

Maybe “evidence-based” medicine should be applied to football. Alan Barra(49)provided 10 sweeping statements, none of which are backed up by facts. 1) “Offense sells tickets, but defense wins championships.” 2) “You need a strong running game.” 3) “A turnover is a turnover.” 4) “Great teams are built around the kicking game.” 5) “The draft creates parity.” 6) “You have to control the ball.” 7) “Home teams have the advantage.” 8) “The pass sets up the run.” 9) “Pass completion percentage is a key stat.” 10) “This is the age of the running quarterback.” He provided some facts that counter these myths.

CROCODILE HUNTER

Steve Irwin had been taught by his father how to catch crocodiles in the rivers of North Queensland, Australia, during childhood (50, 51). This exuberant Aussie, who always dressed in his trademark khaki shirt and shorts and loved to wrestle crocodiles and hold large snakes, had apparently joked: “If I am going to die at least I want it filmed.” Tragically, he got his wish in September 2006. While shooting a documentary called Ocean's Deadliest in the Great Barrier Reef, a stingray's barb pierced his heart as he swam unprovokingly above it. Moments after he yanked the barb out he was dead. A stingray's strikes are rarely fatal, so it was an especially cruel twist of fate. He was only 44. He will be missed.

PILOT AT 100

Clayton L. “Scotty” Scott started flying in the late 1920s (52). He was the first to fly paying passengers across the Gulf of Alaska—a passage so risky that the airline offered a new car to the first pilot to fly 1000 people on the route without killing anyone. Later, he was the Boeing Company's founder's personal pilot and test-piloted 1000 company planes, including B-17 bombers and 727 jets. He stopped piloting after flying to his 100th birthday celebration.

DRIVING ON THE LEFT SIDE

My dear friend, Dr. Joseph K. Perloff in Los Angeles, sent me the following from Biblical Archeology Review, the September/October 2006 issue (53): “In the Middle Ages, maybe earlier, when roads were narrow and robbers or enemies might be encountered, travelers outside of towns on horseback took to riding on the left so that their right hand (the sword hand for most people) faced oncoming riders ready for self defense. This habit eventually evolved into a method of traffic control in cities and elsewhere. A similar idea is behind shaking hands with the right hand. Two sword hands clasped insure safety.”

Thank you, Joe!

—William Clifford Roberts, MD

30 November 2006