Facts and ideas from anywhere

William C. Roberts, MD

HOTTER DAYS

My son Charles sent me “The Hot Zone” by Linda Marsa from a recent issue of Discover (1). She quoted a British scientist writing in the Lancet in 2010 that “climate change is the biggest global health threat of the 21st century.” Climate change brings back some “old” diseases. There is dengue in Texas, malaria in New York, hypertoxic pollen in Baltimore.

Long thought eradicated in the USA, dengue is back. There had been prior cases of the disease's milder cousin, classic dengue fever, in Brownsville, Texas, but now the more serious form of dengue infection, hemorrhagic fever, appeared in a patient in Brownsville, Texas, in 2005. From 1995 to 2005, some 10,000 cases were reported in the USA, including the Texas-Mexico border region. The Centers for Disease Control and Prevention (CDC) suggested that many cases are never counted, so these figures may be large underestimates.

Several factors influence the spread of the dengue virus, but rising global temperatures may be the most important. Like many tropical diseases, dengue is spread by mosquito bites, and mosquitoes are exquisitely sensitive to climate. Frost kills both adult mosquitoes and larvae, which is why the disease hasn't previously been able to get a foothold in the US. But with the advent of warmer winters, there is nothing holding the insects back. The two species of mosquitoes capable of transmitting dengue fever, casually known as the Asian tiger mosquito, have substantially expanded their habitat range since the middle of the 20th century. They are now in 28 US states, even as far north as New York and New Hampshire. Hotter, more humid weather shortens mosquito breeding cycles. Heat speeds up the incubation of the dengue virus, making it infectious much sooner and for more of the insects' lifespan. Female mosquitoes bite more frequently when the temperature rises. Climate change is likely to usher in an era of more extreme weather, including the heavy rains and flooding that create ideal mosquito breeding grounds, and dengue is far from the only risk. Ticks, mice, and other carriers are also surviving milder winters and fanning out across the country, spreading other pathogens: Lyme disease, Rocky Mountain spotted fever, equine encephalitis, St. Louis encephalitis, anaplasmosis, and babesiosis, a once uncommon malaria-like infection.

Despite the 1000 who have been stricken, most Americans are not aware of dengue. Epidemic outbreaks have occurred throughout Latin America—in Brazil, Mexico, Honduras, Paraguay, Costa Rica, Bolivia, and Cuba—and they now hit nearly 1 million people annually. And the virus is affecting people now in many northern states including Maine, Minnesota, and Washington. The aggressive Asian tiger mosquito transmits not only dengue but also Chikungunya fever, a particularly nasty infection that causes excruciating joint pain.

The increased mobility of the modern world also makes the situation worse. The most virulent form of Lyme disease may have reached the USA from Europe by ship. Infected individuals (“parasitic hitchhikers”) can now go anywhere in the world in <24 hours and deliver reservoirs of malaria, dengue, or Chikungunya fever. The warmer temperatures, extreme weather (both wet and dry), and increased mobility enabled the West Nile virus to become entrenched in North America. The deadly pathogen first emerged in Uganda in 1937 and then laid dormant for about 20 years before appearing again in Israel in the 1950s and in Romania in 1996. Each of those outbreaks occurred after an unusually dry hot spell, creating the perfect incubator for Culex pupiens, a common house mosquito that transmits West Nile. In 1999, the virus was identified in New York City. Once again, that summer was unusually hot and dry. Stagnant pools of water teaming with mosquitoes lured birds and they became infected, transmitting the West Nile virus.

Infectious disease is not the only consequence of the rising temperatures. An average increase in the USA of 2°F over the past 50 years worsens pollution and urban crowding. Cities are particularly affected due to air pollution and what are now called “urban heat islands,” created as asphalt, pavement, and buildings concentrate heat. People are moving to these giant urban slums without adequate sanitation, creating perfect mosquito breeding grounds.

Noninfectious diseases like allergies and asthma, already epidemic in the USA, are also likely to gain a boost from rising temperatures. Indeed, at least 50 million Americans suffer from these ailments: asthma affects about 10% of American adults and children. Their incidences are climbing. Both air pollution and pollen, two of the chief culprits behind asthma and allergies, intensify as temperatures increase. Ozone smog is created when sunlight cooks pollutants in the atmosphere. When the air heats up, more ozone is produced. Pollens released into the air by flowering plants, trees, and grasses appear earlier and for longer periods of time under warmer conditions. Hotter temperatures coupled with higher concentrations of carbon dioxide in the air prompt flowering plants to produce pollen that is far more noxious than pollen of the past. US Department of Agriculture scientists grew weeds in three sites: on an organic farm in western Maryland, in a park in a suburb of Baltimore, and in downtown Baltimore, which is cooked with smog and about 3° to 4° warmer than the surrounding countryside because of the urban heat island effect. The weeds in the hotter CO₂-enriched environment grew to nearly twice the size of plants on the farm—up to 12 feet versus 6 to 8 feet in the country—and generated more pollen, specifically, more allergenic pollen.

Intense heat waves will become more common over the next few decades according to a 2009 report released jointly by the National Wildlife Federation and Physicians for Social Responsibility. That increase will elevate the risk of heat-related deaths. Heat waves swept across Europe in 2003 and 2005 and killed >70,000 people. The 2003 event was one of the deadliest climate-related disasters in Western history.

In the summer of 2010, Russia wilted under the worst heat waves in 130 years of recordkeeping there, with daily highs in Moscow exceeding 100° compared with the normal summer average of 85°. In the countryside, severe drought ignited wildfires that smothered the city in poisonous smog for 6 straight days. The combination of unprecedented heat, dryness, and suffocating haze doubled death rates to an average of 700 people a day. People stated that they were hardly able to see more than a block away. People walked around with surgical masks on and kept the windows of their apartments tightly shut. Oscillating fans, which normally sold for about $10, that summer sold for $100.

This is what is on the horizon. Over the next century, global temperature will probably increase another 2° to 12° on average according to a 2009 report from the US Global Change Research Program. This shift will mean more extremely hot summer days. By 2080, it could be above 90° some 120 days a year in Kansas. Much of Florida and Texas could be above 90° for half the year, and many parts of the country, especially the Sunbelt, could have >2 months each year with 100° weather. Temperatures in the 110° to 120° range could soon become commonplace. The sizzling weather in Chicago in 1995, which claimed >700 lives, was possibly a prelude to what will happen in the future. Chronic illnesses could also be aggravated if weather-related national calamities, like fires, floods, and severe storms, overwhelm public services.

The migration to the South may be reversed in coming decades.

WATER GREED

Some predict that water will be more expensive than oil in the decades to come. Although our planet is called Planet Earth, it more appropriately might be called Planet Water since 70% of the surface is covered by water. Nevertheless, many land areas on Earth are enormously short of water. Kim and McCann (2) had a piece recently illustrating water consumption in selected Texas cities in gallons per day in 2008, the most recent statistics available. Highland Park leads the list with an average of 360 gallons per capita per day, followed by Southlake, Texarkana, Frisco, Plano, Richardson, and Dallas (non-Highland Park). Residents of Houston use one third the water per capita that is used in Highland Park. North Texas communities consumed almost 500 billion gallons of water in 2010. That is the largest quantity consumed by any region in Texas. With the huge droughts in Texas, we all need to be more conservative with our water use. A long shower is nice but it's greedy. Leaving the faucet running while we brush our teeth is greedy. Clearly the Dallas–Fort Worth area is a drain on Texas' water supplies.

DALLAS TREES

Trees absorb air pollutants. Their shade lowers temperatures and can reduce energy use. By easing water runoff, they improve water quality and diminish the potential for flooding. They can enhance property values, soften noise, and provide wildlife habitat. They also grow up, get sick or injured, get old or cleared away. To protect and preserve them, trees need to be nurtured and their number and species known. With the help of Dr. Fang Qui, an associate professor at the University of Texas at Dallas, some of his students and an airplane equipped with remote-sensing laser devices determined the location, height, foliage spread, and species of >316,000 trees in two areas of Dallas covering 20 square miles (3). Images collected along Turtle Creek North into the Park Cities identified 92,540 trees with heights ranging from 5 to 29 feet (average, 12). The second area, near and north of White Rock Creek, had 223,788 trees ranging in height from 5 to 39 feet (average, 13). In both areas, cedar elms, pecans, live oaks, and the invasive tree of heaven were most prevalent. Projecting the count across the city's 385 square miles gave an estimate of >6 million trees, almost 5 per person.

Having such specific information and keeping it updated can help foresters, arborists, property owners, government officials, and others to monitor and manage wooded areas. It can help track tree diseases, the health of selected species, and the spread of invasive ones. It can provide evidence of illegal cutting and help guide tree planting and maintenance efforts. Let's try to increase that number to 10 trees per Dallas resident.

WORKING HOURS AND CORONARY HEART DISEASE

Kivimäki and colleagues (4) from United Kingdom, Finland, and France examined 7095 adults (2109 women and 4986 men) aged 39 to 62 years working full-time without evidence of coronary heart disease at baseline (1991–1993) and followed them for evidence of coronary heart disease until 2004. A total of 192 participants developed clinical evidence of coronary heart disease during a median 12.3-year follow-up. After adjustment for their Framingham risk score, participants working ≥11 hours per day had a 1.67-fold increased risk for coronary heart disease compared with participants working 7 to 8 hours per day. Thus, information on working hours appears to improve risk prediction for coronary heart disease in low-risk working populations.

LOWERING CHOLESTEROL MORE

The JUPITER trial, which I consider the best of the lipid-lowering drug trials, included 11,001 men aged ≥50 years and 6801 women aged ≥60 years with low-density lipoprotein (LDL) cholesterol <130 mg/dL, high-sensitivity C-reactive protein (hsCRP) ≥2.0 mg/L, and no history of cardiovascular disease or diabetes mellitus. The trial was published in 2008. The trial was stopped because the event rates were reduced so much in the 20-mg rosuvastatin group compared with the placebo group. The current paper by Hsia and colleagues (5) divided the JUPITER trial participants into those who had their LDL cholesterol lowered to <50 mg/dL and those in whom the LDL cholesterol never got below 50 mg/dL. (In the initial trial of 17,000+ patients, the mean LDL cholesterol at baseline was 109 and nearly 2 years into the trial the mean LDL cholesterol had fallen to 55 mg/dL.) In the recent analysis, there were 4000 patients in whom the LDL never got below 50 and 4156 patients in whom the LDL was <50 mg/dL. There were 8150 patients in the placebo group. The average age of all groups was 66 years, and almost 40% in each group were women. After a median follow-up of 2 years in the rosuvastatin-allocated subjects without and with LDL cholesterol levels <50 mg/dL, baseline and 1-year cholesterol levels (median) were 109 and 110 mg/dL in the placebo group; 113 and 70 mg/dL in the rosuvastatin-allocated subjects with no LDL cholesterol <50; and 103 and 44 mg/dL in the rosuvastatin-allocated patients with LDL <50 mg/dL.

In the previously reported trial, rosuvastatin reduced the primary study endpoint, a composite of cardiovascular death, myocardial infarction, stroke, arterial revascularization, and unstable angina pectoris, by 44%. This treatment effect was consistent regardless of baseline LDL cholesterol level. The magnitude of clinical benefit was directly related to the obtained LDL cholesterol level. Compared with the placebo group, rosuvastatin-allocated patients with no LDL cholesterol <50 had a smaller risk reduction for the primary endpoint. Subjects whose LDL cholesterol was lowered to <50 mg/dL had a 65% reduction in major cardiovascular events compared with those whose LDL was never lowered to that level. Similarly, all-cause mortality was reduced by 20% for the entire 17,000+ patients and by 46% in the patients obtaining an LDL <50 mg/dL.

Rosuvastatin reduced major cardiovascular events by 44% compared with placebo for the entire JUPITER subjects and by 65% among those attaining LDL cholesterol <50 mg/dL. Similarly, all-cause mortality was reduced by 20% for the entire cohort and by 46% among patients attaining LDL <50 mg/dL. With regard to adverse events, myalgia and diabetes mellitus were somewhat more common among participants attaining LDL cholesterol <50, but these rates were not significantly different from rates of those not attaining LDL cholesterol <50 mg/dL. Rates for other adverse events, including muscle weakness, myopathy, neuropsychiatric events, renal dysfunction, hemorrhagic stroke, and cancer, were not higher among patients allocated to rosuvastatin than among patients allocated to placebo, regardless of attained LDL cholesterol level.

A major strength of this analysis is its large sample size. The number of JUPITER study participants with an LDL <50 mg/dL was greater than the entire active treatment group of many placebo-controlled statin trials. This study provides further evidence that the lower the LDL cholesterol, the better. This study suggests that the LDL cholesterol threshold, if it exists, may be <50 mg/dL. I am going for <50 mg/dL from here on.

CALORIE POSTINGS ON MENUS

The calorie labeling provision was part of President Barack Obama's 2010 health overhaul law. The rule, expected to take effect in 2012, provides details on eateries with 20 outlets or more and on vending machines (6). Convenience stores, supermarket eateries, pastry and retail confectionary stores, coffee shops, snack bars, and ice cream bars will be required to post calorie counts. The new law requires the posting of calorie counts of foods and drinks on menu boards. Movie theaters, airplanes, bowling centers, amusement parks, hotels, and other establishments where the sale of food is not the primary business are excluded from having to post calorie labeling. The regulation will apply to establishments where more than 50% of the total floor area is used for the sale of food. Bars and restaurants will not have to post calorie labels on beer, wine, and other alcoholic beverages, which come under the Alcohol and Tobacco Tax and Trade Bureau rather than the Food and Drug Administration (FDA). The FDA estimates that the proposed regulations would apply to just under 280,000 establishments out of an estimated 600,000 restaurants nationwide. These calorie postings are done of course to decrease the average calories per transaction.

HEART ATTACK GRILL

John Basso started Heart Attack Grill in Chandler, Arizona, and now he is bringing it to Dallas' West End (7). Pretend-doctors flip massive burgers and charred-in-lard fries, served by naughty nurses and washed down by Jolt cola. A 2-lb hamburger is served free to anyone weighing >350 pounds. It consists of 4 half-pound beef patties and 8 slices of cheese served in a lard-coated bun. Also available are maximum-density butterfat shakes. Fortunately for its patrons, the grill will be relatively close to Baylor University Medical Center at Dallas.

APPENDICITIS—EMERGENCY SURGERY OR NOT?

Should appendectomy for appendicitis be done in the middle of the night or should it wait until the next morning after putting these patients on antibiotics and pain medications? A 2010 report on 309 appendicitis patients at a New Haven, Connecticut, hospital found those who had surgery within 12 hours of arriving at the emergency room fared no better than those who waited up to 24 hours for their appendectomy (8). Angela Ingraham, a general surgery resident at the University of Cincinnati, analyzed nearly 33,000 US appendectomy patients and found that timing <6, 6–12, or >12 hours after hospital admission made no significant difference in their condition 30 days afterwards. It also made no difference in the length of their operation or hospital stay. No matter when the appendix is removed, people seem none the worse without it. That led Charles Darwin to conclude that it is a useless evolutionary leftover. William Parker at Duke believes the appendix is there to store friendly bacteria that could get wiped out in the gut by severe diarrhea. Appendicitis was pretty much unheard of in Western countries when diarrhea was common. It's still apparently rare where diarrhea from contaminated drinking water is common. “Let's do it in the morning.”

PRESCRIPTION PAIN MEDICATIONS

The deadliest drugs in the USA are not heroin or cocaine. The larger problem is abuse of drugs that are perfectly legal: prescription pain medications. According to a piece in USA Today, they kill an estimated 2 people every hour and send 40 more to emergency rooms with life-threatening overdoses (9). Powerful drugs such as OxyContin, Dilaudid, and Vicodin are obviously blessings to people with severe pain. But by themselves or in combination with antidepressants and muscle relaxers, they have become a scourge that kills >18,000 people a year, according to estimates by the Prescription Monitoring Program Center of Excellence at Brandeis University. The administration's prescription monitoring programs routinely enter prescriptions for certain drugs in a database that physicians can consult when prescribing powerful painkillers. More than 40 states have created these databases and >30 have them up and running. Physicians can consult these databases before writing prescriptions for painkillers. According to the USA Today editorial, most people who abuse painkillers get them from friends and family, sometimes innocently, sometimes by theft. A pernicious problem is unscrupulous physicians who deliberately overprescribe painkillers. Florida is said to be the home to numerous “pill mills,” where it's so easy to get painkillers that people routinely flock from other states along the “OxyContin Highway.” Florida's decision to open a pharmacy database might help deter these predators.

Prescription-monitoring programs may sound like a good idea, but they are not supported by all individuals or all states (10). That's why such proposals have been defeated several times in the past and why some proposals face substantial opposition. First of all, privacy advocates are concerned about creating another online database full of sensitive personal information with every doctor, pharmacist, and health care provider in the state accessing it. Cost also is a major issue, particularly in low-tax states. Federal grants are allegedly available to pay the start-up costs, but expenses are a burden in a number of states. The costs are not equitably spread. Chain pharmacies already have the hardware needed to comply with such programs, but independent neighborhood pharmacies will need to purchase the hardware and train their staff. The entire burden of the program falls on pharmacists to input the data and maintain the system. It's optional for physicians. Considering that one intention of the program is to prevent physician shopping, exempting physicians from checking the database before prescribing seems inappropriate. Some are also concerned about “mission creep.” With the program not yet in place, advocates are already talking about expanding it to more types of medications—eventually to every prescription medication liable to be abused. They also want to extend the time for which records are kept, from the initial 100 days to maybe years.

Finally, one claimed benefit of a monitoring program is that physicians reassured that their patients are not abusing prescription drugs will be able to treat pain without fear of being targeted by the Drug Enforcement Administration for “overprescribing.” Creating a new government program to fix problems with an existing program is a formula for ever-expanding government.

CESAREAN SECTIONS

According to Jason Roberson (11), one third of 4.2 million babies born in the USA in 2008 were delivered by cesarean section, and C-sections make the recovery period from childbirth longer and the cost higher. In 1997, about a fifth of deliveries were performed via C-section. In Texas, C-section charges are about 60% higher than vaginal birth charges. It is said that every 1% decrease in the nation's C-section rate could save more than $300 million in maternity charges. In Texas, the median charge for a C-section birth without complications in 2009 was $13,198, and for a vaginal delivery, $8288. In Dallas County, hospitals charged $10,424 for a C-section compared with $7421 for a vaginal delivery.

LIFE EXPECTANCY AND INFANT MORTALITY RATES

The CDC issued a report in March 2011 on health and well-being across American society (12). Some observations: life expectancy in the US rose from 78.0 in 2008 to 78.2 in 2009. Life expectancy is one of the best measures of socioeconomic progress because it captures improvements in living standards, health care, safety, nutrition, and the environment. Ten years have been added to American life spans since 1950, and 30 years since 1910. Furthermore, Americans are living healthier and more active lives at every age.

Infant mortality rates hit an all-time low of 6.42 per 1000 live births, as did death rates for children under the age of 5. There is less chance of losing a child to early death now than at any time in history. In 2010, the death rate fell 4.2% for those <1, 7.7% for those aged 1 to 4, and 6.7% for those aged 15 to 24. In 1950, a child was nearly 4 times more likely to die before the age of 5 than he or she is today.

The overall age-adjusted death rate (the probability of dying at any particular age) fell to 741 from 759 per 100,000 in 2009, the 10th consecutive year the death rate has fallen. All of this progress took place over a decade when lack of health insurance was supposedly dooming many Americans to inadequate care. Advances in medical treatments matter far more to overall health progress than do insurance coverage rates.

The age-adjusted death rate also decreased significantly for 10 of the 15 leading causes of death: heart disease, cancer, various chronic diseases of the liver or respiratory system, influenza, and pneumonia. Death rates from accidents and homicide also fell significantly. Today, the 5-year US survival from cancer is 66%, the highest rate in the world, and up from 50% in 1975. The death rate from heart attacks and strokes is now one half to one third the age-adjusted rate of 50 years ago.

There also is some bad news: the incidence of obesity and diabetes mellitus has increased. These, of course, are less the result of medical care inadequacies than of lifestyle decisions, particularly quantity of consumed calories and caloric choices. The major health gains in 2009 were achieved by every race except blacks. This reverses the trend of recent decades when the “health gap” between African Americans and European Americans has been narrowing.

These numbers show that average Americans have not seen their living standards fall over the last 30 years, as is often claimed by those who focus only on wage data. Medical breakthroughs are available to the rich, the middle class, and the poor alike. A poor person in America today has access to much better health care than did a billionaire or a prince in the 1950s! Yes, American health care is expensive, but the CDC report shows that its benefits include longer and better lives.

CRIB DEATHS

Sudden infant death syndrome (SIDS) is officially any death of a baby <1 year of age that remains unexplained after a thorough investigation. About 2500 babies die from SIDS each year, down from about 4000 per year in 1992, in part due to campaigns urging parents to put infants to sleep on their backs (13). Infant fatalities attributed to accidental suffocation and strangulation in bed quadrupled between 1984 and 2004, according to the CDC. A study in Pediatrics in March 2011 indicated that on average, 26 babies <2 years old are injured every day in the USA in a crib, bassinet, or playpen.

The use of bumpers, which line the inside of the crib, is controversial (14). The Consumer Products Safety Commission and the American Academy of Pediatrics have urged parents not to use the puffy bumpers—the kind that a baby's face could sink into—but both have stopped short of advising against any bumpers at all, as some consumer groups urge.

Other concerns focus on the cribs themselves. Starting in June 2011, it will be illegal to make, sell, or resell any crib in the US that doesn't meet tough new federal standards. Drop-down sides, linked to 32 infant deaths since 2000, will be prohibited. The new rules also require stronger slates, mattress supports, and hardware that can withstand vigorous shaking by toddlers. Most cribs on the market now do meet these new standards, according to the Juvenile Products Manufacturers Association. Tags with the code 16 CFR 1219 for full-sized cribs and 16 CFR 1220 for compact-sized cribs indicate that cribs meet the standards. The Juvenile Products Manufacturers Association estimated that the new rules will add 10% to 15% to the cost of the new cribs, which can range from $150 to over $1000. Yet millions of old cribs will remain in circulation, many of which are handed down through families or passed along to friends.

Experts and manufacturers agree that pillows, blankets, comforters, and piles of stuffed animals should not be placed in cribs with children <12 months of age. Loose fabric and soft cushions can block a baby's nose and mouth, and sleeping babies may not wake up sufficiently to fight for air, leading to SIDS.

Some baby products marketed as “making babies safer” have ended up posing more hazards. Positioning pillows designed to keep babies from rolling onto their sides or stomachs have been involved in at least 13 infant deaths since 1997. Experts have long warned against having babies sleeping in parents' beds, given the risk of suffocating in bedding or being crushed by a sleeping adult. The safest sleeping arrangement is to have the baby sleep in the parents' room for the first 6 months but in a separate bassinet or crib.

THE CONGENITALLY BICUSPID AORTIC VALVE

It appears that 99% of us have three-cuspid aortic valves and 1%, a bicuspid aortic valve. Fifty years ago (in April 1961), Dr. Jesse E. Edwards published an editorial entitled “The Congenital Bicuspid Aortic Valve” (15). At the time, Dr. Edwards was the world's foremost student of the aortic valve. In that editorial he asked a simple question, “How does a congenitally bicuspid valve open and close during the two phases of the cardiac cycle?” To my knowledge, that question had never been asked previously. Dr. Edwards preceded his answer to the question by describing how the normal three-cuspid aortic valve opens and closes. He demonstrated that the latter does so because the distance between any two commissures (lateral attachments of each independent cusp) along their free margins is greater than a straight line. The greater-than-a-straight-line distance allows each cusp to move to the center of the aortic lumen during ventricular diastole, thus closing the orifice, and move near the wall of the aorta during ventricular systole, thus opening the orifice maximally or nearly so.

So how does a congenitally bicuspid aortic valve open if theoretically the distance between the two commissures across the aortic orifice is a straight line? Dr. Edwards demonstrated that the length of at least one of the two cusps along its free margin is not a straight line but indeed is greater than a straight line. This fact is both its savior and its defeater. It is a “savior” because if at least one of the two cusps was not longer than a straight line, the valve could not open during ventricular systole. That the length of at least one cusp along its free margin is greater than a straight line is also its “defeater” because the elongation allows each cusp to contact the other during ventricular diastole in a traumatic fashion, and that trauma over many years causes the cusps to thicken and eventually to calcify, leading to stenosis. If the cusps do not calcify, pure regurgitation is the usual hemodynamic consequence. Rarely does a congenitally bicuspid valve function normally or near normally during an entire lifetime.

Dr. Edwards also pointed out that a congenitally bicuspid aortic valve was rarely if ever stenotic from birth. The aortic valves that are stenotic from birth are nearly always unicuspid, mainly unicommissural. His publication 50 years ago was a great step forward in our understanding of the congenitally bicuspid aortic valve.

EARLY PUBERTY

According to a study of 1239 girls published in Pediatrics in 2010, about 15% of American girls now begin puberty by age 7 (16). One in 10 white girls begin developing breasts by that age—twice the rate seen in a 1997 study. Among black girls, 23% hit puberty by age 7. During the last 30 years, the childhood of girls has been shortened by about 18 months. According to one investigator, girls are being catapulted into adolescence long before their brains are ready for the change, a phenomenon that may pose risk to their health.

Why the age of puberty is falling is unclear. There is no evidence that boys are maturing any earlier. Girls once matured much later than today, probably because poor diets and infectious diseases left them relatively thin. Girls' lack of body fat may have sent a message to their bodies that they weren't yet ready to carry a pregnancy. In the 1840s, for example, girls in Scandinavia did not begin menstruating until age 16 or 17, according to Paul Kaplowitz, the author of Early Puberty in Girls. As nutrition and living conditions improved, the age at first menstruation occurred 2 to 3 months earlier each decade. By 1900, American girls were getting their periods at age 14. Although the age at which girls get their first period has continued to fall slowly since then, the age at which girls begin developing breasts has declined much more dramatically. Early puberty increases girls' odds of depression, alcohol use, illicit drug use, eating disorders, behavioral problems, and attempted suicide. When these girls grow up they apparently face a higher risk of breast and uterine cancers, likely because they are exposed to estrogen for a longer period of time.

In only a generation, children have become less connected to nature and in many ways less free. Today's children rarely, if ever, are permitted to roam wild or play outdoors alone out of sight of watchful parents. Schools are eliminating recess as vending machines are installed in school cafeterias. This generation of children is heavier, less active, and more prone to chronic disease and hormonal changes.

The clearest influence on the age of puberty seems to be obesity. In general, obese girls are much more likely to develop earlier than thin ones. And the number of heavy girls is growing. According to the CDC, 30% of children are overweight, many being obese. Obesity raises the level of key hormones, such as insulin, which helps regulate blood sugar, and leptin, a hormone made in fat cells that helps regulate appetite. While leptin may not trigger it, puberty cannot start without it. Prematurity, which has increased 18% since 1990, also may contribute to early puberty. Babies born early or who are very small for their gestational age tend to experience “catch-up growth” that can lead to overweight. Another factor may be environmental chemicals, found in everything from pesticides to flame-retardants and perfume, which can interfere with the hormonal system. Chemicals used to soften plastic called phthalates can act like hormones. Bisphenol A (BPA), which is found in hard plastics, the linings of metal cans, and many other consumer products, causes early puberty in animals. Its role in humans is less clear, but 90% of Americans have BPA in their bodies.

CONSEQUENCES OF REQUESTING “DISPENSE AS WRITTEN”

All US states have adopted generic substitution laws to reduce medication costs. Physicians may override these regulations, however, by prescribing branded drugs and requesting that they be “dispensed as written.” Patients also can make these requests. Little is known about the frequency and correlates of “dispense-as-written” requests or their association with medication filling. Shrank and colleagues (17) examined 5.6 million prescriptions for >2 million patients in January 2009. Approximately 2.7% were designated as “dispense as written” by physicians, and 2.0% by patients. Substantial variations in “dispense-as-written” requests were seen by medication class, patient and physician age, and geographic region. The odds of requesting “dispense as written” was 78.5% greater for specialists than for generalists. When chronic prescriptions were initiated, physician “dispense as written” and patient “dispense as written” was associated with greater odds that patients did not fill the prescription. Thus, “dispense as written” requests are common and are associated with decreased rates of prescription filling. Reducing rates of “dispense as written” requests may reduce costs and improve medication adherence.

HIGHWAY DEATHS

Highway deaths have plummeted to their lowest levels in >60 years, helped by more people wearing seatbelts, better safety equipment in cars, and efforts to curb drunken driving (18). The Transportation Department estimated that 32,788 people were killed on US roads in 2010, a decrease of 3% from 2009. It is the lowest number of deaths since 1949 when >30,000 people were killed on US roads. Traffic deaths typically decline during an economic downturn because many motorists cut back on discretionary travel. The number of miles traveled by American drivers in 2010 increased by 20.5 billion or 0.7% compared with 2009, according to the Federal Highway Administration. Separately, the rate of deaths per 100 million miles traveled is estimated to hit a record low of 1.09 in 2010, the lowest since 1949.

WINNING CLOSE CRUCIAL GAMES AND AUTOMOBILE FATALITIES

Researchers from North Carolina and the University of South Carolina found that traffic deaths rise in the hometowns of winning teams on game days, and also that the closer a game is the greater the chance of automobile fatalities (19). The researchers examined data from 271 professional and collegiate football and basketball games from 2001 to 2008, focusing on highly anticipated events such as playoff and rivalry games. They found that the closer the game, the more automobile fatalities there were. The increase in number of fatalities only happened in locations with high numbers of winning fans (game sites and winning hometowns). Prior research has shown that winning fans exhibited sharp increases in testosterone at the end of games while losers exhibited sharp decreases. Increases in testosterone are associated with increased aggressive behavior in both men and women. The researchers found that “going from a blowout to nail-biter” increased fatalities by 133%. They found that the danger of a close game was as detrimental as the absence of use of seatbelts. These researchers found no increase in fatalities in the losing teams' hometowns. Just watch the game from home and don't go out afterwards.

MOTORCYCLIST DEATHS

In 2010 motorcycle deaths fell for the second straight year to about 4376, according to the Governors Highway Safety Association (20). The decline, however, was much smaller than 2009's 16% drop. The 2010 decline was concentrated in the early months when fewer bikers were on the road, and the death rate rose in the later months. The use of helmets approved by the Department of Transportation dropped 16%. Motorcycle ridership appears to be growing as the economy improves. Thus, there is concern that these fatalities will increase in 2011.

The Governors Highway Safety Association recommends that states take measures to further lower motorcyclist deaths. 1) Increase helmet use, which has been shown to help prevent fatal injuries. (In 2008, 42% of fatally injured bikers were not wearing helmets; 30 states do not require helmets for all motorcyclists.) 2) Reduce impaired driving. (In 2009, 29% of motorcyclists killed in crashes had blood alcohol levels above the legal limit for operating a motorized vehicle.) 3) Reduce speeding, a factor in 35% of motorcycle crashes in 2008, compared with 23% for passenger vehicles and 19% for light trucks. 4) Provide training to all bikers who need or seek it.

These two-wheelers are not for me.

JAPAN—A BEAUTIFUL EXAMPLE

Lee Kuan Yew (21), the former minister of Singapore, described some consequences of the March 11, 2011, earthquake centering on Fukushima and the tsunami that hit the coast of Sendai. The city and neighboring countryside were destroyed. The nuclear meltdown of the Fukushima Daiichi Power Plant followed, causing radiation leaks and contamination. These consequences have severely tested the people of Japan. The Fukushima quake measured 9.0 on the Richter scale. But the Japanese have seen this before. In 1923, an earthquake measuring 7.0 on the Richter scale hit Japan near Kanto, devastating hundreds of miles of coastline, and towns were washed away by mudslides and trains were carried out to sea. Three weeks after the disaster, 260,000 households had no running water and 170,000 had no electricity.

The Fukushima power plant has six reactors, whose cooling systems were interrupted and damaged. Efforts to bring the reactors under control have had some success, but it may take months to bring the reactors to a stable cold shutdown. Building new cooling systems is also expected to take several months.

Northeastern Japan, where the tsunami hit, is also where the ports, steel mills, oil refineries, nuclear power plants, and manufacturers of electronic components are situated. Many of these businesses have been damaged, and nationwide power shortages have decreased auto and electronic production, causing many automobile plants in key production centers to be closed. Global companies, from the makers of semiconductors to shipbuilders, face disruptions to their operations because of the destruction of vital infrastructure and the damage to Japanese factories that supply high-tech components. Because Japan is the world's third largest economy, the disaster will severely impact the rest of Asia and the global economy for years. The damage to housing and infrastructure is unprecedented. Japan will experience a huge surge in steel imports to build sturdier structures to replace all those that were damaged or destroyed.

Japan's Food Safety Commission has restricted shipments from Fukushima prefecture of vegetables that register higher than permissible levels of radioactive material. Also restricted are shipments of milk. Parents of babies <1 year old are advised not to use tap water for powdered milk or baby formula. As a result, people are buying up supplies of bottled water. The Japanese consume large quantities of seafood; they will need to find alternative food sources because of the damage in the areas where seafood is processed.

Japan's nuclear safety regulatory agency has taken a hard-headed approach to atomic power expansion. About 30% of the nation's electricity output comes from nuclear power. The government's goal was to increase that to 40% by 2020. Without more nuclear power, Japan will experience rampant blackouts in the future.

The Japanese people's comportment under such severe stress has been remarkable. No panic, no looting. A calm, disciplined, and stoic manner has prevailed, with people caring for one another. Few societies could maintain such order and solidarity during a catastrophe of this magnitude. Group interaction and cooperation are the foundation of Japanese society. The whole world has witnessed Japan's dignity and grace in the face of devastation. The capacity to endure the unendurable is the very essence of the Japanese character.

As of April 2, 2011, the number of deaths totaled 11,578, with 16,451 still missing. Since the March 11 earthquake, there have been 800 aftershocks, and these have registered up to >5.0 magnitude. Japanese scientists believe the last time the Sendai region of Japan was hit by an earthquake and tsunami with a magnitude as high as the March 11 event may have been AD 869. Some 18,000 Japanese troops and 7000 Americans have joined Japanese police, firefighters, and Coast Guard to search for bodies along hundreds of miles of the Japanese northeast coast, which was devastated by the tsunami (22). Sixty-five ships were involved in the effort.

How long can radioactivity hang around? Twenty-five years after the Chernobyl nuclear disaster in the Soviet Union, wild boars in Germany are still too radioactive to eat and the mushrooms the pigs dine on are not fit for consumption either (23). The German experience shows what could await Japan if the problems at the Fukushima Daiichi plant get any worse. The German boars roam in forests nearly 1000 miles from Chernobyl. Yet the amount of radioactive Cesium-137 within their tissue often registers dozens of times beyond the recommended limit for consumption and thousands of times above normal. Cesium's half-life is roughly 30 years. Cesium in high levels is thought to be a risk for various cancers. Nevertheless, an increase in cancers that might be linked to cesium has not occurred in Europe. Cesium also accumulates in the soil, which makes boars most susceptible. They snuffle through forest soil with their snouts and feed on the kinds of mushrooms that tend to store radioactive material. Japan's Fukushima plant so far has not leaked nearly as much radiation as Chernobyl, but authorities there have banned the sale of milk, spinach, cabbage, and other products from surrounding regions as a precaution.

NUCLEAR VS. COAL

According to Holman W. Jenkins Jr. (24), an UN-monitoring project has found no scientific evidence for an increase in overall cancer incidence or mortality rates among residents of the Chernobyl region in Russia, aside from a serious uptick in curable thyroid cancer among those exposed as children. But which is safer: nuclear or coal? Thousands more die in coal mine accidents each year (especially in China) than have been killed in all nuclear-related accidents since the beginning of nuclear power. Additionally, coal plants spew toxins like mercury and other metals—along with more radioactive thorium and uranium than a nuclear plant—which are no less amenable to elimination than from a nuclear plant. In 2004, the Environmental Protection Agency estimated that a new emission standard then being proposed would by itself save 17,000 lives a year. Jenkins has convinced me that if nuclear plants are placed in relatively safe areas, not on the Pacific Rim where earthquakes are common, they are safer over the long haul than is coal.

A METEOROLOGICAL AUTOPSY

A number of meteorologists have gathered to study the consequences of the monstrous tornados that struck some areas in the South in late April 2011 (25). They surveyed damage from the ground and air, asking questions about the buildings that were destroyed. Were they brick, wood, or a combination? Were they secured to a slab or set on concrete blocks? What type of roofs did they have? Answers to those questions will help explain how strong the twisters were. A mobile home, for example, will be demolished by winds of 110 to 136 mph. A well-built home can withstand much stronger winds. One meteorologist for the Weather Service's southern region headquarters in Fort Worth, Texas, likened a roof with a large overhang to a baseball cap with a brim; wind blowing in your face will press on the brim and lift the hat off, and the same can happen with a house. Assessing damage becomes more complicated as the meteorological investigators move along the track of a tornado. Once structures start to break apart, the wind collects debris and then they are moving grinders that impact all downstream structures. These investigators tried to determine if there was one tornado criss-crossing the entire state of Alabama or more than one. If it was a single twister, it would be one of the longest on record, rivaling a 1925 tornado that raged for nearly 220 miles. Thus, living in sturdy houses or buildings potentially saves lives and lowers medical costs.

In contrast to the civility of the Japanese toward one another after their recent earthquake and tsunami, the reaction of some citizens in the destroyed towns in the South after the recent tornado was striking. In Tuscaloosa, Alabama, and other cities, looters have been picking through the wreckage to steal the little the victims have left. One citizen remarked, “The first night they took my jewelry, my watch, my guns…. They were out here again last night doing it again.” Overwhelmed Tuscaloosa police imposed a curfew and got help from National Guard troops to try to stop the scavenging.

Along their flattened paths, the twisters blew down police and fire stations and other emergency buildings along with homes, businesses, churches, and power infrastructures. The number of buildings lost, damage estimates, and number of people left homeless were enormous. Tuscaloosa's emergency management center was destroyed. A fire station in nearby Alberta City, one of the city's worst-hit neighborhoods, was destroyed. The firefighters survived, but damage to their equipment forced them to begin rescue operations without a fire truck. A Salvation Army building was destroyed, costing Tuscaloosa much-needed shelter space. The Federal Emergency Management Agency, of course, has responded to all affected areas and has officials on the ground in Alabama, Mississippi, Kentucky, Georgia, and Tennessee. The death toll has reached well over 350, and almost 75% of the deaths occurred in Alabama.

MACONDO EXPLOSION A YEAR LATER

After BP's Macondo well in the Gulf of Mexico blew out in April 2010, many feared that the resulting oil spill would turn the Gulf into a dead sea, destroy its beaches, kill its vibrant seafood and tourism industries, and mortally wound the economies of states from Florida to Texas (26). It didn't happen. The spill's long-term effects on the environment are still a serious question, but the Gulf turned out to be surprisingly resilient, and so far the news has been unexpectedly good. Most of the oil is gone. Fishing has resumed, the beaches are clean (with a few exceptions), tourists' bookings are up, and Gulf seafood is safe to eat.

The most important change in the past year was the death of the illusion that the oil industry is infallible—a conviction built by 40 years without a major drilling-related accident in US waters. The Macondo accident, which killed 11 men and took 87 days to bring under control, will cost BP an estimated $40 billion. The accident resulted in shutting down temporarily most deep-water drilling operations in the Gulf, and only about half of them have been allowed to resume drilling. The new process for obtaining permits has been slowed enormously. Local economies that depend on Gulf drilling are suffering from this slow-motion recovery. If another such accident occurred, deep sea drilling would probably be finished. Someday, as an editorial in USA Today indicated, the roughly 250 million vehicles on US highways might be able to run on clean energy, but until then, drilling in deep water will be essential for a nation that now buys half its oil from the volatile world market. It is crucial that we drill safely, and it's also crucial that we drill.

Where did all the oil go? Government and university scientists are still trying to reach consensus on where all the oil went. Some of the oil was eaten by microbes, and some of it ended up or will become imbedded on the seafloor or on beaches or marshes. The heavier stuff will wash up on beaches 20 years from now, according to physical oceanographer Robert Weisberg of the University of South Florida. Even the amount of oil that was spilled remains a mystery. Federal officials estimated the amount at >200 million gallons of crude.

What are the health effects of the Deepwater Horizon oil spill? Immediate physical problems linked to the spill have not materialized. Lichtveld and colleagues (27) are especially concerned about the effect that eating potentially contaminated seafood might have on pregnant women and their babies.

METROPOLITAN AREA POPULATION GAINS

According to 2010 Census data released in April 2011, Dallas–Fort Worth–Arlington is the fourth largest metropolitan area in the USA, with nearly 6.4 million persons (28). During the decade of 2000 to 2010, its population increased 23.4%. During the last decade, Houston–Sugar Land–Baytown grew 26.1% (to nearly 6 million); San Antonio grew 25.2% (to 2.2 million); and Austin–Round Rock grew 27.3% (to 1.7 million). Ten of the 51 largest metropolitan areas grew faster than did the Dallas–Fort Worth–Arlington area in the last decade. Areas with the greatest increases in population were Las Vegas–Paradise and Raleigh–Cary, NC, which both increased 41.8%. In contrast, the New York–Northern New Jersey–Long Island population is nearly 19 million, and it grew only 3.1% during the last decade.

THE WORLD'S MEGA CITIES

There are 22 cities with ≥10 million people living in them (29): Paris, 10 million; Cairo, Istanbul, Lagos, Moscow, and Osaka, 11; Beijing, Manila, and Rio de Janeiro, 12; Buenos Aires, Karachi, and Los Angeles, 13; Dhaka and Kinshasa, 15; Kolkata, 16; Shanghai, 17; Mexico City, 19; New York City, 19.4; Mumbai, 20; San Paulo, 20.3; Delhi, 22; and Tokyo, 36.7. By 2025, the following cities (with present-day populations) also will be >10 million: Bogota, 9 million; Lima, 9; Lahore, 7; Jakarta, 9; Chongqing, 9.4; Shenzhen, 9; and Guangzhou, 9. It is these megacities where the growth is, and as they get bigger almost surely health will get worse. A population of 1 million used to be a large city.

FIGHTING AND DRINKING

I am not advocating alcohol, but as Bob Lynn, Alaska state representative and Vietnam veteran, advocates, “If you get shot at, you can have a shot” (30). His effort is to establish a drinking age of 18 for active-duty service members. It's an idea that has gotten consideration in other states, and it makes sense. Unfortunately, Mr. Lynn's proposal would violate the 1984 Federal Uniform Drinking Age Act. The “old enough to fight, old enough to drink” argument has force. In fact, 18-year-olds in the USA are old enough to do pretty much everything except drink alcohol. They can join the military, marry, sign contracts, and take student loans. Colleges encourage students to go into six-figure debt—which can't be discharged in bankruptcy—but forbid them to drink alcohol on campus because they are deemed insufficiently mature to appreciate the risk. To be fair, as Glenn Harland Reynolds writes, over 130 college presidents, as part of something called the Amethyst Initiative, have called for an end to the drinking age of 21.

The higher drinking age, of course, does not stop college students from drinking. It drives drinking out of bars and restaurants and into dorm rooms and fraternity houses, where there is less supervision from the nonintoxicated and less encouragement for moderation. Defenders of the status quo claim that highway deaths have fallen since the drinking age was raised to 21 from 18, but those claims obscure the fact that this decline merely continued a trend that was already present before the drinking age change—one that involved every age group, not just those 18 to 21.

What is really going on here is prohibition. A nation that cares about freedom—and that has already learned that prohibition was a failure—should know better. As Atlantic Monthly columnist Megan McArdle writes, “A drinking age of 21 is an embarrassment to a supposedly liberty-loving nation. If you are old enough to enlist, and old enough to vote, you are old enough to swill cheap beer in the company of your peers.”

Alcohol is dangerous, as we all know, but so are governmental restrictions.

T. R. AND FOOTBALL

Head injuries are common, of course, in football. John Miller (31) reports that in the early 1900s, President Theodore Roosevelt inserted himself in the fight over violence in football and possibly saved the game, if not from extinction then at least from regulation to second-tier status in the world of athletics. Today, a major problem is concussions (32). One study sponsored by the National Football League found that professional football veterans >50 years of age are 5 times as likely as the general population to suffer from dementia.

These numbers are bad, but consider the situation in 1905 when 18 people died on the gridiron. Back then, critics likened the game to gladiator combat in Roman amphitheaters and launched a crusade to decrease its violence. Led by President Charles Eliot of Harvard and joined by the Nation magazine and muckraking journalists, progressive-era prohibitionists wanted to eliminate the increasingly popular sport. At one point, Harvard, Columbia, Northwestern, Stanford, the University of California, and several smaller colleges quit playing the game. Following the 1897 death of Richard Von Gammon, a fullback at the University of Georgia, the Georgia state legislature voted to ban football. The governor vetoed the bill after hearing from Gammon's mother, who urged him not to outlaw a sport that her son had loved. Written in a 1905 report, Harvard's President Eliot was adamant: “No honorable sport embraces the barbarous ethics of warfare.” Roosevelt had little patience for such talk. “Harvard will be doing the baby act if she takes any such foolish course as President Eliot advises,” he wrote. Roosevelt worried about producing “mollycoddles instead of vigorous men.” T. R.'s interest dated back to 1876, when as an 18-year-old Harvard freshman he watched the second-ever game between his school and Yale. He never played football but became an enthusiastic fan. He thought football served a meaningful role in the socialization of boys, helping turn them into men.

Roosevelt, of course, became a noted outdoorsman and war hero in the 1880s and 1890s. He ranched in the Dakotas, hunted big game, and led the Rough Riders to victory in Cuba. In his memoir of the Spanish-American war, T. R. indicated that when he recruited his army unit he was looking for cowboys and football players. (He recruited his Rough Riders in San Antonio.)

In 1899, T. R. gave his famous speech on the cultivation of national virtues, “The Strenuous Life.” When he revised those remarks for a children's magazine, he urged boys to play sports because they “had an excellent effect in increased manliness.” He paid special attention to football: “In short, in life, as in a football game, the principle to follow is: Hit the line hard; don't foul and don't shirk, but hit the line hard!”

In 1905, Roosevelt took up brutality in football. He called a private meeting at the White House and invited Yale's Walter Camp—football's legendary founding father—and coaches from Harvard and Princeton. T. R. told them, “Football is on trial. Because I believe in the game I want to do all I can to save it.” Without dictating a solution, Roosevelt urged the men to take a critical look at the sport. That winter with a little additional nudging from the president, they formed the National Collegiate Athletic Association. They also passed a series of rule changes: they increased the number of yards needed for a first down from 5 to 10, created a neutral zone at the line of scrimmage, and legalized the forward pass. It took a few years to perfect the new rules, but the forward pass changed the way the sport was played. Deaths and injuries subsided as football abandoned its rugby-like origins and became a distinctly American game.

MARATHON RUN

Kenyan Geoffrey Mutal recorded the fastest marathon time ever on April 18, 2011. He won the Boston Marathon in 2:03:02 hours, nearly 3 minutes faster than the previous Boston record and speedier than the 2008 world record of 2:03:59. Running those 26.2 miles in 123 minutes means an average of 4.69 miles/minute. When I was in high school, that time would win the 1-mile race!

WARREN BUFFET PRINCIPLES

The chief executive of a Berkshire Hathaway company told Al Lewis, columnist for Dow Jones Newswires in Denver, that Warren Buffet demanded three things of him: intelligence, energy, and integrity (33). “He said the third part was the most important because the last thing he wanted was a very bright, high-energy crook running one of his companies,” Jerry Henry said in a 2003 interview. Mr. Henry was then CEO of Johns Manville, a building products company in Denver, a part of Berkshire Hathaway.

Al Lewis' column, of course, was prompted by Mr. Buffet's disclosure that one of his executives, David Sokol, had resigned after he had invested more than $10 million of his own money in Lubrizol and then recommended to Mr. Buffet that Berkshire Hathaway buy the company—netting a personal profit of $3 million. Mr. Buffet whitewashed Mr. Sokol's blazingly obvious ethical lapse in a written statement. Anyone who owns Berkshire Hathaway stock and receives Buffet's annual report will see how an episode such as the Sokol one could result in such a quick “retirement.”

Berkshire Hathaway consists of 76 companies, and Mr. Buffet sends a memo to each of the company managers, whom he calls the “All Stars,” every 2 years. Excerpts from his July 26, 2010, letter follow (34):

As I've said in these memos for more than 25 years: “We can afford to lose money—even a lot of money. But we can't afford to lose reputation—even a shred of reputation.” We must continue to measure every act against not only what is legal but also what we would be happy to have written about on the front page of a national newspaper in an article written by an unfriendly but intelligent reporter.

Sometimes your associates will say “Everybody else is doing it.” This rationale is almost always a bad one if it is the main justification for a business action. It is totally unacceptable when evaluating a moral decision…. If anyone gives this explanation, tell them to try using it with a reporter or a judge and see how far it gets them.

If you see anything whose propriety or legality causes you to hesitate, be sure to give me a call. However, it's very likely that if a given course of action evokes such hesitation, it's too close to the line and should be abandoned….

Somebody is doing something today at Berkshire that you and I would be unhappy about if we knew of it. That's inevitable: We now employ more than 250,000 people and the chances of that number getting through the day without any bad behavior occurring is nil. But we can have a huge effect in minimizing such activities by jumping on anything immediately when there is the slightest odor of impropriety. Your attitude on such matters, expressed by behavior as well as words, will be the most important factor in how the culture of your business develops. Culture, more than rule books, determines how an organization behaves.

Pretty good principles.

CIVIL WAR'S 150TH ANNIVERSARY

April 2011 marked the 150th anniversary of the beginning of the Civil War. Over the next 4 years, battlefields and other historic sites across the country will host commemorations, celebrations, and reenactments. Elizabeth Samet, who teaches English at West Point, had a good piece on Ulysses S. Grant, who wrote his memoirs while dying of throat cancer (35). He composed much of it in a cottage at Mount McGregor, New York, now a state historic site on the grounds of a correctional facility. On display is the bed in which Grant died, as well as floral arrangements from his funeral, clothing, personal effects, and a bottle of the narcotics prescribed to dull his pain. Grant wanted to finish the book to save his family from bankruptcy and establish his written legacy. His extraordinary concentration allowed completion of the book, Personal Memoirs of Ulysses S. Grant, which was published about 6 months after Grant died on July 23, 1885.

Several years ago I visited the General Grant National Memorial, aka Grant's Tomb, which was dedicated in 1897. The mausoleum was once, as the historian Joan Waugh documents, “a sacred pilgrimage” for Civil War veterans and remained New York City's most popular attraction through the beginning of World War I. As late as 1929, tourists still visited in large numbers. Today, a visitor is alone there. When I visited with several of my offspring, we were the only ones in sight. The crypt by the sarcophagi containing Grant and his wife, Julia, is encircled by the bronze busts of five Union generals: Sherman, Sheridan, McPherson, Thomas, and Ord.

Grant wrote in his memoirs that after the first bloody day at Shiloh, he made his headquarters under a tree in a drenching rain. He moved for a time to a nearby cabin that had been turned into a field hospital: “All night wounded men were being brought in, their wounds dressed, a leg or an arm amputated as the case might require and everything being done to save life or alleviate suffering. The sight was more unendurable than encountering the enemy's fire, and I returned to my tree in the rain.”

One of Grant's staff officers, Horace Porter, characterized the style of his commander's orders and dispatches as “vigorous and terse, with little of ornament; its most conspicuous characteristic was perspicuity.” This, as Elizabeth Samet writes, is also an apt description of the Memoirs, which many writers from Matthew Arnold to Gertrude Stein have deeply admired.

Now, 126 years have passed since Grant's death and we are at war again: in Afghanistan and Iraq and Libya. Other fighting occurs in Egypt, Yemen, Syria, Tunisia, Bahrain, Iran, and the Ivory Coast, to name a few. General George Marshall observed: “If man does find the solution for world peace it will be the most revolutionary reversal of his record we have ever known.”

WHY THE CIVIL WAR STILL MATTERS

James M. McPherson, the George Henry Davis Professor of History Emeritus at Princeton University and the winner of the 1989 Pulitzer Prize for Battle Cry of Freedom: The Civil War Era, had a piece in the spring 2011 issue of American Heritage entitled “Why the Civil War Still Matters.” He asks, “Why do we care about a war that ended so long ago?” He writes (36):

Part of the answer lies in the continental scope of a conflict fought not on some foreign land but on battlefields ranging from Pennsylvania to New Mexico and from Florida to Kansas, hallowed ground that Americans can visit today. The near-mythical figures who have come to represent the war intrigue us still: Abraham Lincoln and Robert E. Lee, Ulysses S. Grant and Thomas J. “Stonewall” Jackson, William T. Sherman and Nathan Bedford Forrest, Clara Barton and Belle Boyd.

Most important, the sheer drama of the story, the momentous issues at stake, and the tragic, awe-inspiring human cost of the conflict still resonate. More than 620,000 Union and Confederate soldiers gave their last full measure of devotion in the war, nearly as many as the number of American soldiers killed in all the other wars this country has fought—combined.

Americans in both North and South were willing to fight on despite such horrific casualties because their respective nations and societies were at stake. Would America move toward a free-labor capitalist economy and a democratic polity in all regions, or would a slave-labor plantation economy and a hierarchical society persist in half of the country?

The war of 1861–1865 resolved two festering questions that the Revolution of 1776 and the Constitution of 1789 had left unresolved: whether this fragile republican experiment called the United States would survive as one nation, indivisible; and whether this nation born of a declaration that all men are created with an equal right to liberty would persist as the largest slave-holding country in the world. Many Americans, painfully aware of the unhappy fate of most republics through history, worried whether theirs would also be swept into the dustbin of history. Before the Civil War, some Americans had advocated the right of secession and periodically threatened to invoke it; eleven states did invoke it in 1860–61. But since 1865 no state or responsible political leader has seriously threatened secession….

In 1854 Abraham Lincoln said that the “monstrous injustice of slavery … deprives our republican example of its just influence in the world—enables the enemies of free institutions, with plausibility, to taunt us as hypocrites.” Since 1865 that particular “monstrous injustice” has existed no more.

MORE ON FEDERAL BORROWING

Thomas G. Donlan (37), writing in Barron's, points out the following: “All federal revenues—from income taxes, Social Security, and Medicare payroll taxes, corporate taxes, excise taxes, customs duties, estate and gift taxes and user fees—are consumed to pay Americans myriad federal benefits. These include Social Security, Medicare, Medicaid, veterans' benefits, food stamps, farm subsidies and the many other forms of social insurance and welfare, including economic stimulus and job-creation.” In other words, the federal government borrows everything it needs to operate as a government, such as defense, highway construction, foreign aid, aid to states and localities, land management, pollution control, various regulations, scientific research, payment of federal employees' salaries, and payment of interest on the national debt. All of this is being borrowed! The US Treasury now owes 61% more than it did in March 2007, having issued $5.4 trillion in new debt during that period.

According to Donlan, the only thing that is saving us presently is the low interest rates that the federal government is paying to borrow all this money. When interest rates go up, they will be the fastest-growing budget item in the federal government. And they have no way to go but up.

OXYMORON

An oxymoron is usually defined as a phrase in which two words of opposite meaning are brought together. A friend recently sent me this list: clearly misunderstood; exact estimate; small crowd; act naturally; found missing; fully empty; pretty ugly; seriously funny; only choice; original copies; and happily married.

—William Clifford Roberts, MD

5 May 2011