Facts and ideas from anywhere

William C. Roberts, MD

US HEALTH

An expert panel appointed by the US Institute of Medicine reported their findings in January 2013 (1, 2). We in the US live shorter lives than any of 16 peer nations, including Australia, Canada, Japan, and 13 European countries (Figure 1). Swiss men live nearly 4 years longer than American men, and Japanese women live >5 years longer than American women. Americans get their health care in a less coordinated system than in any of the 16 other nations, and we in the US pay more for it. The cost of care in the US in 2011 was $2.7 trillion, or $8680 for each American. The closest among the other 16 nations was Switzerland, which spent $5489 per person. Americans are more reckless than those in the other 16 countries. Only Italians wear seatbelts less often. Nowhere else do motorcyclists go without helmets as often. Americans die more often in traffic accidents linked to alcohol consumption, and they own far more guns (89 per 100 people compared with 46 per 100 people in Switzerland, the peer group country with the next highest rate of gun ownership).

Figure 1.

Mortality from noncommunicable diseases in 17 peer countries, 2008. Reprinted with permission from National Academies Press.

Far fewer Americans than in the past use tobacco, and only the Swedes now smoke fewer cigarettes than Americans. This is a reversal of the situation in the 1950s, when Americans smoked the most. Nevertheless, in 2003, smoking accounted for 1 in 5 deaths among Americans >50 years of age. But, smoking-related deaths are expected to decline further in the USA with the drop in the number of smokers and the rise in countries like France, where 46% of adults smoke.

The panel pointed out, of course, that what we eat is a major factor in the lower US lifespan. Americans eat, on average, 3770 calories a day. That's 1100 more calories than the average adult male needs, and 1700 more calories than an average woman should consume. Between 1999 and 2001, Austrians, Belgians, and Italians ate more but, by 2007, Americans were well ahead of anyone else. The average Swede consumes 17% fewer calories daily than the average American.

GLOBAL OBESITY

Overweight and obese people now outnumber the malnourished by nearly 2 to 1. According to the World Health Organization (WHO), in 2010, 80% of American adult men and 77% of women were overweight (3). Obesity costs at least $150 billion a year in American health care spending. But obesity is spreading rapidly in other parts of the world. Saudi Arabia and other Arab states and many Pacific Island nations are fatter than in the USA. Most of the adult population of Samoa is obese; in 2008, 46% of Egyptian women were obese. Mexican women are heavier than US women, and Mexican men will soon eclipse US men in poundage. These changes in part reflect advances in public health. In 1900, pneumonia, tuberculosis, and childhood diarrhea were the leading killers of Americans. Now, the top causes of death are noninfectious diseases, mainly atherosclerosis, hypertension, and cancer. In 2008, 63% of deaths around the world were caused by noncommunicable diseases and 80% of them occurred in low- and middle-income countries.

Many countries are trying to come to grips with this major shift in public health. Japanese companies require employees to undergo annual physicals that include waistline measurements. Measurements of over 33.5 inches in men and over 35.4 inches in women count against the company. If too many fail the test, the firm has to increase its contribution to public health care for the elderly. Several countries tax soft drinks and other sugared beverages. Mexican legislators introduced a bill in December 2012 that would add a 20% tax to the cost of such drinks. In 2011, the average Mexican adult consumed 728 servings of Coca-Cola; the average American, 403 servings. The China Health Ministry has asked Dr. Kenneth Cooper of Dallas, founder and chairman of Cooper Aerobics, to explore the introduction of Fitness Gram Testing among its schoolchildren. Cooper indicated that Ross Perot contributed $2 million to help pay for a computer system to aggregate the results. Ten years ago there was hardly any obesity in China, according to Cooper. WHO estimates that 45% of Chinese men and 32% of Chinese women are now overweight or obese. The fast-food chains are rapidly expanding in China. Yum Brands, which owns Pizza Hut, KFC, and Taco Bell restaurants, has 38,000 restaurants globally, including 740 Pizza Huts and 4,043 KFC establishments in China.

Business groups complain that taxes, regulations, and unfair trade practices hurt their international competitiveness. Now, we can add body weight to that list. The Organization for Economic Cooperation and Development (OECD) in 2012 updated an obesity epidemic watch among its 34 country members (usually described as the wealthier developed countries) and found that the average rate of obesity across the OECD was 17% (4); in the USA, 34%; in Korea, 4%; in Germany, nearly 15%; in the UK, 23%; and in Mexico, 30%. In 19 of the 34 OECD countries, most of the population is now either obese or overweight. In the US and in Texas, more than two thirds of the population is either obese or overweight (Figure 2). Texas comptroller Susan Combs has estimated that obesity costs Texas employers nearly $10 billion in 2009.

Figure 2.

Prevalence of obesity among adults, 2009 (or nearest year). Reprinted with permission from OECD (2011), “Overweight and obesity among adults,” in Health at a Glance 2011: OECD Indicators, OECD Publishing. http://dx.doi.org/10.1787/health_glance-2011-18-en

BODY WEIGHT AND LEADERSHIP ABILITY

New research suggests that extra pounds or enlarged waistlines affect an executive's perceived leadership ability as well as stamina on the job (5). Leadership experts and executive recruiters say that staying trim is now virtually required for anyone on track for the CEO corner office. Executives with larger waistlines and higher body mass indexes tend to be perceived as less effective both in performance and interpersonal relationships. While weight remains a taboo conversation topic in the workplace, heavy executives are judged to be less capable because of assumptions about how weight affects health and stamina. A business school professor recently stated that he could not name a single overweight Fortune 500 CEO.

SODA CONSUMPTION

In the USA, soda consumption is declining (6). Per capita consumption of carbonated soft drinks in 2005 was over 50 gallons, and by 2012, 42 gallons. Soda companies raised prices in 2011 and again in 2012 and volumes kept falling. The sugary bubbles are simply unhealthy. Sodas’ traditional target market, namely youth, is often now turning to water, energy drinks, and coffee instead. This of course is good news unless you happen to be an investor in Coca-Cola, PepsiCo, or Dr. Pepper/Snapple, which I avoid.

US MILK CONSUMPTION

In 1975, the US milk consumption per capita was 28.6 gallons and by 2011 it had fallen to 20.2 gallons (7). This decline is good news. Cows are the biggest source of our cholesterol, including their muscle, milk, butter, and cheese, and also our biggest source of saturated fat.

RELATION OF PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOR TO SERUM PROSTATE-SPECIFIC ANTIGEN

A recent piece in the Mayo Clinic Proceedings (8) involving 1672 men found that for every 1-hour increase in sedentary behavior, the participants were 16% more likely to have an elevated prostate-specific antigen (PSA) concentration, and for every 1-hour increase in light physical activity, participants were 18% less likely to have an elevated PSA concentration. We men sit on our prostate gland. Get up and keep moving.

FASTING VS NONFASTING MEASUREMENTS OF BLOOD LIPIDS

Current guidelines recommend that total lipids and lipid subclass levels be measured with a patient in a fasting state (>8 hours after the last meal). Fasting recommendations were originally introduced to decrease variability and achieve consistency in the metabolic states of patients at the time of sample collection. Several studies, however, suggest that measurement of lipid subclasses in a nonfasting state is an acceptable alternative, with some nonfasting markers being better at predicting the risk of cardiac events. Sidhu and Naugler (9) measured various lipid levels with fasting intervals varying from 1 to >16 hours in 209,180 individuals. The mean levels of total cholesterol and high-density lipoprotein cholesterol differed little among individuals with various fasting times. The mean calculated low-density lipoprotein cholesterol levels showed up to 10% variation among groups of patients with differing fasting intervals. The mean triglyceride levels showed variations of up to 20%.

MORE ON TATTOOS

Tattoos have become increasingly popular in recent years. In the USA, in 2012, an estimated 21% of adults had tattoos, up from 14% in 2008. The process of tattooing exposes the recipient to risks of infections, some of which are serious and difficult to treat. Historically, as LeBlanc and colleagues (10) emphasize, the control of tattoo-associated dermatologic infections has focused on ensuring safe tattooing practices and preventing contamination of ink used in the tattoo parlors—a regulatory task overseen by state and local authorities. In 2012, several outbreaks of nontuberculous microbacterial infections associated with contaminated tattoo ink raised questions about the adequacy of prevention efforts implemented at the tattoo-parlor level. The Food and Drug Administration (FDA) began reaching out to health care providers, public health officials, consumers, and the tattoo industry to develop more effective measures for tattoo ink-related public health problems. Some reports of tattoo-related nontuberculous microbacterial infections suggested that tap water or distilled water used to dilute inks at tattoo parlors was a likely source of contamination. Findings from more recent outbreaks suggested that the inks were contaminated before distribution.

Under the Federal Food, Drug, and Cosmetic Act, tattoo inks are considered to be cosmetics, whereas the pigments used in the inks are color additives that require premarketing approval. This law requires that cosmetics and their ingredients not be adulterated or misbranded, which means, among other things, that they cannot contain poisonous or deleterious substances or unproved color additives, be manufactured or held in unsanitary conditions, or be falsely labeled. Furthermore, cosmetic manufacturers are supposed to ensure the safety of a product before marketing it. But, the FDA does not have the authority to require premarketing submission of safety data from manufacturers, distributors, or marketers of cosmetic products, with the exception of most color additives (dyes, pigments, or other substances used to impart color). The FDA, however, can conduct investigations, request that a manufacturer recall volatile products, issue advisory letters, and request that the Department of Justice conduct seizures, enjoin a firm or person from manufacturing or distributing products, or file criminal charges against a firm or responsible persons on behalf of the FDA.

It is particularly important to increase awareness about certain types of tattoo ink–related infections because of several features of nontuberculous microbacteria. They may be difficult to diagnose and treat. It can take up to 6 weeks to identify the organism. A special culture medium and a skin biopsy may be required. Antibiotic choices are limited by the susceptibility profile of the organism, and prolonged treatment may be necessary to clear the infection. Moreover, complications such as co-infections with pathogens such as methicillin-resistant Staphylococcus aureus may pose additional challenges. Beware of tattoos.

RENAL SYMPATHETIC DENERVATION FOR DRUG-RESISTANT HYPERTENSION

Esler and colleagues (11) for the Symplicity HTN-2 investigators indicate that among the 7 billion people residing on Planet Earth, nearly 1 billion adults have high blood pressure. Despite the availability of numerous effective antihypertensive medicines, hypertension remains uncontrolled for various reasons, including inadequate treatment. Among hypertensive patients receiving treatment, the estimated proportion of patients with blood pressure uncontrolled (>140/90 mm Hg) ranges from 45% to 85% in Europe and North America. Furthermore, a subset of patients who adhere to a prescribed pharmaceutical regimen of ≥3 drugs, including a diuretic, continue to have uncontrolled or resistant hypertension. In the US, estimates of resistant hypertension prevalence range from 10% to 30% of adults receiving drug treatment for hypertension. These numbers reflect a serious health challenge because every 20/10 mm Hg increase in blood pressure leads to a doubling of cardiovascular mortality.

The sympathetic nervous system plays an important role in hypertension. Catheterization-based renal denervation is a minimally invasive procedure involving the application of radiofrequency energy in short bursts along the length of the main renal arteries to ablate the renal nerves that lie within and just beyond the artery's adventitia.

The Symplicity HTN-2 trial randomized patients with resistant hypertension to either renal denervation or to no renal denervation, with both groups maintained for 6 months on antihypertensive medications. The primary endpoint, change in office-based systolic blood pressure at 6-month follow-up, demonstrated a significant difference in systolic blood pressure between the treatment and control groups. Patients in the control group then had the option to receive the renal denervation procedure. The 1-year results of this second trial, which included 6-month outcomes for the control group who were treated with renal denervation, resulted in a significant drop in blood pressure similar to that observed in patients receiving immediate denervation. Thus, renal denervation appears to provide a safe and sustained reduction of blood pressure to 1 year in patients with previous resistant hypertension.

WHY PATIENTS VISIT DOCTORS

St. Sauver and colleagues (12) from the Mayo Clinic analyzed medical records of 142,377 patients in the county in which the Mayo Clinic is located to learn of the various conditions that prompted patients to visit their physicians during a 5-year period (2005–2009). Fifty-three percent of the patients were female. The 20 most common conditions among these individuals were as follows: skin disorders, 43%; osteoarthritis and joint disorders, 34%; back problems, 24%; disorders of lipid metabolism, 22%; upper respiratory disease (excluding asthma), 22%; anxiety, depression, and bipolar disorders, 20%; chronic neurologic disorders, 20%; hypertension, 18%; headaches, including migraine, 14%; diabetes mellitus, 14%; arrhythmias, 13%; esophageal disorders, 10%; asthma, 9%; thyroid disorders, 9%; iron deficiency and other anemia, 9%; bowel disorders, 9%; cancer, 8%; biliary and liver disorders, 8%; obstructive pulmonary disorders, 8%; and coronary heart disease, 8%. Ten of the 15 most prevalent disease groups were more common in women in almost all age groups, whereas disorders of lipid metabolism, hypertension, and diabetes were more common in men. The prevalence of 7 of the 10 most common groups increased with advancing age. Prevalence also varied across ethnic groups (whites, blacks, and Asians).

BEDBUGS AND SNIFFING DOGS

Canines trained to detect bedbugs did big business in Dallas during the summer of 2012 (13), and that infestation may be back this summer. Bedbugs are resilient and can travel on everything. As someone said, “It's basically a hitchhiker. It goes on suitcases and people spread it to other people. And once they make their way into a home, getting rid of them can cost several thousand dollars.” Apparently there is a pheromone in the bedbugs that dogs can smell. Dogs are about 97% accurate in finding the bugs, while humans are only about 30% accurate.

GRAPHOLOGY

I have kept a visitor's book in my office for years and request a signature and address from all those willing to provide it. A number of years ago, while visiting The Greenbrier in West Virginia, I took a class on graphology. The teacher talked about letters leaning to the left or right, whether or not the long letters touched the top line or the lower letters went below the lower line, and whether or not there were lively movements in the top one and flamboyant swirls in the lower ones and what they meant. She recommended that potential spouses before marriage have a couple of paragraphs of their handwriting analyzed by a graphologist.

Sherlock Holmes asked Dr. Watson in The Sign of Four, “What do you make of this fellow's scribble?” (14). “Look at his long letters,” he said. “They hardly arise above the common herd. That d might be an a, and that l an e. Men of character always differentiate their long letters, however illegibly they may write. There is vacillation in his k's and self-esteem in his capitals.”

THE LEAST HEART-HEALTHY STATE IN THE USA

The official state meal of Oklahoma—designated by the legislature in 1988—includes barbecue pork, chicken-fried steak, sausage, biscuit and gravy, fried okra and squash, strawberries, black-eyed peas, grits, corn, cornbread, and pecan pie. A survey by the Centers for Disease Control and Prevention (CDC), published in 2012, indicates that only 1% of adults in Oklahoma are free from risk factors for or behaviors increasing the risk for heart disease—the highest rate for any state in the nation (15). Oklahomans also are less likely to report eating 5 or more servings of fruits and vegetables a day, and they are the most likely to be overweight.

DROWSY DRIVING

According to a study by the CDC, one in 24 motorists admitted to falling asleep behind the wheel in the past month (16, 17). The problem is more common in men than women and in drivers aged 25 to 34 compared to older drivers. According to Angie Wheaton, the lead author of the CDC study, approximately 2.5% of all fatal motor vehicle crashes (around 730 in 2009) involved drowsy drivers, as did 2% of crashes that resulted in nonfatal injuries (around 30,000 in 2009). They also found that around 4% of respondents fell asleep while driving in the previous year. The government estimated that approximately 3% of fatal traffic crashes involve drowsy drivers, but some studies have put that estimate as high as 33%. Brief moments of nodding off can be extremely dangerous, particularly when traveling 60 miles per hour. A single second translates to moving 90 feet, the length of 2 school buses. According to Dr. Kingman Strohl, a pulmonologist in Cleveland, a typical driver makes about 1000 decisions a minute. If a person has not slept for 18 consecutive hours, his or her impairment on those decision-making tasks is similar to that of someone above the legal alcohol limit. Everyone knows about driving and alcohol drinking, but there is much less emphasis on the importance of sleep before driving.

FALLING TELEVISIONS

According to Kim Painter, falling TV sets have killed >200 children since 2000 (18). The Consumer Products Safety Commission showed that 29 people in the US, most of them children, were killed by falling TVs in 2011 alone, and 18,000 people a year in the US, most of them children, are treated for injuries from falling TVs. That is happening despite the widespread switch to lighter flat-screens. Safety experts say the switch may actually be making the problem worse, because consumers often take old, heavy sets out of their family rooms and put them atop unstable bedroom dressers and playroom shelves. Children climb up on furniture to turn the TV on and there goes the heavy television as well as the piece of furniture. The 50- to 100-pound TVs can crush a child. The TVs often are on shelves never designed to hold the heavy weight. Flat-screen TVs also fall on kids because parents do not install them in the safest way. Let's secure these TVs, and if anchoring is not an option, place the TV on a low sturdy base and remove any items from the top that might attract children.

GUNS

The US has about 315 million people and about 290 million guns. Germany has about 80 million people and 5.5 million guns (19). Germany has recently initiated a large registry that details every legal gun owner in the country, along with information about all of their firearms. The new gun database, which went into service January 1, 2013, allows law enforcement officials to scroll through lists of owners and their guns in seconds on their computers. And the gun owners did not resist the establishment of this registry. Many gun advocates in Germany say that if cars can be registered and regulated, so can weapons. It's not quite that way in the USA, but the US has about 50 times as many guns as are present in Germany.

In the US it is easy to acquire any number of weapons and unlimited amounts of ammunition. Those who pass laws make it possible. The National Rifle Association traditionally muzzles any congressional attempts at gun control laws. Surely there is a relation between the number of people killed with guns and the number of guns available.

VIRGINIA TECH, FORT HOOD, AURORA, SANDY HOOK …

Using news accounts and records from the Federal Bureau of Investigation (FBI) from 2006 through 2010, the most recent years for which complete records were available, USA Today identified 156 murders that met the FBI definition of mass killings, in which 4 or more people are killed by the attacker (20). The attacks killed 774 people, including at least 161 children aged 12 or younger. Mass killers, in other words, target Americans once every 2 weeks on average, in attacks that range from robberies to horrific public shooting sprees like the massacre in Newtown, Connecticut. The USA Today review did not include murders in 2011 or 2012, both of which were marked by a series of high-profile public shootings. The 2006 to 2010 killings offer a portrait of mass murder that in many ways belies the stereotype of a lone gunman targeting strangers: lone gunmen, such as the one who terrorized Sandy Hook Elementary School, account for fewer than half of the nation's mass killers. About one quarter of mass murderers involved 2 or more killers. A third of mass killings did not involve guns. Mass murderers tend to be older than other killers, an average of nearly 32 years of age. Like all killers, they are overwhelmingly men. The mass killings during those 5 years accounted for about 1% of all murders during that time in the USA.

DALLAS CRIME

Despite increases in some major areas—rape, robbery, and murder—overall reported crime in Dallas dropped nearly 11% in 2012 compared to 2011, a record ninth consecutive year crime has fallen in the city (21, 22). The drop is in line with what is happening nationally and was driven by significant decreases in every area of property crime, which had about 7600 fewer offenses in 2012 than the previous year. Twenty percent more thieves were arrested in 2012 than in 2011 through the help of a task force that targets rings that buy and sell stolen property. Police Chief David Brown indicated that the longer a thief is in jail, the better the stats are going to be. Murders in Dallas in 2012 numbered 151, an increase from 133 the previous year. In comparison, Chicago had 506 murders in 2012, nearly twice as many killed than US troops in Afghanistan.

MILITARY SUICIDES

Suicides in the US military surged to a record 349 in 2012, far exceeding American combat deaths in Afghanistan (n = 295 Americans), and up from 301 in 2001 (23). Defense Secretary Leon Panetta and others have called the problem an epidemic. The problem appears to reflect severe strains on military personnel burdened with more than a decade of combat in Afghanistan and Iraq, complicated by anxiety over being forced out of a shrinking workforce. The 349 total in 2012 was the highest since the Pentagon began tracking suicides in 2001. The army, by far the largest of the military services, had the highest number of suicides among active-duty troops in 2012 at 182. The Marine Corps had the highest percentage increase—a 50% jump to 48. The Air Force had 59, and the Navy, 60 suicides, an increase in each of about 15% over the previous year.

GENDERCIDE

There are too many examples of global violence against women. Beverly Hill, who is founder and president of the Gendercide Awareness Project, calls it gendercide—the elimination of females, both young and old, through sex-selective abortion, infanticide, gross neglect, and in the case of older women (particularly widows), lack of access to food and shelter (24). The United Nations Population Fund, which tracks this problem, has estimated that 117 million women are missing in the world because of these practices. “Missing,” as Ms. Hill indicates, equals death. That's more deaths than World War I and World War II combined. She indicates that it is no exaggeration to say that gendercide is an atrocity as colossal as any the world has seen. East Asia, South Asia, West Asia, the Middle East, Africa, and Southeastern Europe are all ravaged by gendercide. Every year, according to Ms. Hill, we lose 2 million baby girls to sex-selective abortion and infanticide alone. That equates to 4 girls every minute.

The United Nations reports that China has the greatest sex imbalance in the world, with 10% of its female population eliminated; India and Afghanistan follow with 7%. These sex imbalances lead to a host of social problems. Contrary to popular belief, the status of women does not improve when females are in short supply. In fact, just the opposite occurs. Sex trafficking increases, as does the buying and selling of brides. Aging bachelors, unable to find women of appropriate age, marry ever younger girls. These child brides leave school and begin bearing children. Maternal death rates are high. Ms. Hill goes on to indicate that there is a strong correlation between sex imbalance and crime. Sex ratios apparently are the best predictors of murder rates in India—better predictors than poverty, illiteracy, or urbanization. Crime spiked in the Chinese regions where sex-selective technology first became available. And finally, Ms. Hill writes: “Gendercide proceeds from the belief that female life is disposable. Gendercide devastates the hopes of women everywhere. It is unworthy of us as human beings. It is time to end this slaughter.”

WOMEN IN CONGRESS

Of the 100 US Senators, 20 (20%) are women and of the 435 House Representatives, 78 (18%) are women; both of these are records (25).

FIBRONACCI NUMBERS

By definition, the first 2 numbers of the Fibronacci sequence are 0 and 1. Each subsequent number is the sum of the previous two (26). The Fibronacci sequence is:

0, 1, 1, 2, 3, 5, 8, 13, 21, 34, 55, 89, 144, etc.

The ratio of any two consecutive numbers eventually approaches the “golden ratio” of 0.618.

1/11/22/33/55/88/1313/2121/3434/5555/8989/144

1.00.500.6670.600.6250.6150.6190.6180.6180.6180.618

The sequence made its first appearance in the West in the book Liber Abaci (1202) by Leonardo of Pisa, also known as Fibronacci. (The sequence first appeared in Indian literature centuries before.) The Fibronacci sequence is important in nature: it describes the branching in trees, the arrangement of leaves on a stem, the fruitlets of a pineapple, the flowering of an artichoke, the uncurling of a fern, and the arrangement of a pine cone. Fibronacci numbers are truly fascinating. They have many implications for mathematicians.

PUBLIC HIGH SCHOOL GRADUATION RATES

The percentage of students at public high schools who graduate on time has reached its highest level in nearly 40 years (27). The public high school graduation rate, i.e., students earning a diploma within 4 years of starting high school, reached 78% for the class of 2010, the highest rate since 1974. Graduation rates improved for every race and ethnicity in 2010. The student graduation rates were as follows: Asians, 93%; Whites, 83%; Hispanics, 74%; American Indians and Alaskan natives, 69%; African Americans, 66%. In 2010, 38 states had higher graduation rates, while rates for the other 12 states were flat.

SMART DEVICES WINNING

Using a cellphone during class used to mean possible confiscation and perhaps detention for students (28). Now, a growing number of schools are turning to the smart phones students bring to school as an instructional device that can augment classroom learning. Teachers ask students to use their smart phones to look up vocabulary words, take photos of an assignment written on the board, or text themselves homework reminders. Teachers use countless apps to better connect students with coursework on a platform they are familiar with. The Verizon Foundation chose 12 schools in 2012 and 24 in 2013 to receive up to $50,000 in grant funding to bring laptops, tablets, and mobile phones to class. The focus is on science, math, and technology studies. The apps offer an easy way to do research, solve problems quickly, and motivate students.

IQ

The average American in 1900 had an IQ that by today's standards would measure about 67 (29). Since the traditional definition of mental retardation was an IQ < 70, that leads to the remarkable conclusion that most Americans at the beginning of the 20th century would today be considered “intellectually disabled.” The trend of rising intelligence is known as the Flynn effect, named for James R. Flynn, the New Zealander who pioneered this area of research. The average American IQ has been rising steadily by 3 points a decade. Spaniards gained 19 points over 28 years, and the Dutch, 20 points over 30 years. Kenyan children gained nearly 1 point a year. These figures are from Flynn's new book entitled Are We Getting Smarter? It's an uplifting tale, a reminder that human capacity is on the upswing. The country that tops the IQ charts is Singapore, at 108. Singaporeans have great respect for learning and an outstanding school system. Flynn argues that IQ is rising because in industrialized societies we give our brains a constant mental workout, much greater than when we were mostly living on isolated farms. Modern TV shows and other entertainment can be cognitively demanding, and video games require more thought that Solitaire. It appears that talent is universal but opportunity is not. Our public school budgets are being slashed. According to Nicholas Kristof, some 61 million children in the world still don't attend primary school. The cost of a single F-35 fighter could pay for more than 4 years of the Reading Is Fundamental program in the entire USA.

DEGREES AND INCOMES OF US ETHNIC GROUPS

As reported by Siegel (30), in 2010, the percentages of Americans aged 25 and older with at least a bachelor's degree were as follows: all US, 28%; Asians, 49%; Whites, 31%; Blacks, 18%; and Hispanics, 13%. The median household income in the US in 2010 was as follows: all US, $49,800; Asians, $66,000; Whites, $54,000; Hispanics, $40,000; and Blacks, $33,300.

TWO INTERESTING HERBIVORES

My friend, Dr. Vince Friedewald in Austin, sent me the following information on camels and kangaroos (31). Camels can live where food and water are scarce. They have an amazing ability to conserve water. When dehydrated, a camel can drink as much as 120 liters (32 gallons) in 15 minutes. To conserve water, camels can regulate their body temperature so that they hardly sweat, their kidneys can concentrate the urine, and they store a lot of water in their erythrocytes, which have the ability to swell to over twice their normal size without bursting. The camel's hump functions as a reservoir of adipose tissue that they can metabolize to provide emergency energy. As the fat is depleted, the hump wilts and flops to one side. The fatty humps also help keep the animal cool, as fat conducts the sun's heat relatively slowly and their woolly covering provides extra insulation. Thus, camels can go for weeks with little or no water or food.

Kangaroos in Australia have the ability to cross vast distances in search of food and water, keys to their survival. Capable of an 8-meter (25-foot) single bound across level ground, the red kangaroo is one of the world's greatest long jumpers. Thanks to large feet and strong legs, it can travel at over 50 kilometers (30 miles) per hour for hours. While a kangaroo's hind legs are big and powerful, they can't work independently of each other, and so kangaroos have to hop on two feet. The hind leg tendons are strong and elastic. With every hop, elastic energy is recaptured in the tendons ready for the next jump. The kangaroos use their long tail for balance and counterbalance. It swings up as the animal leaves the ground and down as the legs swing back with every bounce to help propel the kangaroo. A kangaroo's big toes are in the center of the other toes, not to one side like in humans, and are thus in line with their leg bones, enabling them to push off with great force. The kangaroo has a pouch to carry the newborn for about 10 months after birth. To win the Olympics a human has to jump further than a kangaroo (to nearly 9 meters). The best jumper of all is the snow leopard, who can leap 15 meters.

THE AVALANCHE OF UNFUNDED DEBT

Mortimer B. Zuckerman, the editor of U.S. News & World Report and the publisher of The New York Daily News, in a December 2012 column paints the picture well (32, 33): “A sound in the mountain range…. It's the sound made by an avalanche, the trillions of dollars of debt that's heading our way, gathering speed and mass. For most people, it's out of earshot.” Liabilities are not set out by our government in accordance with well-established norms of the private sector, where our overhang of liabilities would set off alarm bells in the markets, with boards of directors in emergency sessions. We have gone from being the world's largest creditor nation, with no foreign debt at the end of World War II, to the world's largest debtor, with half of our public debt held by foreign countries. During the last 4 years alone, our national debt has grown by more than $5 trillion to over $16 trillion. Although the Federal Reserve is keeping borrowing rates historically low, the cost of paying interest on the debt for fiscal year 2012 was just under $360,000,000,000!

Despite our huge annual deficit, the greatest fiscal challenge to the US government, opines Zuckerman, is its total liabilities. Our federal balance sheet, he indicates, does not include the unfunded obligations of Medicare, Social Security, and the future retirement benefits of federal employees. The estimated unfunded total of these commitments is more than $87 trillion, or 550% of our gross domestic product. And the debt per household is more than 10 times the median family income! The real annual accrued expense of Medicare and Social Security is $7 trillion. The government's balance sheet does not include any of these obligations but focuses on the current year deficits and the accumulated national debt. The annual budget deficit, however, is only about one fifth of the more accurate figure! Zuckerman argues that if Americans saw our financial statements in the same way that public companies report their pension liabilities, these liabilities would require borrowing on a scale that would not only bankrupt the programs themselves but would bankrupt the entire government. Zuckerman adds that the Social Security programs and other mandatory programs are not subject to an annual spending limit. Today, <40% of our budget is actually decided by Congress and the president, down from 62% 40 years ago. Our liabilities are so huge and are multiplying so fast that eventually they cannot be honored. Today, all payroll taxes for Social Security and Medicare are spent in the year that they are collected, leaving no leftovers for the unfunded obligations! And this does not take into account other risks such as the fact that the Federal Housing Authority confronts a $16.3 billion net deficit after its latest audit that may force a taxpayer bailout for the first time in its 78-year history. And, by 2016, the Disability Insurance Trust Fund will be fully depleted.

US TAX RATES

Taking into account all taxes on earnings and consumer spending—including federal, state, and local income taxes, Social Security and Medicare payroll taxes, excise taxes, and state and local sales taxes—the US average effective tax rate is around 40%. High tax rates—on labor, income, and consumption, as indicated by Prescott and Ohanian (34)—reduce the incentive to work by making consumption more expensive relative to leisure. The incentive to produce goods for the market is particularly depressed when the tax revenue is returned to households either as government transfers or transfers in kind—such as public schooling, police and fire protection, food stamps, and health care—that substitute for private consumption. In the 1950s, when European tax rates were low, many Western Europeans, including the French and Germans, worked more hours per capita than did Americans. Over time, tax rates that affect earnings and consumption rose substantially in Western Europe and have accounted for much of the nearly 30% decline in work hours in several European countries—to 1000 per adult per year today from around 1400 in the 1950s. The average American today works just over 1300 hours per year, the same as Japan, which has the same tax rate essentially as does America.

OBAMACARE’S INDEPENDENT PAYMENT ADVISORY BOARD

The Independent Payment Advisory Board (IPAB) is a government-appointed panel to help slow the growth of Medicare spending (35). The 15-person IPAB will propose Medicare cuts if the growth in the program's spending exceeds inflationary targets. Some fear that their decisions will lead to rationing. The law, however, gives the panel no authority to ration care or cut benefits for Medicare recipients. It can't touch reimbursement to hospitals until 2020. Instead, it is expected to find savings by eliminating fraud and reducing payments to private insurance companies that work with Medicare and prescription drug providers. And, it can only do that if the government is projected to spend more than it's supposed to. Each spring, the Office of the Actuary of the Centers for Medicare and Medicaid Services forecasts how much the programs will cost 2 years in the future. On April 30, 2013, the panel will issue its per capita estimates for 2015. The actuary also will release a spending target, based on predictions about the pace of health care inflation. If the increase in expected Medicare costs exceeds the spending target, the IPAB steps in to propose cuts. It will take a 60% Senate vote to reject its recommendations, and then legislators must find alternate cuts that achieve the same savings. The law allows them to debate the IPAB's proposal for 30 hours maximum, making it filibuster proof.

How will the White House recruit the board members? So far no IPAB members have been appointed, even though the board is supposed to get to work by April 2013. The law requires the panel to be made up of prominent physicians, economists, hospital executives, and insurance industry representatives. Candidates are subject to Senate approval, which means that they must endure potentially hostile public hearings. Board members willing to go through all that must also agree to serve for 6 years, full time; they have to quit their current jobs because of conflict of interest concerns. The annual salary for each board member is $165,300. And, the life of an IPAB member may be rather dull since its powers kick in only if spending is surging. It's no wonder that Obama has yet to announce his candidates. If there is no IPAB in place by the time its services are needed, the law allows the secretary of the US Department of Health and Human Services to do its job until the panel is up and running. I can't imagine who would want to be one of the 15 on that panel!

WATER

When the headline of the Dallas Morning News reads “The word on water: Conserve,” we have a problem (36). The state is running out of water, as shown in Figure 3. The projected Texas population in the next 50 years is expected to grow from 25 million to about 46 million (54%↑) and the projected need for additional water from 3.62 to 8.33 million acre-feet per year (43%↑). Get ready. Life with limited water will not be the same. Quick showers, low-flush toilets, and irrigation restrictions will be the norm. San Antonio, Texas, apparently is already in the swing of water conservation, and we must follow in Dallas.

Figure 3.

The supply and demand for water in Texas. Reprinted with permission from The Dallas Morning News.

US OIL BOOM

It's really unbelievable, at least to me. The US oil output is surging so fast that the USA could soon overtake Saudi Arabia as the world's biggest producer (37). Driven by high prices and new drilling methods, US production of crude and other liquid hydrocarbons rose approximately 7% in 2012 to an average of just under 11 million barrels per day. This is the fourth straight year of crude increases and the biggest single year since 1951. The Energy Department forecast that US production of crude and other liquid hydrocarbons, which include biofuels, will average 11.4 million barrels per day in 2013. That would be a record for the US and just below Saudi Arabia's output of 11.6 million barrels per day. The production is forecast to reach 13 to 15 million barrels per day in the US by 2020, helping to make North America “the new Middle East.” I used to think that making the US “energy independent” was a joke, but it is great to see that it isn't.

BALLPOINT PEN

We all use them. Peter Pesic summarized the book Ballpoint written by Hungarian author György Muldova (38, 39). The Hungarians are astonishingly creative. Eleven won the Nobel Prize during the 20th century, far more per capita than from other nations. There were other Hungarian geniuses, including mathematician John Von Neumann and physicists Leo Szilard and Edward Teller. Talented students flourished in some Budapest schools until the 1920s when the government began limiting university admissions to those “who are completely reputable in respect of their national allegiance,” effectively excluding Jews, who thereafter emigrated when they could.

One of the Jewish beneficiaries of those Budapest schools was László Biró (1899–1985), a journalist and artist in the 1930s who noted that the ink used for newspapers dried relatively quickly compared with the ink for fountain pens. Handwritten papers had to be carefully blotted or set aside until the ink dried. Biró tried using quick-drying ink in a fountain pen, but the fluid was too thick to flow down to the nib and simply clogged the reservoir. He solved the problem of how to deliver thick, quick-drying ink to a paper surface without requiring the ink to flow by closing the end of the pen instead of using a nib, leaving an opening with just enough room for a tiny metal ball that would spin against the ink in the reservoir, distributing it to the paper. Through much trial and error and with the help of an early backer and business partner, Endor Goy (1896–1991), Biró developed a working ballpoint pen. The two men signed a contract to produce and market the pen in 1938. Biró kept refining the pen and experimenting with recipes for the ink paste essential for his concept while fleeing dangers in Europe and finally settling in Argentina. Though Biró faced the hardships of wartime immigration, he soon started up a pen-manufacturing operation in Argentina. Biró's story is relatively well known in much of the English-speaking world. “Biró” is synonymous with ballpoint pen. In Argentina, the pen is known as a “Birome,” and Biró's birthday, September 29, is celebrated as “Inventor's Day” in Argentina. Thus, the ballpoint took its place alongside the zipper, the pencil, and the paperclip devised by inventors who long struggled to produce objects we now take for granted.

EPPIE AND POPO

These were their nicknames. They were identical twins, Esther Pauline Friedman Lederer and Pauline Esther Friedman Phillips, aka Abigail Van Buren, born in Sioux City, Iowa, on July 4, 1918. They shared a joint wedding and honeymoon trip. Esther was the first to become a columnist, taking over the Chicago Sun-Times’ “Ann Landers” column in 1955. Pauline, living in California, started a replacement advice column for the San Francisco Chronicle, “Dear Abby,” in 1956. She created her own byline, combining a biblical wise woman with the eighth president of the US. Within 2 years, both columns were in a combined 400 newspapers. Pauline's Dear Abby column at its peak appeared in 1400 papers. Life magazine in 1958 said the sisters were “the most widely read and most quoted women in the world.” For a long time they did not speak to each other, but their differences were eventually patched up. Mother and daughter started sharing the byline in 2000, and Jeanne Phillips took over in 2002. Amazing (40).

SPORTS

Stan Musial: Years ago I was invited to give a talk in St. Louis by the son-in-law of Stan Musial, a physician, who brought me a baseball signed by Stan-the-Man. It is one of my favorite sport collectibles. When I was growing up, Musial was one of my baseball heroes. He played 22 years in the Major Leagues, all with St. Louis, in 3026 games. He had 10,972 at-bats and only struck out just over 600 times (41). He had 3630 hits, scored 1942 runs, had 6134 total bases, and hit 475 home runs. He won the National League batting title 7 times and participated in 24 all-star games. And all the time he was a great guy. He contributed to his community generously. He was 6 feet tall and weighed 175 pounds. Those also are my dimensions, but Musial had a much better eye for the ball.

Stacy Lewis: She is the first American to be named Player of the Year on the Ladies Professional Golf Association tour since 1994 (42). She had severe scoliosis and wore a back brace 18 hours a day for 7 years as a child. She had a steel rod with 5 screws installed in her spine just after getting her high school diploma. She didn't know at that time whether she could play golf again, but she certainly did.

Johnny Manzial: As a red-shirt freshman, “Johnny Football” won the Heisman Trophy Award for 2012 and shortly after doing so set the Cotton Bowl record for total offense with 516 yards (43, 44). Seven other college football players have played in the Cotton Bowl after receiving the Heisman Award, but none came close to doing what Johnny Manzial did in the January 2013 classic.

Golf: The average professional golfer takes 15,000 steps during an 18-hole round, walks 7 miles, and burns 2000 calories. The numbers when using a cart are unclear.

BODY WEIGHT IN THE NATIONAL FOOTBALL LEAGUE

Fran Tarkenton, a National Football League quarterback from 1961 to 1978 and member of the Pro Football Hall of Fame, in a recent piece in The Wall Street Journal discussed body weight of professional football players when he played and subsequently (45). When Tarkenton entered pro football in 1961, every member of his offensive line weighed <250 pounds. During his last year, 1978, the biggest lineman on his team weighed 260 pounds. No Super Bowl–winning team had a 300 pounder on its roster until the 1982 Washington Redskins. Now, it is unusual for a team to have fewer than ten 300 pounders. This year's Super Bowl teams, the San Francisco 49ers and the Baltimore Ravens, had twenty-four 300 pounders between them.

Have players gotten bigger thanks to genetics, diet, and nutrition? Or is there something else going on? Shortly after retiring from football, Tarkenton learned from an owner of one of the biggest gym chains in the country that muscles can only get so big by weightlifting regimes alone. Huge muscles come from performance-enhancing drugs, which Tarkenton indicated were just starting to enter professional football during his time. The National Football League does not talk about steroids or human growth hormone, but these drugs make players bigger, faster, and stronger, and they are used widely in football. Why do so many former players look like miniature versions of themselves after they retire?

In their most recent collective-bargaining agreement, signed in 2011, the National Football League and the Player's Union agreed to start testing players for human growth hormone. Yet, two seasons later there still isn't any testing! (In contrast, Major League Baseball in recent years worked out a testing regime that includes human growth hormone.) At the college football level, meanwhile, testing looks almost exclusively for recreational drugs, with practically no attention to performance-enhancing ones.

Although everyone claims to care about player safety at all levels of the game, the use of performance-enhancing drugs, which have made current players bigger and stronger than ever, causes collisions to be more violent and players therefore to suffer worse injuries. These violent encounters on the field not only affect the safety of the players during games but they clearly affect long-term health—dementia, Alzheimer's disease, depression, suicide, and early death.

William Clifford Roberts, MD

1 February 2013