Facts and ideas from anywhere

ALZHEIMER'S

William C. Roberts, MD.

About 5.2 million Americans had Alzheimer's in 2014 (1). By 2050, an estimated 13.5 million are predicted to have the disease. Alzheimer's care cost $226 billion in the last fiscal year, and some $150 billion fell to Medicare and Medicaid; the remainder mostly was handled by patients and families. Alzheimer's disease is escalating as baby boomers—a generation of 76 million Americans born between 1946 and 1964—turn 65 at a rate of roughly 10,000 a day. The risk of Alzheimer's of course increases with age, and as baby boomers get older the number of people developing the disease will rise to levels far beyond anything we've seen before. The disease is more prominent in women than in men. At age 65, seemingly healthy women have about a 1 in 6 chance of developing Alzheimer's during the rest of their lives, compared with a 1 in 11 chance for men.

Lauren Neergaard of the Associated Press suggested five tips to help guard against Alzheimer's (2). 1) Get plenty of sleep: poor sleep can spur the brain-clogging protein amyloid that is a hallmark of Alzheimer's. 2) Exercise the gray matter: working crossword puzzles, taking music lessons, or learning a new language keeps the brain engaged. Learning and complex thinking strengthen connections between nerve cells, building up “cognitive reserve” so that as Alzheimer's brews the brain can withstand more damage before symptoms become apparent. 3) Get plenty of physical activity: the least active have the worst cognition when they are middle-aged. Sedentary behaviors increase the chances of Alzheimer's. 4) Maintain mental health: depression and loneliness accelerate cognitive decline. Experiencing stress is one thing, but how we cope with it is more important. 5) Eat healthy: diets high in fruits and vegetables and lower in fat and sugar are good for the arteries that keep blood flowing to the brain. Diabetes mellitus and excessive weight raise the risk of dementia.

THE GOLDEN RULE FOR STATIN THERAPY: STAY ON THE DRUG

The European Atherosclerosis Society Consensus Panel statement on assessment, etiology, and management of statin-associated muscle symptoms was published in February 2015, and several of the panel members were interviewed thereafter (3). Dr. Erik Stroes of Amsterdam stated, “Let's start with the Golden Rule: never stop using your statin.” His thesis was that if statins reduce the risk of major vascular events 20% with every 39 mg/mL reduction in low-density lipoprotein (LDL) cholesterol, that risk returns if the lipid-lowering drugs are stopped. He mentioned a recent article showing that patients who had had a myocardial infarct who stopped their statins had a 4- to 7-fold increase in risk of cardiac death over the following 4 years. Stroes stressed that “stopping a statin is not just an important decision, but pivotally important.” He mentioned at least 7 studies where discontinuing a statin had unwanted consequences. His view: Before abandoning a statin because of muscle symptoms, physicians need to be absolutely certain the muscle-related events are attributable to the drug. When a statin is discontinued in a patient, that discontinuation is liable to do the patient harm.

The panel statement indicated that the rate of myopathy is 0.5 events per 1000 patients over a 5-year period. This event frequency is based on data from randomized controlled clinical trials. The risk of rhabdomyolysis is 0.1 events per 1000 patients over a 5-year period.

When experts began preparing the consensus statement, a number of the contributors blamed the media for sensational headlines trumpeting risks with statins. Several believe the media was responsible for blowing the potential side effects out of proportion and led to patients' stopping the drug needlessly. Some contributors to the report found fault not only with the media but also with research universities or institutions that trumpeted data from observational studies where data are not as consistent or as reliable as those from randomized controlled clinical trials. The consensus panel recommended that if a patient is identified with statin-associated muscle symptoms, the first task is to rechallenge the patient with another statin after stopping the first drug for 2 to 4 weeks. One Cleveland Clinic study showed that more than 70% of patients who stopped their statin because of side effects could be successfully restarted with a different statin. A Boston-based study showed that 92% of patients who stopped their statin were successfully rechallenged with statin therapy and still taking the drug 12 months later. If the rechallenged patient is still not able to tolerate a statin, the panel recommended that physicians try again, aiming for a lower dose with a particularly potent statin or advising the patient to take a statin every other day or twice weekly. If still unsuccessful, the remaining step may involve trying again with the highest maximally tolerated dose of statin and then adding ezetimibe.

PCSK9 INHIBITOR APPROVED

In June 2015, a Food and Drug Administration (FDA) advisory panel recommended that the agency approve the cholesterol-lowering drug Praluent (alirocumab) (4–6). The drug is produced by Sanofi SA and Regeneron Pharmaceuticals and is the first of these PCSK9 inhibitors approved. This new class of medicines blocks a protein called PCSK9, which interferes with the liver's ability to clear LDL cholesterol from the bloodstream. Praluent is an injectable medicine only and is administered every 2 weeks. It will probably be recommended only for patients with heterozygous or homozygous familial hypercholesterolemia, the former occurring in 1 of 500 people and the latter in 1 in 1,000,000 people. The drug is expected to cost about $1000 monthly or $500 for each injection. The two companies state they already have a study underway to see if cardiac outcomes improve with the drug, and the results are expected in 2017. In clinical studies evaluated by the FDA and the advisory committee, Praluent showed “no marked disparities in deaths, serious adverse events, or adverse events leading to discontinuation of the drug.” The studies showed patients with the drug had their LDL cholesterol lowered by 40% to 60%.

NEW BLOCKBUSTER DRUGS

In 2014, the FDA gave the green light to 41 new drug compounds for a wide range of diseases, including viruses, cancer, and skin infections (7). It was also the year of the most successful drug launch in history, Sovaldi, the new hepatitis C drug from Gilead Sciences ($10.3 billion in sales). The class of 2015 brings promising new treatments for high cholesterol levels, cystic fibrosis, and heart failure. Although it is never easy to predict which drugs will win approval by the FDA, Barrons considered the following drugs to have a high probability of regulatory approval in 2015 and the potential to deliver annual sales of $1 billion or more.

Novartis has a new blockbuster with LCZ696. In the US alone, just over 5 million people have chronic heart failure. Data have shown that, compared with current treatments, use of LCZ696 has led to a 20% lower risk of death caused by a “cardiac event” and fewer hospitalizations.

Regulators approved a drug in January 2015 from Novartis that offers a new way to treat psoriasis. Known as Cosentyx, the drug blocks a protein that plays a role in inflammation. In four clinical trials, more than 80% of patients taking it saw at least 75% of their symptoms disappear.

Vertex Pharmaceuticals became the first drug maker in more than a decade to launch a new treatment for cystic fibrosis when the drug Kalydeco won regulatory approval. This drug is effective in only a small fraction of patients, but when paired with an experimental drug, also from Vertex, the new combination was more effective.

CYSTIC FIBROSIS DRUGS

Boston-based Vertex Pharmaceuticals' newest cystic fibrosis drug, Orkambi, is a combination of Kalydeco (ivacaftor) with another compound called lumacaftor (8). It treats the most common form of cystic fibrosis but at an annual wholesale cost of $259,000 per patient. It is administered twice daily in an oral tablet. Vertex already sells Kalydeco, which treats a different genetic type of cystic fibrosis and has an annual price of $311,000 per patient in the US. The FDA advisory committee of 13 independent physicians, scientists, consumers, and patient representatives recommended approval in May 2015 by a vote of 12 to 1. The new drug appears to be only modestly effective. That's a lot of money for modest effectiveness.

COST OF CANCER

Jim Landers had an extensive piece on the cost of cancer care recently in The Dallas Morning News (9, 10). Prescription drug costs for new cancer treatments are soaring at unsustainable rates. By 2020, the cost of specialty drugs for cancer and other diseases could reach $400 billion a year, about $100 billion more than the entire prescription drug industry today. Cancer now is the second leading cause of death in the US behind cardiovascular disease and is heading rapidly toward the number one spot. Worldwide, annual cancer cases are expected to rise over the next 2 decades from 14 million diagnoses to about 22 million. In 2015, nearly 2 million Americans will be diagnosed with cancer. Drug companies, of course, need to recoup research investments, which can run more than $1 billion for development of a new drug. Medicare, the federal health insurance program, is prohibited from negotiating with the pharmaceutical industry over prices! Although many hospitals receive discounts on cancer drugs under Medicare rules, they are not required to share those discounts with patients. Also, it is illegal to import the same drug at a less expensive price from pharmacies abroad!

JONAS SALK AND HIS POLIO VACCINE

When I was a youngster, my mother kept my brother and me out of public swimming pools in the 1940s because of fear of polio. In post-World War II, polio struck seemingly out of the blue each summer as temperatures rose. The virus hit kids particularly, causing paralysis and breathing only by iron lungs. Apart from the atomic bomb, America's greatest fear after World War II was polio. As a result, scientists were in a frantic race to find a way to prevent or cure the disease. In 1938, a US president, Franklin D. Roosevelt, the world's most recognized victim of the disease, founded the National Foundation for Infantile Paralysis (later known as the March of Dimes Foundation), an organization that would fund the development of a vaccine. As described in the recent book by Charlotte DeCroes Jacobs entitled Jonas Salk: A Life, Salk (1914–1995) in 1947 accepted an appointment to the University of Pittsburgh School of Medicine (11). In 1948, he undertook a project funded by the National Foundation for Infantile Paralysis to determine the number of different types of polio virus. He extended the project towards developing a vaccine against polio and devoted himself to this work for the next 7 years. The field trials set up to test the Salk vaccine were considered the most elaborate program of its kind in history, involving 20,000 physicians and public health offices, 64,000 school personnel, and 220,000 volunteers. Over 1,800,000 school children took part in the trial. When news of the vaccine's success was made public on April 12, 1955, Salk was hailed as a miracle worker and the day almost became a national holiday. Around the world, an immediate rush to vaccinate began. Almost overnight Salk became the most adored man in the nation. Fan letters and awards poured in for the rest of his life.

The Jacobs book concerns primarily Salk's career after developing the safe and effective vaccine for polio. Salk's vaccine was a killed version of the polio virus, and it coaxed a person's antibodies to protect against the live virus. Although the country accepted Salk's work with great adoration, other researchers were not as approving. Salk's great rival, Albert Sabin (1906–1993), had developed a different virus, one that relied on a live version of the polio virus. For the rest of their careers, Salk and Sabin battled over which vaccine was safer and more reliable. In the end, both approaches proved crucial to slowing polio worldwide. To date, the disease is endemic only in Afghanistan, Nigeria, and Pakistan, and public health experts continue to push full eradication.

The polio fight for Salk was just the beginning. Having established his vaccine at the age of 40, he struggled to have the rest of his life mean as much. There was some family turmoil. In 1968, he divorced his first wife (with three children) and married French artist Francoise Gilot, the mother of two of Pablo Picasso's children. Toward the end of his career, he worked on an AIDS vaccine. Although he did not succeed, his fame brought attention to the fact that AIDS was an important disease that should not be shunted to the sidelines as some kind of distasteful gay epidemic.

EXTENDING LONGEVITY

A recent piece by Ariana Eunjung Cha described what is happening in Silicon Valley about the possibility of living many decades longer than presently (12). In 2004, Peter Thiel, who had recently made a fortune selling PayPal, which he cofounded, to eBay, gathered in San Francisco with a group of tech titans who founded Google, Facebook, eBay, Napster, and Netscape with the desire of convincing them to use their billions to rewrite the nation's science agenda and transform biomedical research. Their objective was using the tools of technology—chips, software programs, algorithms, and big data, which they had used in creating the information revolution—to understand and upgrade what they considered to be the most complicated piece of machinery in existence, namely the human body. The entrepreneurs want to rebuild, regenerate, and reprogram patients' organs, limbs, cells, and DNA to enable people to live longer and better. The work they are funding includes hunting for the secrets of living organisms with insanely long lives, engineering microscopic nanobots that can fix the body from the inside out, figuring out how to reprogram the DNA we are born with, and exploring ways to digitize our brains based on the theory that our minds could live long after our bodies expire. Oracle founder Larry Ellison, who wishes to live forever, has donated more than $430 million to aging research. Sean Parker, the Napster cofounder, has donated millions to finding a cure for allergies and cancer therapies. Google's Sergey Brin has proposed a new kind of science that starts with masses of DNA and a community of people with certain genes. He apparently has the Parkinson's disease gene and has donated $150 million to the effort. Pam Omidyar, a biologist and former research assistant in an immunology lab, cofounded the Omidyar Network with her husband, eBay's Pierre Omidyar, who became a billionaire at 31. They have donated millions to research on resiliency—the trait that helps people bounce back from illness or other adversity. And Page, who is now 41 and chief executive of Google, has made the biggest bet on longevity yet, founding Calico, short for California Life Company, a secretive antiaging research center, with an investment of up to $750 million from Google. Microsoft cofounder Bill Gates and his wife, Melinda, the wealthiest couple in the world with an estimated worth of $79 billion, believe that charitable giving is the key element to close the gap between the poor and the rich.

Of course, there are many who are ambivalent about using new medical treatments to live radically longer lives. A survey indicated that nearly two-thirds worry that radical life extension would strain natural resources, that only wealthy people would get access to new treatments, and that medical scientists would offer the treatments before they fully understood how it affected people's health.

MEDICINE FROM THE PULPIT

A piece in the AARP Bulletin recently described a strategy of the Reverend Sean Dogan, pastor of the Long Branch Baptist Church in Greenville, SC (13). The article indicated that Reverend Dogan had given over 400 eulogies for his parishioners, most of whom had died from heart disease, diabetes mellitus, obesity, or stroke, and after each funeral he would sit with friends and families of the deceased to a meal of fried chicken, mac and cheese, and collard greens boiled in fatback. Then one day 4 years ago, Dogan had a revelation. It was the food that was killing his people. Thus, one Sunday morning he stepped up to the altar with a weight scale in hand for all to witness as he weighed himself. Like many in his congregation, he was overweight. “The time for change,” he declared, “has come.” With that passionate appeal, Dogan joined scores of African American ministers around the country who, from their powerful perches, have been making the health of their congregation a priority. Nationally, nearly 48% of African Americans are obese compared with 33% of European Americans. Perhaps nowhere are these problems more evident than in the rural South. Not only Reverend Dogan's church, but a number of similar churches are now trying to turn the tide. They are enlisting community foot soldiers to give them a hand. Good for Reverend Dogan!

ADDING BODY MASS INDEX TO VITAL SIGNS

The vital signs, of course, include blood pressure, heart rate, respiratory rate, and body temperature. I don't believe many physicians count the respiratory rate. Recently, after throwing the ball to my granddaughter's pitbull in the backyard, I noticed that her respiratory rate was well over 100 breaths per minute. Dogs, of course, in contrast to humans cool their bodies by panting. Like other carnivores, they have no capacity to sweat. If a human being was breathing over 100 times a minute, I think that recording would be worthwhile, but for people breathing normally, the number of breaths per minute is infrequently counted. I recently attended a conference where a patient was discussed nearly 30 minutes and at the end it was brought out that the patient weighed 350 pounds and was only 64 inches tall. If that information had been provided initially, the whole discussion would have changed. Body mass index (BMI) will determine many of our fates and is more important than the respiratory rate.

FASHION, BODY MASS INDEX, AND MORE

Most of the world is getting heavier. About two-thirds of adults in the USA are overweight, and half of them are obese (BMI ≥30 kg/m²). The fashion models have the rare problem of too little weight. In 2007, Spain enacted regulations that barred models below a BMI of 18.5 from being featured in fashion shows (14). In the same year, Italy started insisting on health certificates for models as well as banning models under 16 years old from its runways. In 2013, Israel enacted similar BMI rules for models. In 2015, French lawmakers voted in favor of a measure that would ban excessively thin fashion models from the runways and potentially fine their employers in a move that prompted resistance in the modeling industry. Those who hire underweight models could be fined as much as $82,460 and face up to 6 months in prison. The point of the bill was to combat anorexia. The image of so-called “ideal beauty” augments the risk of eating disorders. The amendment is part of a broader bill that still requires approval by France's Senate before becoming law, but it is expected to pass and to be enforced by the end of 2015. The modeling industry in France, of course, opposes the proposal.

The National Assembly, Parliament's lower house in France, also voted in the same bill to alter the packaging of cigarettes such that the package would be less attractive and help discourage young people from starting to smoke (15). About 30% of the French smoke. Additionally, people who encourage minors to drink excessively could face a year behind bars and a 15,000 euro ($16,000) fine. The sale to minors of products inciting people to get drunk, such as t-shirts, would be forbidden. Also, the same bill would require changes to the business model of some fast-food chains. The bill would ban free soda refills in restaurants in a move aimed at fighting obesity. Also, amid concerns about skin cancer, the bill would bar tanning salons from selling sun-bed services to customers under age 18 or to engage in advertising targeting minors. The bill also would allow for a 6-year test period in which intravenous drug users would be given access to clean needles under medical supervision and in the presence of drug counselors. Medicine is moving not only into the pulpit but certainly into the legislative halls of numerous countries.

OBESITY AMONG POLICE OFFICERS

Robert Atcheson, a former captain in the Washington, DC, Metropolitan Police Department, wrote a piece entitled “Why Real Men Don't Eat Meat” (16). He indicated that “law enforcement is the fattest profession in the world” according to a study published in The American Journal of Preventive Medicine. Police officers are 25 times more likely to die from weight-related disorders such as heart disease than from fighting crime. Atcheson, who retired at age 50 after 25 years in the DC police force, switched from a meat-eating lifestyle to 100% vegan, thanks to encouragement from his daughter. After examining the benefits of the vegetarian-plant lifestyle and thinking about the preventable chronic diseases in his family, he made the switch. He indicated that approximately 75% of the nation's $2 trillion health care bill in 2012 was treating diet-related chronic diseases such as heart disease, diabetes mellitus, high blood pressure, and obesity. He wrote:

It's ludicrous that those responsible for protecting the people of this country are themselves in dire need of protection—and from entirely preventable diseases, no less. Because I don't eat animal products my risk of cancer is a fraction of the average. I weigh the same today as I did at 21. I bet my life savings that unlike many of my family members—and fellow jarheads and cops—I will never get heart disease or diabetes…. Once I went vegan I gave my officers a message I'd like the whole country to hear: When you eat meat and other animal products, you are playing a losing game of chicken with your health. It takes courage and discipline to ditch that crap and clean up your plate. Do what I did, and what many of my best officers eventually did, too: trade in that morning donut for a smoothie. Swap that chicken sandwich for a black bean burger. Your health—and your family—will thank you.

He also indicated that obesity is the #1 cause of military ineligibility, and according to Mission: Readiness, a group of 300 retired military generals and admirals, it costs the Pentagon about $1 billion annually. Chronic diseases also disproportionately affect veterans: One in four have diabetes, and nearly 80% are overweight or obese.

OBESITY AND NATIONAL GROWTH

Morgan Stanley recently prepared a 70-page report warning that sugar consumption might sharply curtail economic expansion around the world (17). Many countries, the firm said, will experience slower growth than expected over the next 20 years as diabetes mellitus and obesity take a toll on workers' productivity. The US's 2.5% annual growth, projected by the Organization for Economic Cooperation and Development, falls to 1.8% when the full cost of sugar is factored in. Per capita sugar consumption worldwide has climbed nearly fivefold over the past century to 53 pounds a year as American diets take hold overseas. Some health experts call sugar the new tobacco, addictive and lethal. The problem is particularly pressing in the emerging markets, indicated Carmen Nuzzo, a Morgan Stanley European economist who coauthored the report. Rising middle classes show a clear penchant for sugary drinks and foods—the higher the income, the higher the rate of sugar consumption and the greater the rate of sedentary living. Now, more than 40% of the world's 3.87 million diabetics live in India and China. But, the greatest danger to economic growth rates, according to Morgan Stanley, is in Chile, the Czech Republic, Mexico, the USA, and Australia because of the very high rates of diabetes and obesity.

HIGH-SPEED POLICE CAR PURSUITS

Since 1979, more than 11,500 people have been killed in police chases, including 6301 fleeing drivers, 5066 nonviolators, and 139 police (18). Most bystanders were killed in their own cars by fleeing drivers. US police chase tens of thousands of people each year—usually for traffic violations or misdemeanors—and drivers often speed away recklessly. These police chases lead to many injuries and too many deaths. Pursuit of fleeing drivers is probably the most dangerous job law enforcement officers do. The Justice Department in 1990 urged police departments to adopt policies listing exactly when officers can and cannot pursue someone. Police chases have killed nearly as many people as justifiable police shootings.

Despite the Justice Department's warning, the number of chase-related deaths in 2013 was higher than the number in 1990—322 compared with 317. Many police departments let officers make on-the-spot judgments about whether to chase based upon their perception of a driver's danger to the public. Officers continue to violate pursuit policies concerning when to avoid or stop the chase. Some departments allow chases only of suspected violent felons; others let officers chase anyone if they decide the risk of letting someone go outweighs the risk of a pursuit.

Injuries are more difficult to determine than fatalities. Records from six states show that 17,600 people were hurt in chases from 2004 through 2013—an average of 1760 injuries a year in those states, which make up 24% of the US population. Those numbers suggest that chases nationwide may have injured 7400 people a year, more than 270,000 since 1979.

Some of the chases are for relatively small crimes. California records of 63,500 chases from 2002 through 2014 showed that more than 89% were for vehicle code violations, including speeding, vehicle theft, reckless driving, and nearly 5000 instances of a missing license plate or an expired registration. Just 5% were an attempt to nab someone suspected of a violent crime, usually assault or robbery; 168 sought a known murder suspect. Nearly 1000 were for safety violations that endangered a driver only, including 850 drivers not wearing a seatbelt and 23 motorcycle riders not wearing a helmet. In 90 instances, police chased someone for driving too slowly. Most dangerous are chases on slippery roads and pursuits of inexperienced, risk-prone teenage drivers and of motorcyclists, who have little crash protection. In Michigan since 2004, 74% of motorcyclists fleeing police were killed, injured, or possibly injured when they crashed; in contrast, just 18% of chased car drivers were killed, injured, or possibly injured in a crash. Police departments routinely warn officers about hazardous road conditions and high-risk drivers. Some bar motorcycle policemen from pursuits because of the danger if an officer crashes.

Police departments that resist chases have faced resistance from officers. In 2012, the Florida Highway Patrol stopped letting officers chase anyone and allowed pursuits only of suspected felons, drunken drivers, and reckless drivers. The number of pursuits fell almost in half, from 697 in 2010–2011 to 374 in 2013–2014. Dallas' crime rates have plummeted since restricting police chases.

TELEDOC

It is the Dallas provider of phone-based medical care where doctors diagnose and prescribe medications over the phone for unknown and unseen patients. Teledoc is the largest telemedicine provider in the country. In the first 3 months of 2015, it provided more than 150,000 remote visits for patients across the country seeking routine medical care (19). Patients whose employers or insurers have deals with Teledoc can call one of the company's referral centers, day or night, 365 days a year. The referral center tracks down the patient's medical record and shares it with a physician on duty, and the physician calls the patient back, usually within 10 minutes. The physician and patient can use a video service, like Skype, exchange digital images, or just talk on the phone. Once the doctor interviews the patient and has made a diagnosis, he or she suggests remedies and may prescribe medicine. No controlled substances, like opiates, are allowed to be prescribed, and no lifestyle drugs, like Viagra, are either. The cost to the patient is no more than $40. Depending on insurance arrangements, it might be less.

The Texas Medical Board has fought Teledoc over this model since 2011. In April 2015, it voted that it was okay for patients to have remote visits with their regular physicians or on-call physicians who work in the same office, but the board's ruling against Teledoc, by a 13 to 1 vote, means that a patient unknown to a doctor must be examined in person before a physician can issue a diagnosis or a prescription. The Texas Medical Association supported the ruling.

“NO JAB, NO PAY” POLICY

The Australian government has ramped up pressure on parents who oppose vaccinations by threatening to withhold child care and other payments from families who do not immunize their children (20). The government announced in April 2015 that families could lose up to 15,000 Australian dollars (about $11,000) per child per year in tax and child care benefits from January 1, 2016, unless their children were vaccinated under a “no jab, no pay” policy. The government is removing a category of “conscientious objector” that allowed parents to remain eligible for full welfare benefits despite not immunizing their children. Although 97% of Australian families that claim tax benefits for their offspring are vaccinated, the number of children under 7 years old who are not vaccinated because their parents are objectors has increased by about 24,000 over the past decade to 39,000. Parents, however, will still be able to resist immunizing their children on medical and religious grounds without financial penalties.

GETTING TO YOUR DOCTOR

The federal government has 42 programs run by six different departments to help people get to their doctors' offices, according to the findings of a Government Accountability Office report released in April 2015 (21). The Department of Agriculture has a grant program to help assisted living facilities in rural areas buy vans; the Department of Housing and Urban Development provides bus tokens and taxi fares for people with AIDS; and the Department of Veterans Affairs provides mileage reimbursement or bus, train, boat, or even airplane tickets. The largest program, administered by Medicaid, spends more than $1.3 billion a year to get people to the doctor. Because medical transportation at other agencies is so fragmented, there's no accounting of how much the government spends in all.

BIRTH TOURISM

According to a piece in the USA Today by Calum MacLeod (22), business is booming in Beijing, China, for companies that coach pregnant women on how to deceive US immigration authorities so that they can enter the US for the sole purpose of giving birth to an American citizen. At least 500 companies offered “birth tourism” services in China in 2014. The number of Chinese citizens heading to the USA to give birth is not entirely clear, but it appears to be in the tens of thousands each year. The cost of the trip, including medical expenses, runs from $20,000 to $80,000. The business is legal in China, but the tactics for entering the US are not. The women apparently are coached to lie about the purpose of their visit by listing “tourism,” which makes it easier to get a visa. They also are told to hide their pregnancies when going through US Immigration and avoid declarations that they are traveling for medical treatment. The US State Department says there is no law barring foreigners from traveling to the US for the purpose of giving birth. The tourism visa they usually travel on, known as a B-2 visa, allows foreigners to enter the US for “medical treatment.” As long as the applicants are truthful about their intentions, prove they can afford their medical care, explain why they can't have the procedure done in their home country, and assert that they will abide by the time restrictions of their visa, such travel is generally allowed under US law.

Birth tourism is expected to grow. The main attraction: when children born in the USA turn 21, they can sponsor their parents to become legal US residents so the family can immigrate to the USA. The Chinese apparently admire America's clean air, safe food, and its respect for human rights; they seek a better education and environment for their children and hope to evade China's “one-child” policy. Expectant mothers typically arrive 2 months before birth and stay one more for postpartum recovery. They then return to China where government officials don't punish the parents for violating birth control rules because a second child is considered an American. At 18, however, the child must choose whether to be a US or a Chinese citizen. Birth tourism has become more popular than a US immigration program that lets wealthy applicants gain American residency by investing at least $500,000 in a US business.

JOGGING AND IMMORTALITY

Some investigators from Copenhagen, Denmark, recently compared the mortality of joggers running 1 to 2.4 hours per week with that of sedentary nonjoggers (23). The joggers were divided into light, moderate, and strenuous joggers. The lowest mortality was found in the light joggers followed by moderate joggers and, lastly, the strenuous joggers. The findings show a U-shaped association between all-cause mortality and the dose of jogging as calibrated by pace, quantity, and frequency. Light and moderate joggers had lower mortality rates than sedentary nonjoggers, whereas strenuous joggers had a mortality rate similar to that of sedentary nonjoggers. Thus, a little but not too much.

MILES RUN DURING PROFESSIONAL NATIONAL BASKETBALL GAMES

The NBA has SportVU Player Tracking technology in every NBA arena (24). The system includes cameras and STATS proprietary software, which tracks the movements of all the players and the ball on the court. During the 48-minute scheduled games, each of the 30 NBA teams as a group run just over 1000 miles. The distance covered per 48 minutes for the individual players is just over 3.0 miles per game. The average speed of each of the players averages 4.0 miles per hour. Most of the players in the starting lineup of NBA games average just over 30 minutes per game, and nearly all of them play in about 60 games per year. A number of the starters put in about 150 miles during the 72 regular season games.

MEDICARE'S 50TH BIRTHDAY

Medicare of course was part of Lyndon B. Johnson's great society expansion in the 1960s. In its first year, 1966, Medicare spent $3 billion. In 1967, the House Ways and Means Committee predicted that the program would cost $12 billion by 1990. It ended up costing $110 billion that year (25, 26). In 2014, the program cost $511 billion, and 7 years from now it will be $1 trillion. The latest projections from Medicare's trustees, released in July 2015, are that the program's main trust fund, for hospital care, will be exhausted by 2030. To keep Medicare's spending under control, payments to health care providers by the program have consistently been lower than those made by private insurers. The American Hospital Association reported that hospitals took in $0.88 for every $1.00 spent caring for Medicare beneficiaries in 2013. Now, nearly 3 in 10 seniors on Medicare struggle to find a primary care physician who will treat them.

Maybe a partial fix to the problem could start with increasing the age when Americans can enter Medicare. In 1965, eligibility for Medicare was set at age 65 because life expectancy then was 70 years. Today, life expectancy is 79 years of age and could reach 84 by 2050. The number of Medicare beneficiaries also has skyrocketed since the program's inception. It initially served 19 million people. Today, the program serves almost 50 million, and every day 10,000 baby boomers join the program's ranks. Raising the eligibility age for Medicare by just 2 years would save $19 billion by 2023. Some have figured that changing the eligibility age will not be enough to save Medicare. One proposal is to convert the open-ended entitlement to a system of means-tested vouchers. The government would give every senior a voucher based on health status, income, and age. Seniors in better health and those with the most money would receive smaller vouchers, and sicker or needier seniors would receive large ones.

But there is some good news for Medicare, according to an article by Krumholz and colleagues (27). From 1999 to 2013, mortality rates among Medicare patients fell 16% (from 5.3% to 4.5%); hospitalizations during the same period fell (from 35,274 to 26,930 per 100,000 person-years); and costs per patient fell (from $3290 to $2801 per patient). Among fee-for-service from 1999 to 2013, in contrast, hospitalization rates fell 24% (>3 million fewer hospitalizations); mortality rates fell 45% during hospitalization, 24% within a month of hospitalization, and 22% within a year of hospitalization; and costs for hospitalized patients fell by 15% during the 14-year period. Thus, not all Medicare news is bad news.

FEDERAL SPENDING AND FEDERAL TAXES

The US government spent $3.5 trillion in fiscal year 2014 (28). Of that, 86%, or about $3 trillion, was financed by tax revenue (income tax, payroll tax, corporate income tax, and other taxes). The rest came from borrowing. The federal spending breakdown is the following: Social Security, 24%; Medicare, Medicaid, CHIP, and marketplace subsidies, 24%; defense and international security, 18%; safety net programs, 11%; interest on debt, 7%; and other programs, 17%. The sources of federal tax revenue in 2014 were income tax, 46%; payroll tax, 34%; corporate income tax, 11%; and excise and estate taxes and others, 9%. Federal taxes are paid by 59% of American households; 41% of American households do not pay federal income tax. US charitable donations in 2013 totaled $335 billion, of which $241 billion was from individual donors. The largest charitable donations in 2013, namely $106 billion, went to religious groups, and $52 billion went to education institutions, most to 4-year colleges and universities. A survey of taxpayers receiving tax refunds this year indicated that 34% planned to use the money to pay down debt, another 33% to save the money or invest it, 26% for necessities, 3% for vacations or shopping, and 3% for other items. Thus, medicine accounts for nearly a quarter of our federal government's spending!

MORE ON THE AFFORDABLE CARE ACT

Scott W. Atlas, a physician and a senior fellow at Stanford University's Hoover Institution, writing in The Wall Street Journal, indicated that in 2013, 107 million people in the US were on Medicaid or Medicare, and that number will increase to 135 million by 2018, a growth rate tripling that of private insurance (29, 30). At the same time, private health care insurance premiums are expected to skyrocket in 2016, many by more than 30%. Private insurance, of course, is superior for both access and quality of care. Insurance without access to medical care is a sham, he argued, and that is where the country is heading. According to a 2014 Merritt Hawkins survey, 55% of physicians in major metropolitan areas in the US refuse new Medicaid patients. The harsh reality awaiting low-income Americans is dwindling access to quality physicians, hospitals, and health care. Simultaneously, while the population ages into Medicare eligibility, a significant and growing proportion of physicians do not accept Medicare patients. According to the nonpartisan Medicare Payment Advisory Commission, 29% of Medicare beneficiaries who were looking for a primary care physician in 2008 already had a problem finding one. Articles in several medical journals, including The American Journal of Cardiology, clearly show that patients with private insurance have better outcomes than similar patients on government insurance. It is highly likely, Dr. Atlas argued, that restrictions in access to important drugs, specialists, and technology account for these differences.

Of the many negative effects of the Affordable Care Act, the increasing unaffordability of private insurance might be the most damaging. Thanks to its regulations on pricing and coverage, the law has already forced termination of private health insurance for more than 5 million Americans. That is projected to be as many as 10 million by 2021, a tenfold increase from 2011 projections at the onset of the law. Atlas concluded that reforming America's health care rests on reducing costs while improving access to the best physicians and hospitals. That comes from private insurance, not government insurance.

SUNSCREENS VERSUS VITAMIN D

We all know how important sunscreen is to decrease exposure to the sun's ultraviolet radiation, which causes skin aging, wrinkling, and skin cancer. We also know that vitamin D, made in the skin from sun exposure, is vital for good health. According to Joe and Teresa Graedon, in places like Phoenix and Tampa, just 6 minutes of sun exposure midday offers enough ultraviolet for fair skin to make 1000 IU of vitamin D (31). These authors suggest that 15 to 20 minutes of sun without sunscreen several times a week allows a good production of vitamin D. After that, lather up with sunscreen.

PATIENT MODESTY

Patient modesty might seem like an oxymoron when those seeking medical care are routinely told to remove their clothes, put on a flimsy gown, lie back, and let the professionals do their work (32). To many people, everything about those instructions induces anxiety and sometimes anger. They fear the vulnerability that comes with it. They can't relax when they're ceding control over what is happening to them, and it's irrelevant that physicians and nurses have seen thousands of bare bottoms and private parts. I was surprised to learn that there is a website on Medical Patient Modesty (www.patientmodesty.org), a fledgling nonprofit based in North Carolina that offers emotional support and practical resources.

COMPETENCE OF OLDER PHYSICIANS

One of every four US physicians is now >65 years of age (33). In June 2015, the American Medical Association (AMA) adopted a plan to help decide when it's time for senior physicians to bring down their shingle. The nation's largest organization of physicians agreed to spearhead an effort to create competency guidelines for assessing whether older physicians remain able to provide safe and effective care for patients. Physicians, of course, have no mandatory retirement age, unlike pilots, military personnel, and a few other professions. Physicians must meet state licensing requirements, and some hospitals require age-based screening. But there are no national mandates or guidelines on how to make sure older physicians can still do their job safely. The AMA agreed it's time to change that view. The plan it adopted noted that US physicians aged ≥65 has quadrupled since 1975 and now number 240,000. The AMA agreed to convene groups to collaborate in developing preliminary assessment guidelines. The report says that “testing should include an evaluation of physical and mental health and a review of physicians' treatment of patients.”

ALCOHOL CONSUMPTION INCREASING

Average alcohol consumption in Europe, North America, and Northeast Asia is roughly 10 liters a year (34). That's the equivalent of 100 bottles of wine or 200 liters of beer (23.5 cases) for each person. Most of that consumption is accounted for by heavy drinkers. In the USA, 20% of drinkers account for three-fourths of alcohol consumed. Just over 4% of US deaths stem from alcohol use. In contrast, in Russia, it is 30%. Worldwide, alcohol use is responsible for 3.3 million deaths annually—more than HIV, tuberculosis, and violence combined. Between 1990 and 2010, alcohol rose from the eighth to the fifth leading cause of death. In 2006, the US Centers for Disease Control and Prevention (CDC) estimated that alcohol use costs the nation $223 billion, mostly for loss of productivity at work, but including $25 billion for direct medical expenses. In contrast, crime and justice costs were estimated at $38 billion. A 2013 study estimated the cost of alcohol abuse in Texas at $27 billion, or $703 for every resident. Federal officials in June 2015 reported a decline in teen binge drinking—having five drinks or more on one occasion within a month—between 2002 and 2013. The National Institutes of Health reported in June 2015 that as many as one-third of American adults have alcohol use disorder at some point in their lives. The Organization for Economic Cooperation and Development (OECD) in June 2015 found that alcohol taxes help discourage alcohol drinking. The US has the lowest taxes on alcohol among the OECD's 34 members, with an average of 14¢ per drink. Many studies on cigarette smoking have shown that higher taxes on a pack of cigarettes lead to lower smoking rates.

SNAKE BITES AND THEIR COSTS

In an average year in the USA, an estimated 7000 to 8000 people are bitten by poisonous snakes. The record rain in Texas in the springtime of 2015 pushed water out of the rivers and into people's homes and displaced snakes, which increased their biting opportunities. Joan Schulte, a pediatrician and public health service physician who works at the North Texas Poison Control Center at Parkland Health & Hospital System, writing in The Dallas Morning News in July 2015, detailed the experiences of several Texas victims of snake bites (35). One was a 65-year-old woman bitten by a rattlesnake. She was on Medicare. The federal government will pay up to $2493 per antivenom vial in the case of a snake bite. This particular woman received 18 vials at a cost of nearly $45,000. A 10-year-old girl put her arm on the railing of a bridge and immediately received a bite from a copperhead. Fortunately, she didn't need antivenom, which is the case in about 20% of those bitten by poisonous snakes in the US.

Why is the antivenom so expensive? The current version has been around 10 years and is considered more effective and safer than older antivenoms that were made with horse serum. A new antivenom, intended only for rattlesnake bites, was approved in spring 2015 by the FDA, and it may reduce prices when it becomes widely available in the next 2 years. The least expensive treatment is to avoid being bitten in the first place. If you are out in tall grass or hiking, wear real shoes, not flip-flops. Use a hiking stick and poke around before going into a weed bank. Don't get out of a boat in a muddy bank of water plants because cottonmouths and copperheads like that habitat. If you pick up firewood or rocks, first poke around with a long stick, and if you see a rattlesnake, don't try to pick it up to see if it really rattles.

PHARMAPHOBIA

Some physicians see pharmaceutical and device representatives frequently, and others do not see them at all. I favor physicians having good relations with pharmaceutical and device persons. I don't know any physician who has come up with a new drug in the past few decades. The new drugs come about through research almost entirely by the pharmaceutical industry. Dr. Thomas Stossel, who is the American Cancer Society Professor of Medicine at Harvard Medical School, a senior physician at Brigham and Women's Hospital in Boston, and a member of the National Academy of Sciences and the Institute of Medicine, has recently written a book entitled Pharmaphobia: How the Conflict of Interest Myth Undermines American Medical Innovation (36). He stated the following:

The case underlying the conflict-of-interest movement is a mixture of moralistic bullying, opinion unsupported by empiric evidence, speculation, simplistic and distorted interpretations of complicated and nuanced information, superficially and incompletely framed anecdotes, inappropriately extrapolated or irrelevant psychological research results, and emotionally laden human-interest stories.

The reality of modern medicine, Dr. Stossel argued, is that private industry is the engine of innovation, with productivity and new advances dependent on relationships between commercial and academic and research interests. Companies, not universities or research with federal funding, run 85% of the medical-products pipeline. “We all inevitably have conflicts all the time…. The only conflict-free situation is the grave,” he argued.

Dr. Stossel had much to say about the leading medical journals, which he called “mere magazine, not holy scripture.” He pointed out the irony that most peer-reviewed studies could never survive the FDA's withering scrutiny, yet they are usually taken to be more rigorous and disinterested than the clinical trial data that drug makers generate for FDA approval. The medical journals maintain their prestige and brands by creating false scarcity and rejecting original and high-quality papers.

The New England Journal of Medicine, possibly the world's most influential medical periodical, in the spring of 2015 had a three-part series by a physician and correspondent, Liza Rosenbaum, encouraging a rethink of the conflict-of-interest doctrine, introduced with a piece by editor Jeffrey Drazen (37). Dr. Rosenbaum's measured, thoughtful essays called for a more rational approach to managing conflicts and “to shift the conversations away from one driven by indignation toward one that better accounts for the diversity of interactions, the attendant trade-offs, and our dependence on industry in advancing patient care.”

MEDICAL EMERGENCY WHEN TRAVELING ABROAD

Though many travelers take important steps against infectious disease, including vaccinations, malaria pills, and diarrhea remedies, often overlooked are other physical dangers (38). From July 2013 to June 2014, a total of 802 US citizens died in foreign countries from “nonnatural” causes: vehicular accidents, 213; homicide, 184; suicide, 134; drowning, 108; drug related, 20; aviation, 18; terrorism, 13; maritime, 10; and all other, 102. A sudden catastrophic illness when traveling abroad might warrant prior membership in one of the transportation companies that provide flights back to the US. Global Rescue Grid membership, for example, based on trip length and the extent of services, starts at $119 for 7-day trips, and annual membership starts at $329 for an individual and not quite double that for a family. Other companies also offer travel evacuation and medical assistance services when abroad, including MedjetAssist and Medex. The CDC and the State Department offer free travel websites and apps to help travelers assess health and security risks when abroad. The CDC's TravWell includes destination-specific recommendations, checklists, and packing lists. It also has an app that lets users search for health risks by country and food type, called “Can I Eat This?” CDC's Health Information for International Travel—also known as the Yellow Book (because of the color of the cover)—is primarily aimed at health professionals who advise patients about travel risks, but it can also help consumers. The State Department offers “Smart Traveler,” an app with frequently updated country information, travel alerts, warnings, maps, and US Embassy locations.

PATIENT-PARTICIPATING HEALTH CARE

Scott Burns in The Dallas Morning News recently had a piece on wearable devices that provide some inkling of our bodily functions (39). He mentioned the Tricorder v1.0, which costs about $150, much less expensive than the iWatch. He mentioned the Fitbit Charge HR, part of a new wave of health and fitness tools, that records heart rate from the wrist. Press a button on the band once and it tells the time, press again and it tells the total steps you've taken today, press it once more and the heart rate appears. Since the band detects motion, the FitBit app also tells how long one has slept and how often the sleep was restless or awake. It calculates resting heart rate, total calories burned for the day, and time spent in “fat burn” heart rate. One can enter the food eaten screen and watch the balance between calories ingested and calories burned. (He mentioned that dancing for 2 hours is the best calorie burner for him.) Another company, AliveCor, makes a tiny $75 device that will do a 30-second electrocardiogram any time you want it. At the end of 30 seconds, an algorithm reviews the reading and identifies atrial fibrillation if you have it. If it is atrial fibrillation, you can make notes on the condition that might have induced it. The device comes with an adhesive back so you can attach it to your smartphone, and then an email of your electrocardiogram, from the app, can be sent to your physician. He also mentioned the Stroke Riskometer app, which provides Framingham Heart Study risks of stroke. All of this, of course, will create a whole new mode of health research: medical data crowd sourcing. It will also build a world of participant patients rather than passive patients.

FRUGAL PHYSICIANS

Thomas J. Stanley and William D. Danko published in 1996 The Millionaire Next Door: The Surprising Secrets of America's Wealthy (40). Stanley, who obtained his PhD in economics from the University of Georgia and was a professor for many years at Georgia State University in Atlanta, was killed earlier this year in an automobile accident near his home in Marietta, Georgia (41). He and Danko interviewed hundreds of low-profile millionaires. They wrote: “Wealth is not the same as income. If you make a good income each year and spend it all, you are not getting wealthier. You are just living high. Wealth is what you accumulate, not what you spend.”

According to the two authors, there are a lot of rich pretenders. They spend on prestige products and services but are two or maybe even one paycheck away from financial disaster. Typical millionaire couples don't buy clothes at upscale stores. They don't swap cars frequently. Many don't live in upscale neighborhoods. They live below their means. Warren Buffett apparently said that the best way to accumulate wealth is not to have a divorce and/or to have a frugal spouse. Physicians who are living on the edge—spending what they bring in—may be more prone to order that expensive test for their patient or perform that procedure or operation if in a bit of financial trouble. Herb Shriner stated: “Our doctor would never really operate unless it was necessary. He was just that way. If he didn't need the money, he wouldn't lay a hand on you.”

BIG TOBACCO AND MARIJUANA

Tobacco companies for generations have talked privately about getting into the weed business (42). In the summer of 2014, researchers pouring through millions of pages of previously secret tobacco industry documents found that big tobacco has long had an interest in pot. Since at least the 1970s, the tobacco companies have been interested in marijuana and marijuana legalization as both a potential and a rival product. As public opinion shifted and government relaxed laws pertaining to marijuana criminalization, the tobacco companies modified their corporate planning strategies to prepare for future consumer demand. In many ways, the marijuana market of 2014 resembles the tobacco market before 1880, before cigarettes were mass-produced and marketed. According to Trevor Hughes, writing in USA Today, the legalization of marijuana opens the market to major corporations, which have the financial resources and product design technology to transform the marijuana market. Stay tuned!

MARRIAGE DECLINING

According to the Pew Research Center, 72% of Americans aged 18 years or older were married in 1960, and in 2015 the percentage was down to 50% (43). As someone indicated, “Marriage takes four ‘C's’: companionship, communication, cooperation, and commitment.” All of this may be too much for some today.

INCOME OF DALLAS LAWYERS

Of the 29 law firms with operations in Texas, most provided financial data to The Texas Lawbook (44). Six of the law firms, which included 981 lawyers, had an average revenue per lawyer of over $1 million annually, including two with revenues >$1,240,000/lawyer annually. The other 23 firms had revenue per lawyer ranging from $489,000 annually to $999,000 annually. Most of the public, I suspect, believe that physicians make a lot of money, but I can assure you that very few practicing physicians in the USA make incomes approaching the average of these law firms. Only a handful of physicians make $1 million a year in Dallas. The list compiled by The Dallas Morning News did not include all law firms because some declined to provide any financial information. If one needs a lawyer, too often it is very difficult to increase one's total worth.

INCOME VARIABILITY BY REGIONS

Jo Craven McGinty described regional differences in cost that affect how far a dollar will stretch and shape how people in different parts of the country can achieve their goals (45). The basic aspirations of the middle class seem simple: earn enough to purchase a home; sock away a sufficient amount for retirement; cover the cost of the children's education; have one or two family trips each year. Although there are vast differences in how far a dollar will go in various parts of the country, top earners are classified by the federal government as individuals who make more than $200,000 a year or households bringing in >$250,000 annually, irrespective of where they live. The cost for goods and services in different metropolitan areas varies by as much as 40%, and the disparity in rents is even greater. Until recently, data on relative purchasing power have not been readily available. In 2014, for the first time, the US Bureau of Economic Analysis published differences in the cost of goods and services across states and metropolitan areas. The results illustrate stark regional differences in purchasing power, and they help explain why some top earners don't feel rich and why some in the middle class feel especially strapped for cash.

The Bureau calculated the average prices paid by consumers for more than 200 different goods and services divided into categories including apparel; education; food; housing expenses, such as utilities and furniture; medical costs; recreation; transportation; and rents, which also included costs for homeowners. The percentage difference from the national average in prices for goods and services, including shelter, in 2012 varied from +18% in the District of Columbia to −14% in Mississippi. Hawaii was the next most expensive followed by New York, New Jersey, California, Maryland, Connecticut, Massachusetts, Alaska, New Hampshire, Virginia, Washington, Delaware, Colorado, Vermont, and Illinois. The remaining states were below average. Texas was 3.5% below average and 10th among the 35 states below average. The spread among all the states and the District of Columbia was nearly 32%, and the range in rents was even wider, varying by almost 97%. Hawaii's rents were 59% more than the national average; Mississippi had the least expensive rents, 38% below the national average. If the national average was $1000, someone in Mississippi would pay $621 and someone in Hawaii would pay $1590 for the same type of dwelling. Such disparities may also occur within the same state. These differences show why it is so difficult to pin down a definition for the middle class that feels right to all Americans. One size does not fit all.

RELIGIOUS SHIFTS

The present size and projected growth of religious groups, as a percentage of the world's population, will change considerably from 2010 to 2050 (46) (Figure). Presently, Christians make up about 31% of the world's population and Muslims, about 23%. From 2010 until 2050, the Muslim population around the world is expected to increase by about 73%; the Christian population, 35%; Hindu, 34%; Jewish, 16%; folk religions, 11%; unaffiliated, 9%; other religions, 6%; and Buddhism, −0.3%. The world population during these 40 years is expected to increase about 35%.

Figure. Size and projected growth of religious groups, as a percentage of the world's population, in 2010 and 2050. Data from Zoroya, USA Today (46).

GLOBAL GARBAGE

In an accounting of global garbage, researchers in the US and Australia, led by Jenna Jambeck, an environmental engineer at the University of Georgia, calculated the share that each of 192 countries could have contributed to plastic waste in the oceans (47). Dr. Jambeck and her colleagues calculated that people living within 30 miles of the coast in these countries generated a total of 275 million metric tons of plastic waste in 2010. A small but alarming fraction of it—between 4.8 million and 12.7 million tons of discarded bottles, bags, straws, packaging, and other items—ended up in the oceans. If the amount of plastic waste fouling the seas remains unchecked, they predicted that it may double by 2025, reaching levels “equal to 10 bags full of plastic per foot of coastline.” The worst offender was China. Its coastal population generated 8.82 million metric tons of mismanaged plastic waste in 2010, about 28% of the world's total; of that, between 1.32 and 3.53 million metric tons ended up as marine debris. Indonesia, the world's fourth most populous nation, generated about 3.22 million tons of mismanaged plastic waste in 2010, about 10% of the world's total; of that, between 0.48 and 1.29 million metric tons ended up as marine waste. Thus, China and Indonesia alone account for more than one-third of the plastic bottles, bags, and other detritus washed out to sea. The US, ranked 20th, was responsible for just under 1% of the mismanaged plastic waste. Good for us!

DROUGHT IN THREE CONTINENTS

California is experiencing its worst drought in 40 years, and it has brought unprecedented water shortages, increased threats to wildlife and crops, higher electric bills, and huge economic losses. Brazil is experiencing its worst drought in 50 years, and it is impacting a fifth of Brazil's 200 million people, including those of the megacities of São Paolo and Rio de Janeiro. Additionally, water in Brazilian cities and reservoirs is extremely polluted. In Brazil, wastewater is not treated but just dumped into rivers. South Africa is experiencing its worst drought in 20 years. Food production for much of Central and Southern Africa is likely to be lower in 2015 than last year because of the drought. Water shortages have reached crisis levels in some of South Africa's eastern provinces. North Korea is said to be undergoing its worst drought in 100 years. Deaths of young children increased markedly in the first 6 months of the year in the drought-affected provinces. The country is experiencing electric shortages because of the drought and is reducing its hydroelectric generation capacity. Of all of the countries in the world, North Korea may be the one least capable of dealing with drought (48).

William Clifford Roberts, MD
August 11, 2015