Facts and ideas from anywhere.
Article Type: Reprint
Author: Roberts, William Clifford
Pub Date: 04/01/2012
Publication: Name: Baylor University Medical Center Proceedings Publisher: The Baylor University Medical Center Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 The Baylor University Medical Center ISSN: 0899-8280
Issue: Date: April, 2012 Source Volume: 25 Source Issue: 2
Accession Number: 306359155

Benjamin Franklin stated in his Poor Richard's Almanac, "When the well is dry we learn the worth of water" (1). Steven Solomon, in his book entitled Water: The Epic Struggle for Wealth, Power and Civilization, stated that "water is overtaking oil as the world's scarcest critical natural resource" (2). He indicated that oil is substitutable, albeit painfully, by other fuel sources, or in extremis can be done without, but water's uses are pervasive, irreplaceable by any other substance, and indispensable. In his 2010 book he provides numerous observations, some of which are the following.

There is hardly an accessible freshwater source or a strategically placed waterway in an economically advanced part of the planet that has not been radically engineered by man. As the world population moves toward 9 million and with so many third world inhabitants moving toward consumption and waste-generation levels of the one fifth living in industrialized nations, demand for more fresh water is soaring. Yet no new breakthrough capable of expanding the usable water supply is anywhere evident.

Water scarcity is cleaving an explosive fault line between fresh water-haves and have-nots: among relatively well-watered industrial world citizens and those of water-famished developing countries; among those upriver who control river flows and their neighbors downstream whose survival depends upon receiving a sufficient amount; and among those nations with enough agricultural water to be self-sufficient in food and those dependent upon foreign imports to feed their populations. The new fresh water fault line is fomenting a more divisive competition among interest groups and regions for a greater allocation of limited domestic water resources: between heavily subsidized farmers on the one side and nonsubsidized industrial and urban users on the other; between the well-healed situated within close proximity to fresh water sources and the rural and urban poor remote from water sources; between those able to pay the top price for abundant, wholesome drinking water and the water destitute who glean the dredges; between those who dwell in locations with effective pollution regulations, modern wastewater treatment, and sanitation facilities, and those whose daily lives are contaminated by exposure to impure, disease-plagued water; between the privileged minority living in the planet's relatively well-watered and forested temporal zones and the largest part of the human race living on water-fragile dry lands, oversaturated tropics, or more exposed to the costly unpredictability of extreme precipitation that causes floods, mudslides, and droughts.

Every day across the planet, armies of the water poor, mainly women and children compelled by thirst to forego school and productive work, march barefoot 2 or 3 hours per day transporting water in heavy plastic containers from the nearest clear source for their barest household survivor needs--some 200 pounds per day for a four-person household. This portion of humanity includes over 1.1 billion people, almost one fifth of all humanity, who lack access to at least a gallon per day of safe water to drink. Some 2.6 billion, 2 out of 5 people on earth, are sanitary have-nots lacking the additional 5 gallons needed daily for rudimentary sanitation and hygiene. Far fewer still achieve the minimum threshold of 13 gallons per day for both basic domestic health and well-being, including water for bathing and cooking. The lives of the most abject of water have-nots are chronically afflicted and shortened by diarrhea, dysentery, malaria, dengue fever, schistosomiasis, cholera, and the other conditions that make waterborne diseases human beings' most prevalent scourge. Half the people in the developing world of Africa, Asia, Latin America, and the Caribbean suffer from diseases associated with inadequate fresh water and sanitation. This side of the humanitarian divide includes the 2 billion human beings whose lives are uprooted catastrophically every decade from inadequate public infrastructure protection from water shocks. By contrast, on the water-have side of the humanitarian divide, industrialized-world citizens use 10 to 30 times more water than their poorest, developing nation counterparts. In the water-wealthy USA, each person uses an average of 150 gallons of water per day for domestic and municipal purposes, including such extravagances as multiple toilet flushes and lawn watering.

Water rationing is increasingly commonplace in water have-not societies. So too are internecine conflicts and violent protests over scare supplies and high prices. Inadequate water supply commonly manifests itself in the form of insufficient food output, stunted industrial development, and a shortage of energy, which requires copious volumes of water for cooling and power generation. Chronic water scarcity undercuts the political legitimacy of governments, fomenting social instability and failed states. Water rights, bombings, deaths, and other violent warning signs occurred from 1999 to 2005 in conflicts over water in Karachi, Pakistan, in Gujarat, India, in provinces of arid North China, in Cochabamba, Bolivia, between Kenyan tribes, among Somalian villages, and in Darfur, Sudan. The wars in the last century were often about oil; in this century, water.

Up to half the world's wetlands disappeared or were severely damaged in the 20th century's drive to obtain more arable land and fresh water for agriculture. Worldwide expansion of irrigable farmland is now peaking for the first time in history. Mankind's withdrawal of useable, renewable fresh water from the surface of the planet is expected to rise about 60% by 2025!

In the first decade of the 21st century, an increasing number of nations were so critically water stressed that they could no longer grow all the crops they needed to feed and clothe their populations. Growing crops is a water-intensive enterprise: about three quarters of mankind's water is used for farm irrigation. Food itself is mainly water. To produce a single pound of wheat requires half a ton or nearly 250 gallons of water; a pound of rice needs between 250 and 650 gallons. Livestock for meat and milk multiplies the water requirements since the animals have to be nourished with huge quantities of grain; up to 800 gallons or over 3 tons of water is needed to produce a single hamburger and some 200 gallons for a glass of cow's milk. A well-nourished person consumes about 900 gallons of water each day in the food he or she eats. Production of an ordinary cotton t-shirt requires about 700 gallons of water.

As water-poor countries fall short of self-sufficiency, they are growing increasingly dependent upon importing grain and other foods from water-wealthier farming nations. By 2025, up to 3.6 billion people in some of the driest, most densely populated and poorer parts of the Middle East, Africa, and Asia will live in countries that cannot feed themselves. The growing bifurcation between water-poor food importers and water-rich exporters is further exacerbated by manmade ruination of crop land from soil erosion and polluting runoff. The upward spiraling international food prices as the era of cheap water and cheap food comes to an end is already causing grave consequences. What is needed is a new Green Revolution, perhaps including the development of genetically modified plant hybrids that grow with less water.

Man's access to this renewable fresh water supply is limited to a maximum of one third, since about two thirds quickly disappears in floods and into the ground, ultimately returning to the sea. Even so, that one third totals enough available renewable water to more than suffice for the planet's 7 billion people if it were distributed evenly. But it is not. A large share runs off unused in lightly inhabited jungle rivers like the Amazon, the Congo, and the Orinoco, and across Russia's Siberian expanses toward the Arctic, in the giant Yenisei and Lena Rivers. Thus, the amount of readily available fresh water per person is less than the threshold annual 2000 cubic meter measure of water sufficiency. And it is declining sharply as the world population increases. Hot climates suffer much higher losses from evaporation than cool, temperate ones. In Africa, only one fifth of all rainfall transforms into potentially utilized runoff.

Thus, each region's actual water challenge varies enormously by environment, availability, and the population it has to support. Australia, by far the driest continent, has only 5% of the world's runoff, but it supports the smallest human population--a mere 20 million, or less than one half of 1% of the world's population. Asia, the largest continent, receives the most renewable water, about one third of the total. Nonetheless, it is the most water-stressed continent because it has to meet the needs of three fifths of humanity, contains some of the world's arid expanses, and receives over three quarters of its precipitation in the form of hard-to-capture seasonal monsoons. The water-richest continent is South America, with 28% of the world's renewable water and only 6% of its population. On a per-person basis, it receives 10 times as much fresh water each year as Asia and 5 times as much as Africa. Yet most of it flows away unused through jungle watersheds, while some high desert regions remain bone dry. North America is water wealthy, with 18% of the world's runoff and 8% of its population. Europe has only 7% of the world's water for its 12% share of population, but it is comparatively advantaged in its wet, northern, and central half because much of its water falls year round, evaporates slowly, and runs off in easily accessible navigable small rivers.

The planet's dry lands, encompassing one third of humanity, or over 2 billion people, have only 8% of the world's renewable supply of water in their surface streams and fast-recharging ground water tables. More than 90% of the dry-land inhabitants live in developing nations, making water famine one of the key vexing challenges of international economic development. It is hardly surprising that the vast dry land belt stretching from North Africa and the Middle East to the Indus Valley is also one of the world's politically volatile regions. At the other end of the spectrum are super water-have countries such as Brazil, Russia, Canada, Panama, and Nicaragua, with far more water than their populations can ever use. The USA and China have large hydrological imbalances: the modestly populated American far west feels constraints on its rapid growth, and the fertile northern plain of China is one of the most severely water-scarce, environmentally challenged regions on earth. India's huge population is outstripping the highly inefficient management of its fresh water resources, forcing farmers, industry, and households to pump ground water faster and deeper than prudent. Western European nations have managed successfully because they use their limited water resources more productively, using a higher proportion for industry and cities and less for agriculture.

Because water is so heavy and needed in such vast quantities, chronic shortages cannot be permanently relieved by transporting it over long distances. One reliable indicator of water wealth is the amount of water storage capacity each nation has installed per person to buffer it against natural shocks. The storage leaders are the world's wealthiest nations, while the poorest remain most exposed to the natural caprices of water.

Despite its growing scarcity and preciousness to life, water is also man's most misgoverned, inefficiently allocated, and profligately wasted natural resource in both democracies and authoritarian states. Modern governments routinely maintain monopolistic control over their nation's supply, pricing, and allocation; commonly, water is distributed as a social good, a political largesse to favored interest groups and to public projects. Governments treat water as if it were a limitless gift of nature to be freely dispensed by any authority with the power to exploit it. In contrast to oil, and nearly every other natural commodity, water is largely exempted from market discipline. Rarely is any inherent value ascribed to the water itself. Only the cost of capturing and distributing it is routinely accounted. Nor is any cost ascribed to the degradation of the water ecosystem from whence it comes and to which, often in a polluted condition, it ultimately returns. By belonging to everyone and being the responsibility of no one, water for most of history has been consumed greedily and polluted recklessly.

The result, compounded over time, is a colossal underpricing of water's full economic and environmental worth. This fact sends an insidious, illusionary economic signal that water supply is endlessly plentiful, promoting wasteful use. Man's most egregious waste of water came from the distortions caused by the chronic underpricing of water for irrigation. Irrigation farmers in Mexico, Indonesia, and Pakistan paid little more than 10% of the full cost of their water. Because Islamic tradition held that water should be free, many Muslim countries charge little or nothing for it. American government dam water subsidies were grandfathered upon a small number of farmers who cultivated a quarter of the irrigated crop land in the arid lands of the west. Inefficient flood irrigation is still subsidized in many water-poor regions. Underpriced water is also a disincentive to urban conservation. Through leaky infrastructure, thirsty Mexico City loses enough water every day--some two fifths of its total supply--to meet the needs of a city as large as Rome. The world faces a trillion-dollar-plus water infrastructure deficit in the years immediately ahead just to patch the leaks!

Water's peculiar treatment economically was contemplated in the 18th century by Adam Smith. In his Wealth of Nations, he pondered, "Nothing is more useful than water; but it will purchase scarce anything; scarce anything can be had in exchange for it." Why was water, despite being invaluable to life, so cheap, while diamonds, though relatively useless, so expensive? Smith's answer was that water is ubiquity and the relatively easy labor required to obtain it accounted for its low price. His theory was superseded within mainstream economics in the late 19th century by a more refined explanation. Water's price was determined by a sliding scale based on its availability for its least valued uses: watering lawns, filling swimming pools, quenching the thirst of wildlife. Its premium rose as it became scarce for its most precious uses, reaching its zenith as priceless drinking water. The worth of water is now rising and to reflect Smith's original observation, nothing is more useful.

Bottled water is the world's fastest growing beverage, with annual global sales of over $100 billion, increasing at 10% per year and reaching handsome profits for several corporate giants (Nestle, Coca-Cola, and Pepsi-Cola). The markup is 1700 times over the cost of public tap water. Privatized management of water utilities is another huge global sector, as is wastewater services, dominated by corporate multinationals. In total, water is a fast-growing, highly fragmented, competitive $400 billion per year industry. Subjecting water to market forces has enormous capacity to stimulate badly needed efficiency gains and innovations. But water is too precious to human life and too politically explosive to be left to the merciless logic of market forces alone.

Water scarcity requires nothing less than a comprehensive reevaluation of water's vital importance as the new oil--a precious resource that has to be consciously conserved, efficiently used, and properly accounted for on the balance sheet: from public health, food production, and energy production to national security and the sustainability of the human civilization.

Turn off the faucet!


A June 2011 article in Pediatrics warned that "stimulant-containing energy drinks have no place in the diets of children or adolescents" (3). In October 2011, the National Federation of State High School Associations cautioned that caffeinated energy drinks--often confused with such products as Gatorade, a fluid replacement drink--should not be consumed before, during, or after physical activity because they could raise the risk of dehydration and increase the chance of potentially fatal heart illnesses. The organization also warned of possible interactions with prescription medications, including stimulants used to treat attention-deficit hyperactivity disorder.

The energy drink business is now a $7.7 billion industry. Most best-selling energy drinks (Monster, Red Bull, and Rockstar) contain about 80 mg of caffeine per 8 oz, though they are often sold in containers as large as 20 to 24 oz (Table 1). Other more extreme products abound, some of them in mix-your-own powders or concentrates, in strengths researchers say range from about 50 to 500 mg per serving. At their maximum strength, energy drinks contain about 300 mg more than the 2-oz shots of 5-Hour Energy frequently seen near checkout counters. A 16-oz can of the top-selling energy drinks contain about 160 mg of caffeine. A 16-oz cup of Starbucks' robust Pike Place Roast contains 330 mg. Some researchers have complained that identifying caffeine content and other ingredients is difficult for consumers because US Food and Drug Administration (FDA) regulations do not require products marketed as dietary supplements--as many energy drinks are--to adhere to the same labeling requirements as food and beverages. Canada, in November 2011, moved to limit caffeine in energy drinks to no more than 180 mg in containers up to 20 ounces. In the USA, cola-type drinks are limited by the FDA to 71 mg of caffeine per 12-oz serving. But no such limit applies to energy drinks marketed as dietary supplements, and manufacturers are not required to list the caffeine content or all ingredients on the label, sometimes opting for the term "energy blend" or "proprietary blend."

Additives, including the herbal supplements guarana, green tea, and yerba mate, can boost the effective level of caffeine. Less common additives such as yohimbine and bitter orange can increase heart rate, cause changes in blood pressure, and interact with certain antidepressive medications, according to the National Institutes of Health. Monster, the US leader in sales, does not list the amount of caffeine on its can, although independent sources place it at about 80 mg per 8-oz container, or 240 in Monster's 24-oz can. So far the FDA has not acted on petitions by academics and other experts to limit caffeine or change labeling requirements for energy drinks.

Emergency room visits associated with energy drink use increased more than 10-fold, from 1128 in 2005 to 13,114 in 2009, according to a report released in November 2011 by the federal government's Substance Abuse and Mental Health Services Administration; in 44% of visits, patients combined energy drinks with other substances such as alcohol, pharmaceuticals, or illicit drugs. Most adverse reactions were in those who consumed two to eight energy drinks or >200 mg of caffeine. A report from the Mayo Clinic by Higgins and colleagues (4) listed the side effects of these energy drinks as insomnia, nervousness, nausea, rapid heartbeat, and in rare cases seizures, cardiac arrhythmias, and cardiac arrest.


Each year the American Cancer Society estimates the numbers of new cancer cases and deaths expected in the USA in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on data from the National Cancer Institute, the Centers for Disease Control and Prevention (CDC), the North American Association of Central Cancer Registries, and the National Center for Health Statistics (5). A total of 1,638,910 new cancer cases and 577,190 deaths from cancer are projected to occur in the USA in 2012 (Table 2).

During the most recent 5 years for which there is data (2004-2008), overall cancer incident rates declined slightly in men (by 0.6% per year) and were stable in women, while cancer death rates decreased by 1.8% per year in men and by 1.6% per year in women. Over the past 10 years (1999-2008), cancer death rates have declined by >1% per year in men and women of every racial/ethnic group with the exception of American Indians/Alaskan Natives, among whom rates have remained stable. The most rapid declines in death rates occurred among African American and Hispanic men (2.4% and 2.3% per year, respectively). Death rates continue to decline for all four major cancer sites (lung, colorectal, breast, and prostate gland), with lung cancer accounting for almost 40% of the total decline in men and breast cancer accounting for 34% of the total decline in women. The reduction in overall cancer death rates since 1990 in men and since 1991 in women translates to the avoidance of about 1,024,400 deaths from cancer.

Nevertheless, cancer is still the second leading cause of death in the USA behind heart disease. About 1 in 2 men and 1 in 3 women develop cancer during their lifetimes. The reduction in breast cancer deaths has been attributed to the decreased use of hormone replacement therapy, to earlier detection, and to better treatments. Both colonoscopy screening and mammography screening rates are higher than they were a year ago. Although the frequency of cancer in general is decreasing, seven cancers are increasing: mouth and throat cancers caused by human papillomavirus, the same virus that causes cervical cancer; esophageal adenocarcinoma, which is linked to chronic acid reflux, obesity, and smoking; melanoma, caused by exposure to ultraviolet radiation from the sun and tanning beds; liver cancer, which may be related in part to increases in hepatitis B and C infections; thyroid cancer, for unknown reasons, but maybe because of better detection; kidney cancer, which may be related to rising obesity; and pancreatic cancer, which is linked to smoking, obesity, and family history. Thus, preventing obesity will decrease the frequency of cancers of the esophagus, liver, kidney, and pancreas. Another reason to lose weight.


According to a January 2012 report from the CDC, 1 in 6 adults in the USA is a binge drinker, consuming an average of eight drinks per occasion and doing so four times a month (6). The risky behavior exists in all states, causing more than half of the 80,000 deaths and three quarters of the $23 billion in economic cost. Most alcohol-impaired drivers binge drink. Binge drinking means men drinking [greater than or equal to] 5 drinks within a short period of time and women drinking [greater than or equal to] 4 drinks. The authors analyzed self-reported data collected during 2010 of US adults aged >18 in 48 states and in the District of Columbia. The prevalence was twice as likely in men (23%) than women (11%). The highest prevalence of binge drinking was among those aged 18 to 34 years. The highest frequency was among the 65+ group. Those with an income of >$75,000 annually were more likely to binge drink. Those with an income of <$25,000 annually did it most often and drank the most per binge. Most people, however, who binge drink are not alcoholics.


A survey by the American Psychological Association (APA) indicates that the average stress level in the USA in 2011 was 5.2 on a 10-point scale, down from 6.2 in 2007 (7). Among those surveyed, 39% indicated that their stress rose in 2011, 17% said it dropped, and 44% said it stayed the same. According to the APA, until 2011, stress has been rising each year since 2007. The newest survey involved 1226 adults aged 18 and older. Those reporting extreme stress, grade 8, 9, or 10, dropped from 32% to 22%, and 27% of adults said their stress had decreased in the past 5 years. Better economic conditions may be the explanation, because the 10 top causes of stress are money, work, the economy, relationships, family responsibilities, family health, personal health, job stability, housing costs (mortgage or rent), and personal safety. The APA also has recommendations to handle stress: take a break, exercise, laugh, get support, and meditate. Of these, the most successfully used stress management tool is exercise. The APA survey found that adults aged 18 to 32 (the so-called "Millennials") are less likely than older adults to feel stressed by the economy. Unlike older adults who have watched their nest eggs disappear, younger people have been most affected by the downturn's impact on jobs.


Compassion fatigue is a combination of burnout and secondary traumatic stress from witnessing the suffering of others. The group that is affected the most is nurses, and compassion fatigue can lead to a feeling of sadness and despair that affects their health and well-being (8) (Table 3). A number of hospitals are tackling the problem in the midst of a worsening shortage of nurses. Compassion fatigue has been linked to decreased productivity, lessened empathy, more sick days, and higher turnover, particularly among cancer-care providers.

A study led by the University of Nevada's nursing school in Reno found that about 12% of US registered nurses were not working. Of those, more than 25% cited burnout or stressful work environments. The high turnover increases the workload on remaining nurses, and that can result in higher death rates and lessened patient safety. Compassion fatigue was identified as a special problem for nurses in the early 1990s. The New York State Nurses Association conducted its first compassion-fatigue workshop at a hospital last year and is urging hospitals and nursing schools to offer such programs.


It's a common complaint: fly on a crowded airplane and come home with a cold. Air travelers suffer higher rates of infection than do non--air travelers. A reported number is 20% (9). Air that is recirculated through the cabin is most often blamed. But studies have shown that high-efficiency particulate air filters on most jets today capture 99.97% of bacterial and virus-carrying particles. When air circulation, however, is shut down, which sometimes happens during long waits on the ground or for short periods when passengers are boarding or exiting, infections can spread rapidly. A study in 1979 found that when a plane sat 3 hours with its engines off and no air circulating, 72% of the 54 passengers on board got sick within 2 days. The flu strain they had was traced to one passenger. For that reason, the Federal Aviation Administration issued an advisory to airlines in 2003 saying that passengers should be removed from planes within 30 minutes if there is no air circulating, but compliance is not mandatory. Much of the danger comes from the mouths, noses, and hands of passengers sitting nearby. The "hot zone" for exposure is generally two seats beside, in front of, and behind, according to a study in the July 2011 issue of Emerging Infectious Diseases, published by the CDC.

A number of factors increase the odds of bringing home a cold from an airplane. The environment at 30,000 feet enables easier spread of disease. Air in airplanes is extremely dry, and viruses tend to thrive in low-humidity conditions. When mucus membranes dry up, they are far less effective at blocking infection. High altitudes also tire the body, and fatigue plays a role in making people more susceptible to catching colds. Also, viruses and bacteria can live for hours on some surfaces; some viral particles have been found to be active up to a day in certain places. Tray tables can be contaminated, and seatback pockets, which get stuffed with used tissues, soiled napkins, and trash, can be particularly dangerous. It is also difficult to know what germs are lurking on airline pillows and blankets.

There are some basic precautions passengers can take to keep coughs away. 1) Hydrate: drinking water and keeping nasal passages moist can reduce the risk of infection. 2) Keep hands clean: frequently use an alcohol-based hand sanitizer. We often infect ourselves, touching mouth, nose, or eyes with our own hands that have picked up something. 3) Use disinfectant wipes to clean off tray tables before using. 4) Avoid seatback pockets. 5) Open the air vent and aim it so it passes just in front of your face. Filtered airplane air can help direct airborne contagions away from you. 6) Change seats if you end up near a cougher, sneezer, or someone who looks feverish. 7) Inform the crew if air circulation is shut off for an extended period. 8) Avoid airline pillows and blankets.

Fortunately, most people sitting near someone who is ill do not get sick.


According to a 2007 study in the Journal of the American Diabetic Association, 86% of the estimated 3.2 million truck drivers in the USA are overweight, and most are obese (10). The US Transportation Department requires truck drivers to pass a certifying medical exam every 2 years. Drivers are checked for severe heart conditions, high blood pressure, and respiratory maladies, including sleep disorders. The results are bleak. Driving is a sedentary activity. Most truckers are paid by the mile, so they tend to squeeze every minute out of the 11 hours they are allowed on the road in a 24-hour period. Recently, transportation carriers, industry organizations, and even truck stops are unrolling initiatives to help truckers slim down, shape up, and improve their health. Employers are holding health seminars, building on-site gyms, bringing in nutritionists and fitness trainers, and offering financial incentives to employees who stop smoking or lose weight. Some drivers are cooking in their rigs, walking or biking around truck stops, and blogging about their experiences at sites like truckingsolutionsgroup.org and safetythruwellness.com.


Rajaratnam and colleagues (11) from Boston screened 4957 North American police officers who participated in either an online or an onsite screening and monthly follow-up surveys between July 2005 and December 2007, and 40% screened positive for at least one sleep disorder: 1666 (34%) for obstructive sleep apnea, 281 (6%) for moderate to severe insomnia, and 269 (5%) for shift work disorder. Respondents who screened positive for any sleep disorder had an increased prevalence of physical and mental health conditions, including diabetes mellitus, depression, and cardiovascular disease. Police officers need to be awake.


The US Medicare system recently announced that it will cover intensive behavioral counseling for willing participants with a body mass index of >30 kg/m2. The plan, expected to cover more than 30% of the Medicare population, will mean 6 months of in-person therapy, extending to 12 months if the beneficiary has successfully lost 3 kg.


Sherman and associates (12) from Seattle, Washington, and Portland, Oregon, designed a trial to determine whether yoga is more effective than conventional stretching exercises or a self-care book for patients with chronic low back pain. A total of 228 adults with chronic low back pain were randomized to 12 weekly classes of yoga, conventional stretching exercises, or a self-care book. Back-related functional status and bothersomeness of pain at 12 weeks were the primary outcomes. At both 12 weeks and 26 weeks, the outcomes for the yoga group were superior to those of the self-care group but not superior to conventional stretching exercises at any time point. Keep stretching and moving.


As the baby boomer generation grows older, the average life expectancy also increases. In the USA, life expectancy in 2008, the last year available, was 78.1 years. The number of people living in nursing homes nationwide has dropped in the last decade as other services--such as home health care and assisted living--have become more readily available (13). In 2000, 1.72 million lived in nursing homes in the US, and that had dropped to 1.5 million by 2010. Daily rates for rooms in private nursing homes vary across the continental US from <$200 to >$350 per day. The average in Texas is $188 per day and in Alaska, $655 per day. The hourly cost of hiring a home health aide across the US varies from $15 to $30 daily. In Texas, the average is $18. Adult day care centers in the US range from $40 to >$100 per day; in Texas the average is $40 per day.

Who should consider a long-term care insurance policy? Not the wealthy. Not those of modest means who qualify for Medicare. It is those in between, where paying long-term care expenses would impoverish the spouse. Many people believe Medicare covers long-term care, but generally it does not. One must meet certain conditions for Medicare to pay for these types of care. People are staying in assisted living facilities for a lot longer than in the past. They are a lot less institutional than nursing homes: their appearance is better, they smell nicer, and they offer nice activities, such as live bands every week.


By some estimates, more than 5% of the approximately 6050 military dogs deployed by US combat forces are coming down with canine posttraumatic stress disorder (PTSD) (14). Of those, about half are likely to be retired from service. Although veterinarians have long diagnosed behavioral problems in nonhuman animals, the concept of canine PTSD is only about 18 months old, having come into vogue among military veterinarians who have been seeing patterns of troubling behavior among dogs exposed to explosions, gunfire, and other combat-related violence in Iraq and Afghanistan. Like humans with the analogous disorder, different dogs show different symptoms. Some become hypervigilant, others avoid buildings or work areas that they had previously been comfortable in, and some undergo sharp changes in temperament, becoming unusually aggressive with their handlers or clingy and timid. Many stop doing the task they were trained to perform. Treatment can be tricky since the patient (dog) cannot explain what is wrong; veterinarians and handlers must make educated guesses about the traumatizing events. Care can be as simple as taking a dog off patrol and giving it lots of exercise, play, and gentle obedience training. More serious cases receive what is called "desensitization counter conditioning," which entails exposing the dog at a safe distance to a site or sound that might trigger a reaction--a gunshot, a loud bang, or a vehicle, for instance. If the dog does not react, it is rewarded, and the trigger is moved progressively closer until the dog is comfortable with it.


About 1 in 10 US adults has diabetes mellitus; it is the seventh leading cause of death in the USA, according to the CDC. A recent study (15) disclosed that the number of diabetic patients aged >40 years who had lost a toe, foot, or leg fell from 1988 through 2008 from >11 to 4 per 1000 people. Among nondiabetics during the same period, the frequency of amputation had not changed. Even though the frequency of type 2 diabetes mellitus is continuing to increase in the USA because of the great increase in body weight, some of the other dreaded complications of diabetes including blindness and kidney failure have also decreased during this 20-year period. The exact reason for the decrease in amputations is unclear, but CDC officials believe that improved patient education, earlier diagnosis, better blood sugar monitoring, protective shoes and other medical devices, and better care of feet are paying dividends.


Matthew White, a self-described atrocitologist, necromatrician, and quantifier of hemoclysms, has compiled the most comprehensive, disinterested, and statistically nuanced estimates available of the death tolls of history's major catastrophes in a book entitled The Great Big Book of Horrible Things (16). His scorn is directed at the stupidity and callousness of history's great leaders and at the indifference of traditional history to the magnitude of human suffering behind momentous events. The largest numbers of victims in the top 25 events are listed in Table 4. The Second World War heads the list with 60 million fatalities. The American Civil War (1861--1865) resulted in 620,000 soldier fatalities and 75,000 civilian fatalities, and it is listed at number 75 in the all-time list. The Korean War, which resulted in 3 million soldier and civilian fatalities, is number 30. Our enemies in World War II, namely Germany and Japan, now are our best friends internationally.


As Matthew Futterman described in a January 27, 2012, piece in The Wall Street Journal, in signing C. C. Sabathia, Albert Pujols, and Prince Fielder (son of big leaguer Cecil Fielder), the New York Yankees, Los Angeles Angels, and Detroit Tigers have committed $590 million to 825 pounds of baseball player (17). The Detroit Tigers reached a reported 9-year, $214 million deal with 71-inch, 275-pound 27-year-old Fielder. Albert Pujols (Prince Albert) is 75 inches tall and weighs 230 pounds at age 31. He signed a 10-year $254 million contract with the Los Angeles Angels. Sabathia at age 31 is 79 inches in height and weighs 290 pounds. He signed a contract extension last year to pitch for the Yankees for 5 more years for $122 million (plus a $25 million option for 2017). All three of these players need a nutritionist. Their late-night meals and free (to them) room service in hotels is too tempting for them.


Thomas Jefferson thought they were poisonous, and although he grew many in his yard in Monticello they were for decoration only. Now, 90% of backyard gardens include tomato plants, and in 2009 Americans bought $5 billion worth of commercially grown fresh tomatoes. Barry Estabrook has recently written a book entitled Tomatoland ... and he asks the question: "What has happened to the good flavor that used to be in tomatoes?" (18). He found that the lack of flavor in today's crop of tomatoes is the result of science and business working together to create fruits that have a long shelf life and are nearly impervious to bruising or harsh handling. Most tomatoes Americans eat whole (as opposed to in a sauce or ketchup form) are grown in Florida. The Sunshine State's sandy soil lacks the basic nutrients needed to produce good-tasting fruit, so farmers rely heavily on chemical fertilizers, pesticides, and herbicides to give the plants a boost. The high environmental and human cost of this chemical is a fruit devoid of tomato flavor and one that contains less vitamin C, thiamine, niacin, and calcium and 14 times as much sodium as a tomato grown in the 1960s. The best tomato is the one grown in one's backyard. If you can't grow your own, shop at the local farmer's market or find locally grown in-season tomatoes in the supermarket. Whole Foods sells only "organic" tomatoes that have not been sprayed with chemicals.


Newspapers often focus on reporting errors produced by members of our society, particularly those in prominent positions. The Washington Post publishes its own errors, a total of 875 corrections in its print edition in 2011, a 17% decrease from 1054 in 2010 (19). The 875 number is the lowest for any year since the Post began counting in 2005, when it had >1300 corrections. Good for the Post!


European leaders are trying to stop a debt crisis that is threatening to shadow their 12-year-old experiment: a common Euro currency (20). The monetary union has existed since the Euro was created in 1999, but the European Union, which includes the 17 Euro nations and 10 others that use their own currencies, has no central authority over taxing and spending. Government debt as a percentage of gross domestic product in 2010 among the European countries ranges from 7% in Estonia to 143% in Greece, and not one of the 17 countries is in the black. The unemployment rate in the 17 nations ranges from 5% (Cyprus) to 20% (Spain). The US cannot provide leadership because we also are broke. Individuals have a hard time saving money without frugality; nations must learn that virtue.


In the 1970s, the members of Congress included a barber, a pipefitter, and a housepainter, and they organized into what was called the "blue collar caucus" (21). The financial gap between Americans and their representatives in Congress has widened considerably since then, according to an analysis of financial disclosures by The Washington Post. Between 1984 and 2009, the median net worth of a member of the House of Representatives more than doubled, from $280,000 to $725,000 in inflation-adjusted 2009 dollars, excluding home equity. Over the same period, the wealth of an American family declined slightly, with the comparable median figure sliding from $20,500 to $20,000 according to the Panel Study of Income Dynamics from The University of Michigan. The growing disparity between Representatives and the represented means that there is greater distance between the economic experience of Americans and those of lawmakers.

The growing financial comfort of members of Congress relative to most Americans is consistent with the general trend in the USA toward inequality of wealth. Members of Congress have long been wealthier than average Americans, and in recent decades the wealth of the wealthiest Americans has outpaced that of the average. In 1984, the earliest year for which consistent wealth statistics are available for members of Congress, the 90th percentile of US families had holdings worth 6 times those of the median families; by 2009, the 90th percentile had holdings worth 12 times those of the median families. These figures include home equity. Not only has the median wealth of members of Congress increased, but the proportion of Representatives who have little besides a home has shrunk. In 1984, 1 in 5 House members had 0 or negative net worth, excluding home equity; by 2009 that number had dropped to 1 in 12.

Another possible reason for the growing wealth of Congress is that running a campaign has become much more expensive, making it more likely that wealthy people, who can donate substantially to their own campaigns, gain office. Since 1976, the average amount spent by winning House candidates quadrupled in inflation-adjusted dollars, to $1.4 million. The congressional pay is not one of the reasons for the growing disparity between Representatives and their constituents. In inflation-adjusted dollars, a member of Congress in 1977 earned $215,000; today, a member of Congress earns $174,000. The growth of income inequality has tracked closely with measures of political polarization, which has been gauged using the average difference between the liberal/conservative scores for Republican and Democratic members of the House.

A person's financial circumstances affect a person's political outlook. People identified as lower or middle class have been more likely to see income inequality as a problem and to favor redistribution of income. A Representative's occupation before being elected influences how liberal or conservative he or she is in voting, according to a study from Duke University. In order from most conservative to most liberal: farm owners; business people such as bankers or insurance executives; private-sector professionals such as physicians, engineers, and architects; lawyers; service-based professionals, such as teachers and social workers; politicians; and blue-collar workers. Although party affiliation is the strongest determiner of voting records, the differences between legislators of different occupational backgrounds are striking. This information was gathered by Peter Whoriskey of The Washington Post.


Kenneth Libbrecht, a Cal-Tech physics professor, has been studying snowflakes under the microscope for nearly 2 decades (22). His photos of the frozen crystals of water grace more than 3 billion US postage stamps. He also has authored numerous articles on the molecular dynamics that dictate how ice crystals grow. The shape that snow takes depends on the temperature. From about freezing to 25[degrees]F, snow forms as flakes; when the temperature hits about 23[degrees], the snow forms into needles; and at about 22[degrees], into hollow columns. When the temperature drops to 10[degrees], flakes start forming again, but when it gets to -8[degrees] or so, it once again turns to columns, and at -30[degrees], snow stops forming altogether. A copy of one of his stellar dendrites is shown in the Figure.



An Associated Press survey in 2011 found that the 50 states in the USA have a combined $690 billion in unfunded pension liabilities and just under $420 billion in retiree health care obligations (23). In California it was recently pointed out that a public education teacher there for 40 years can retire at age 59 with a pension of $174,000 a year for the rest of his or her life. Many cities, counties, and states in the US are struggling to pay pension bills, but changes are afoot. In November 2011, San Francisco voters supported a local ballot initiative to raise minimum retirement ages for some city workers. Laws increasing retirement ages for government workers have been signed in Rhode Island and Massachusetts in efforts to address underfunded pension systems. In New Jersey the retirement age was raised from 62 to 65. Most private-sector workers no longer receive defined benefit pensions that will pay them for life. Most must wait until age 65 or 67 to collect their full Social Security benefits or draw from 401k (closed) accounts that are invested in the stock market.


In 1960, 72% of adults 18 and older were married. That fell to 57% in 2000 and to 51% in 2011, according to Pew Researcher DVera Cohn (24). The share of marrieds could dip below 50% in a few years as single-person households, single parents, and couples living together outside of legal marriage multiply. The number of new marriages in the USA fell 5% from 2009 to 2010, a fall that may or may not be related to the bad economy. The decline is spread among age groups but is most dramatic among those under 30. Nearly 3 of every 5 adults aged 18 to 29 were married in 1960; but in 2011, it was only 1 in 5.


Electronics contain lead, mercury, cadmium, and other potentially harmful chemicals, but only 25% of discarded devices (by weight) were recycled in 2009, the most recent year for which the Environmental Protection Agency has data (25). Seventeen states have banned electronic waste from landfills, requiring it to be recycled so its toxic materials do not leach into ground water. If we all recycled computers, computer displays, hard-copy devices, keyboards, mice, television sets, and mobile devices, we would all be better off.


Many Filipinos, largely influenced by Chinese tradition, believe that noisy New Year's celebrations drive away evil and misfortune. But many in the Philippines have carried that superstition to extreme, exploding huge firecrackers and firing guns to welcome the new year despite threats of arrest. Firecrackers in Manila on New Year's Eve 2011 injured 454, and 18 others were injured by stray bullets (26). The injured revelers included many children and filled hospital emergency rooms in Manila shortly after midnight. About a dozen plane flights, including two from the USA, were diverted or cancelled early New Year's Day after dark smog caused by a night of firecracker explosions obscured visibility at Manila's airports. Additionally, firecrackers ignited at least three fires that destroyed several houses in the capital area. Be careful with firecrackers.


The US debt is now about $16 trillion! The US population now is about 313 million people, and thus the debt for every adult and child amounts to $52,500. Countries in debt appear to be at the mercy of countries not in debt.

William Clifford Roberts, MD

6 February 2012

(1.) Franklin B. Poor Richard's Almanack. New York: Peter Pauper Press (77 pp.).

(2.) Solomon S. Water: The Epic Struggle for Wealth, Power and Civilization. New York: HarperCollins, 2010 (596 pp.).

(3.) Norwood R. Young athletes, energy drinks: A bad mix? USA Today, December 2-4, 2011.

(4.) Higgins JP, Tuttle TD, Higgins CL. Energy beverages: content and safety. Mayo Clin Proc 2010;85(11):1033-1041.

(5.) Siegel R, Naishadham D, Jernal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62(1):10-29.

(6.) Lloyd J. "Dramatic" findings on binge drinking. USA Today, January 11, 2012.

(7.) Jones S. Yeah, we're STRESSED but dealing with it. USA Today, January 11, 2012.

(8.) Landro L. When nurses catch compassion fatigue, patients suffer. Wall Street Journal, January 3, 2012.

(9.) McCartney S. Where germs lurk on planes. A survival guide. Wall Street Journal, December 20, 2011.

(10.) Ellin A (New York Times). Truckers driven to shape up. Dallas Morning News, November 27, 2011.

(11.) Rajaratnam SM, Barger LK, Lockley SW, Shea SA, Wang W, Landrigan CP, O'Brien CS, Qadri S, Sullivan JP, Cade BE, Epstein LJ, White DP, Czeisler CA; Harvard Work Hours, Health and Safety Group. Sleep disorders, health, and safety in police officers. JAMA 2011;306(23):2567-2578.

(12.) Sherman KJ, Cherkin DC, Wellman RD, Cook AJ, Hawkes RJ, Delaney K, Deyo RA. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med 2011;171(22):2019-2026.

(13.) Yip P, Alcott K. The cost of growing old. Dallas Morning News, December 19, 2011.

(14.) Dao J. Our furriest solders get PTSD, too. Dallas Morning News, December 5, 2011.

(15.) Li Y, Burrows NR, Gregg EW, Albright A, Geiss LS. Declining rates of hospitalization for nontraumatic lower-extremity amputation in the diabetic population aged 40 years or older: U.S., 1988--2008. Diabetes Care 2012;35(2):273-277.

(16.) White M. The Great Big Book of Horrible Things. New York: WW Norton, 2012 (669 pp.).

(17.) Futterman M. Will cholesterol kill baseball? Wall Street Journal, January 27, 2012.

(18.) Harris M. What happened to tomatoes? Erickson Living, January 2012.

(19.) Pexton PB. The year in corrections. Washington Post, January 1, 2012.

(20.) Act or face collapse, eurozone is warned. Dallas Morning News, November 29, 2011.

(21.) Whoriskey P. Congress looks less like rest of America. Washington Post, December 27, 2011.

(22.) Weise E. Wondering about snowflakes. USA Today, December 19, 2011.

(23.) Pear R. Hefty price tag thwarts payroll tax deal, others. Dallas Morning News, December 5, 2011.

(24.) Associated Press. Fewer Americans wedded to the idea of matrimony. Dallas Morning News, December 21, 2011.

(25.) Koch W. More states ban disposal of electronics in landfills. USA Today, December 19, 2011.

(26.) Gomez J. Philippines New Year firecrackers injure nearly 500. Huffington Post, January 1, 2012.
Table 1. Approximate caffeine content in selected drinks *

Beverage               Serving size (oz)   Caffeine(mg)

Soft drinks

  Coca-Cola                  12                34
  Diet Coke                  12                46
  Pepsi                      12                38
  Sprite                     12                 0


  McDonald's brewed          16               100
  Starbucks Caffe latte      16               150
  Starbucks Pike             16               330
    Place Roast

Energy drink

  Amp                        16               160
  Full Throttle              16               197
  Monster                    16               160 ([dagger])
  NOS                        16               260
  Red Bull                   16               154
  Rockstar                   16               160
  Spike Shooter              8.4              300
  Wired X 344                16               344

Energy shots

  5-Hour Energy              2                207

(*)Reprinted with permission from Norwood, 2011 (3). Sources: Product
labels, MayoClinic.com, company reports.

([dagger]) Monster energy drinks do not include caffeine content on
the label, but company and independent reports put it at about 160 mg
per 16-oz serving.

Table 2. Estimated new cancer cases and deaths in the USA, 2012 *

Site                             New cases    Deaths

All                              1,638,910   577,190
Oral cavity and pharynx           40,250      7,850
Digestive system                  284,680    142,510
Respiratory system                244,180    164,770
Bones and joints                   2,890      1,410
Soft tissues (including heart)    11,280      3,900
Skin ([dagger])                   81,240     12,190
Breast                           229,060     39,920
Genital system                   340,650     58,360
Urinary system                   141,140     29,330
Eye and orbit                     2,610       270
Brain and nervous system          22,910     13,700
Endocrine system                  58,980      2,700
Lymphoma                          79,190     20,130
Myeloma                           21,700     10,710
Leukemia                          47,150     23,540
Other or unspecified              31,000 *   45,900

* Adapted from Siegel et al., 2012 (8) with permission.

([dagger]) Excludes basal and squamous.

([double dagger]) Underestimated.

Table 3. Symptoms of compassion fatigue *

Work-related         Physical                Emotional

* Avoidance or       * Headaches             * Mood swings
  dread of working   * Digestive             * Restlessness
  with certain       problems: diarrhea,     * Irritability
  patients           constipation,
* Reduced ability    stomach                 * Oversensitivity
  to feel empathy    * Muscle tension        * Anxiety
  towards patients   * Sleep disturbances:   * Excessive use of
  or families                                substances:
* Frequent use       inability to sleep,     nicotine, alcohol,
  of sick days       insomnia,               illicit drugs
                     too much sleep          * Depression
* Lack of            * Fatigue               * Anger and resentment
  joyfulness         * Cardiac symptoms:     * Loss of objectivity
                     chest pain/piessuie,    * Memory issues
                     palpitations,           * Poor concentration,
                     tachycardia             focus,
                                             and judgment

* From Landro, 2012 (8).

Table 4. The 25 deadliest multicides *
No   Event                                            (millions)

1    Second World War (1939-1945)                        66
2    Chinggis Khan (1206-1227)                           40
3    Hao Zedong (1949-1976)                              40
4    Famines in British India (18th-20th centuries)      27
5    Fall of the Ming Dynasty (1635-1662)                25
6    Taiping Rebellion (1850-1864)                       20
7    Joseph Stalin (1928-1953)                           20
8    Midwest slave trade (7th-19th centuries)           18.5
9    Timur (1370-1405)                                   17
10   Atlantic slave trade (1452-1807)                    16
11   Conquest of the Americas (after 1492)               15
12   First World War (1914-1918)                         15
13   An Lushan Rebellion (755-763)                       13
14   Xin Dynasty (9-24)                                  10
15   Congo Free State (1885-1908)                        10
16   Russian Civil War (1918-1920)                        9
17   Thirty-Year War (1618-1648)                         7.5
18   Fall of the Yuan Dynasty (ca. 1340-1370)            7.5
19   Fall of the Western Roman Empire (395-455)           7
20   Chinese Civil War (1927-1937, 1945-1949)             7
21   Mahdi Revolt (1881-1898)                            5.5
22   The Time of Troubles (1598-1613)                     5
23   Aurangzeb (1658-1707)                               4.6
24   Vietnam War (1959-1975)                             4.2
25   The Three Kingdoms of China (189-280)               4.1

* From White, The Great Big Book of Horrible Things, 2012 (16).
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.