Pet food poison and pithed America

We all know frogs will jump out of a beaker of slowly warming water -- long before it boils.

If they've been "pithed" however, they'll just lie there. Pithed frogs don't hop.

Americans have been pithed. Fifteen years ago any of the melamine/cyanuric acid pet food poisoning, Heparin contamination, surveillance society or a dozen similar stories would have resulted in general excitement and even regulatory action.

Now, we just give 'em a stunned look and move on. Maybe it's all we can do. After 12 years of GOP rule (8 of Bush, 4 where the GOP held the House and Senate) we're kind of crushed.

So I really shouldn't be quoting this SF Chronicle article telling us nothing has changed in the pet food world (emphases mine):

The Pet Food Recall: One Year Later, Has Anything Changed?

A year ago, Canada's Menu Foods announced it was recalling more than 60 million containers of dog and cat food sold in the United States. Although the name Menu Foods wasn't familiar to pet owners, the recalled cans and pouches bore the labels of dozens of the most familiar and trusted brands in the marketplace.

In the end, more than 1,000 brands of pet food were recalled over a period of about four months, and two chemicals, melamine and cyanuric acid, were blamed for kidney failure that killed thousands and sickened tens of thousands of pets from what came to be called melamine-associated renal failure....

...I didn't guess when I began covering this story with Gina Spadafori at Pet Connection that it would turn into the largest consumer recall in history, trigger an international trade scandal, launch congressional hearings, spur proposed legislation on food safety and get both American and Chinese businesses owners indicted. I couldn't have foreseen that the incident would put a spotlight on Chinese imports which would eventually reveal lead in children's toys and toxins in toothpaste, and prompt the recent recall of the drug heparin.

But it's equally hard to believe that after all that, the answer to the question "Could it happen again?" is probably "Yes."

The reason for that is simple: None of the changes that might prevent a repeat of last year's pet food recall have been implemented. There have been no improved inspections of pet food plants, no comprehensive overhaul of the patchwork of state, federal and industry manufacturing standards and regulations, no increased transparency and accountability — not even something as simple as printing the name and contact information of the actual manufacturer on pet food labels — and no revisions to pet food labeling laws. The Food and Drug Administration still does not have the authority to issue mandatory recalls.

Most of us closely involved in this story find all that hard to understand. "In this age of potential bio-terror and random cross-species crossover horrors like the avian flu, this is incomprehensible," said Pet Connection editor Gina Spadafori. "Our animals are the canaries in the coal mine, and as bad as the death toll was in our pets, it could have been much, much worse, in both animal and human populations. So why is there still not a national veterinary reporting system for a nationwide emergence of disease that is not only killing animals but could also potentially already be in or emerging in the human population? And why are we still unable to inspect all but the tiniest percentage of imported foods?"...

...The adulteration of protein concentrates with melamine and cyanuric acid was found to be both longstanding and widespread in China, so it seemed unlikely something like this hadn't happened before.

And in fact, it had. The Journal of Veterinary Investigative Diagnosis recently reported that melamine and cyanuric acid contamination was responsible for the deaths of thousands of pets in 2004.

Researchers working with tissue samples from animals who died in the U.S. recall compared them to samples from pets who died in a number of Asian regions including the Philippines, Japan, South Korea and Hong Kong. Those deaths led to a recall of Pedigree dog foods and Whiskas cat foods, and were blamed on mycotoxin contamination. But the study found that both groups of pets had the unmistakable crystals and damage in the kidneys caused by melamine and cyanuric acid.

While there's no evidence any other mycotoxin-attributed food recalls, pet or human, were misidentified, it does put the pet food recall squarely in the big picture of this country's broken food safety system.

A fix for that broken system may be coming, even if it's a bit slow. The FDA recently announced a meeting where it will discuss changes in the regulation of pet food ingredients, processing and labeling with representatives from the pet food industry, government agencies, veterinary medical associations, animal health organizations and pet food manufacturers at that meeting. One group not on that list is pet owners, but they have asked to hear from us. Comments should be made on docket number 2007n-0487 at www.regulations.gov/. [jf: I tried this. I don't think the site is accepting comments yet on this item. I'd recommend an email to your Senator or Representative instead.]

"The recalls exposed deep problems with food safety regulation in China as well as in the United States, and I see many signs of efforts to do something about them," said Nestle. "Lasting improvements won't happen overnight, and they won't happen at all unless people who care about these issues keep pressuring the industry and the FDA to do what they say they will do."

Did you catch the implication that we ought to be reexamining other "mycotoxin" or "fungal" related food poisoning episodes to see which were the result of fraud?

I'm sympathetic to the stunned -- I'm about half-pithed myself. It takes a lot of energy to put pressure on the FDA in the best of times, but this is Bush's FDA -- neutered, broken, led by people opposed to their own mission.

If we put McCain into the White House we deserve to eat Melamine and lead for breakfast.

How old is this retiring pastor?

I really don't know what "Obama's Pastor Wright" said, but I gather it wasn't very nice. In reading Obama's response though, I had only one thought.

How old is this retiring pastor?

When people start saying odd things inconsistent with past behavior, it's worth remembering that dementia is an exceedingly common disorder.

It's official. We live in a surveillance state.

Not a police state, not yet. Surveillance state is a good term.

INTEL DUMP - NSLs and the National Surveillance State

I agree with Yale law professor Jack Balkin -- we live today in a national surveillance state. This article in the Washington Post detailing the FBI's use of "national security letters" (NSLs) tells an important part of that story. According to the Post:...

....For reasons of convenience, expediency, secrecy and efficiency, federal law enforcement has increasingly turned towards surveillance and investigative methods which do not require ex ante review or approval by an Article III court...

...If you still think you've got a reasonable expectation of privacy in your daily life -- check again. The exceptions very nearly swallow the rule today.

Is this a problem? Depends on your perspective. What worries me here is the slow bureaucratic expansion of power -- like the ever-expanding Blob of movie fame. The FBI and intelligence community may need administrative tools like this. Ultimately, we may decide it's in our interest to allow law enforcement the use of these tools -- whether for targeting suspected terrorists, drug dealers, organized crime figures, or even Client No. 9. But that's got to be a public debate, and it's got to be a debate held by accountable officials, not agency officials behind closed doors. We have a stake in this policy, and we should get a say.

It's been a long transition. I think technologic progression alone would have brought us to this point by 2013 even if 9/11 had not occurred, but terrorism accelerated the timetable.

To think it was only a few years ago that pundits scoffed at claims of widespread domestic surveillance. Nobody's scoffing now.

Will Americans actually demand a public debate? I doubt it. We're a future shocked culture -- dazed, numb and pithed; hit by too much too fast. We're going to live with this.

We're all Singaporeans now.

Sheldon Brown - one of the original riders of the web

My old, long neglected web page on bike touring included a section on bike reference links. Surprisingly most of the links still work, including my link to Sheldon Brown's eclectic bicycle site.

I revisited the site tonight. It's very 1994 -- HTML 2.0 tables with links to his personal interests -- including my home province and his personal pages. It's only on the Harris Cyclery page though, that we learn Sheldon Brown died on February 3rd, 2008.

He kept a personal journal. There's an entry for the last day of his life:

... I've finally made up my mind, I'll be voting for Obama in the primary on Tuesday. When you live in Massachusetts, the primary is the only presidential vote that matters--if a Democrat can't carry Massachusetts in the final, there's no hope!

I'm still a big fan of Clinton, and would still be on the fence, except that my daughter is very strongly for Obama and has been working for him, which is enough to tip the balance for me...

The Times of London, has an extensive and affectionate obituary. He died of a heart attack after two years of progressive multiple sclerosis.

I hope one of his many fans will be archiving his pages and writings.

No more spouses at the press conference

I thought Gail Collins had the very best comment on the Spitzer story:

Unwelcome Surprises - New York Times

...Memo to future disgraced politicians: The nation has discussed this at length, and we do not want to see any more stricken spouses at the press conference. Not even if she volunteers...

If the politicians walks the plank alone, we'll consider forgiveness. Bring a spouse and forgiveness is off the table.

The only other comment I'd make on the Spitzer case is the young woman involved seems confused, lost, and vulnerable. That's not surprising given her employment. It's the only other part of the story worth any attention.

Mass disability and Great Depression 2.0

Wired magazine's front page claimed recently that "free" was the new cheap. That would be consistent with Robert Reich's latest "Great Depression" post (aka, GD 2.0. Emphases mine):

Robert Reich's Blog: Are We Heading Toward Depression (Part 3)?

American consumers are coming to the end of their ropes and don't have the buying power they need to absorb the goods and services the U.S. economy is capable of producing. This is likely to mean fewer jobs, which will force Americans to pull in their belts even tighter, leading to still fewer jobs – the classic recipe for recession. That recession may turn into a full-fledged Depression if fiscal and monetary policies can't make up for consumers' lack of buying power. And there's reason to worry they cannot because consumers are in a permanent bind. They're deep in debt, their homes are losing value, and their paychecks are shrinking...

...We're reaping the whirlwind of many years during which Americans have spent beyond their means and most of the benefits of an expanding economy have gone to a relatively small group at the very top. Adjusted for inflation, the median wage is below where it was in 1999. The nation's median hourly wage is barely higher than it was thirty-five years ago. The income of a man in his 30s is now 12 percent below that of a man his age three decades ago. The rich, meanwhile, can't keep the economy going on their own because they devote a smaller percentage of their earnings to buying things than the rest of us: After all, they're rich, and they already have most of what they want. Instead of buying, they're more likely to invest their earnings wherever around the world they can get the highest return...

... Go back to the years just before the Great Depression and you see the same pattern. As I've noted before, Marriner S. Eccles, who served as Franklin D. Roosevelt's Chairman of the Federal Reserve from 1934 to 1948, noted this in his memoir "Beckoning Frontiers":

"As mass production has to be accompanied by mass consumption, mass consumption, in turn, implies a distribution of wealth -- not of existing wealth, but of wealth as it is currently produced -- to provide men with buying power equal to the amount of goods and services offered by the nation's economic machinery. Instead of achieving that kind of distribution, a giant suction pump had by 1929-30 drawn into a few hands an increasing portion of currently produced wealth. This served them as capital accumulations. But by taking purchasing power out of the hands of mass consumers, the savers denied to themselves the kind of effective demand for their products that would justify a reinvestment of their capital accumulations in new plants. In consequence, as in a poker game where the chips were concentrated in fewer and fewer hands, the other fellows could stay in the game only by borrowing. When their credit ran out, the game stopped."...

There's so much opportunity for productivity driven growth in China, India, and even Africa that we ought to be able to dodge a GD 2.0, or even a Japanese-style 1990s depression. Of course if we really are entering Peak Oil territory, this is not a great time to have a markedly sub-optimal spending capacity distribution across America.

My take? I believe that about 20% of adult Americans aged 25 to 65 are effectively disabled in our current globalized post-industrial economy. I believe this number will rise as our population ages. I believe this is the fundamental problem, along with network effects, driving modern wealth concentration.

Over time the economy will change to develop niches for unused capacity (servant economy?), but the transition need not be comfortable. In the meantime technological shocks, such as ubiquitous robotics, may induce new disruptions to a non-equilibrium economic structure -- risking extensive economic breakdown.

Even if we avoid GD 2.0 this time around, we need to rethink our economics and social models.

Update 4/4/2010: Changed the title of this post - the original was kind of meaningless.

NBC's "To Catch a Predator". Please tell me this is satire ...

Please tell me this is satire...

What’s on TV Tonight? Humiliation to the Point of Suicide - New York Times

In November 2006, a camera crew from “Dateline NBC” and a police SWAT team descended on the Texas home of Louis William Conradt Jr., a 56-year-old assistant district attorney. The series’ “To Catch a Predator” team had allegedly caught Mr. Conradt making online advances to a decoy who pretended to be a 13-year-old boy. When the police and TV crew stormed Mr. Conradt’s home, he took out a handgun and shot himself to death.

“That’ll make good TV,” one of the police officers on the scene reportedly told an NBC producer. Deeply cynical, perhaps, but prescient. “Dateline” aired a segment based on the grim encounter. After telling the ghoulish tale, it ended with Mr. Conradt’s sister decrying the “reckless actions of a self-appointed group acting as judge, jury and executioner, that was encouraged by an out-of-control reality show.”

Mr. Conradt’s sister sued NBC for more than $100 million. Last month, Judge Denny Chin of Federal District Court in New York ruled that her suit could go forward...

No, I suppose it's real. I honestly didn't realize that American television had fallen this far. I live in a different world.

I'm sure NBC is now begging to settle, but I hope Mr. Contradt's family nails them publicly. I've vote for  a $30 billion dollar fine myself ...

Whatever happened to medical progress?

By an odd bit of synchronicity I'm simultaneously engaged with leading edge research in "Translational Bioinformatics" and refreshing my very dusty knowledge of family medicine.

How dusty? It's been about ten years since I took care of a patient, though other work has kept me somewhat connected to clinical practice. My medical school ended in 1986, so we're talking antique knowledge with dust on it.

Problem is, my old knowledge is more topical than it should be.

In 1983 I wrote a friend an enthusiastic note boasting of how quickly medical knowledge was moving. I was sure that the future was bright for treating and preventing diabetes, the "Haitian disease" (later HTLV, then HIV), rheumatoid arthritis, ALS, autoimmune disease, osteoarthritis, lupus, hypertension, heart disease, migraine, asthma, schizophrenia, dementia, viral and bacterial infections, multiple sclerosis ...

Ok, so I was a tad naive -- but the twenty years from 1962 to 1982 had been amazing. Infectious disease, nutritional disorders, thyroid disorders, insulin, hypertension, angina, -- we were doing great. All we had to do was keep up the pace ...

Splat.

We hit a wall. Now we're relearning how to fear bacterial infections, and the antibiotic pipeline is dry. We can't even treat menopause any more -- estrogen is a bad word. Lipitor and Glucophage are great, but we thought Diabetes Mellitus would be cured by now. We can slow the progress of HIV, but we still don't have a vaccine. Our progress against everyday medical conditions has been lousy over the past twenty years. Mostly we've learned to stop doing silly things, like given people with heart oddities antibiotics prior to minor dental work.

Forget the propaganda about zillions of articles being published -- that's not translating to big changes in people's lives. Yes, we do make progress -- but automobile-style progress, not computer-storage type progress. No wonder we're expecting to spend 99% of our GDP on health care -- we're not getting any big productivity boosts from breakthrough treatments.

Which brings me back to the "translational bioinformatics" stuff. This is the dream that we can apply enormous progress in computational power, and basic science breakthroughs in genomics, to the intractable diseases that have been jeering at us for 20 years.

I'd really like to see us knock off just one of those suckers before I retire. Multiple sclerosis would be a good start. Make my 20 year old knowledge completely obsolete. Please!

Support Tom Harkin's Complete Streets legislation - write your senator

In a nation heading to $7/gallon gasoline and malignant obesity Tom Harkin's "Complete Streets" legislation is both good business and good public health:

Tom Harkin Introduces "Complete Streets" Legislation || Integrated Road Planning || Ride Boldly!

Senator Tom Harkin (D-IA) introduced a bill last week designed to promote proper road planning - designing facilities that are safe for all street users, including motorists, public transit, bicyclists, and pedestrians.

Tom’s office has put out a complete media release, including the list of organizational supporters, on his Senate site. Many organizations devoted to promoting livable communities have signed on to this bill.

Writing your own Senator to encourage passage of this bill is best done by e-mail in the post-anthrax Senate, per a friend who used to be a Harkin advisor. If you need info on contacting your Senators, check out the Senate web site.

Please shoot off a supportive email. I know I will.

Oil price speculation: is it rational investment or a bubble?

I've read recently that oil prices "now" are driven by "speculation" rather than "fundamentals". In other words, based on near term supply and demand curves, including our current recession, prices should be stable or dropping, not rising.

Yet rise they do.

In August of 2007 I'd thought that, absent any surprises, gas would hit $5/gallon in the midwest around 2011:

2011: The year American life changes (Aug 2007)

When will energy costs in general, and gasoline costs in particular, fundamentally change the way middle-class Americans live and work? We know gasoline prices will rise until something changes, even if the US never implements a carbon tax...

...I think a reasonable marker is the year that the baseline gasoline price hits $5 a gallon...

So when does it happen? I'll pull a number out of the air, extrapolating from my amateur chart and the Copernican Principle, and guess, even without a carbon tax or the complete collapse of Iraq, that it's 2011.

I'm in California today, and it's $4/gallon here in early 2008. My 2011 prediction for a change in American life is looking conservative.

So, is today's oil price rational speculation or bubbly speculation?

Well, I haven't read any good discussions of this lately, so I'll say something and hope Brad DeLong decides to clear things up

One way this speculation could be rational is of the people who are paid to know believe that peak oil is coming any time in the next 10-15 years -- especially given the current bleak options for alternative investments. For non-economist readers, here's why:

Gordon's Notes: Gasoline and the rule of 72 (May 2007)

... There's some smaller rate of return that would make retaining rather than selling petroleum products the right way to invest. This is what all the "peak oil" crowd get excited about; but the term is a bit misleading. It's not that oil production needs to peak, it's simply that demand has to persistently outstrip supply. Prices, of course, don't wait for demand to outstrip supply, they begin rising as soon as a demand/supply gap can be reasonably anticipated within the time frame of investment decisions (10 years roughly).

This, by the way, is a very good thing. It means that prices rise long before we run out of oil, giving everyone time to adapt and adjust.

I do wonder what the sober experts calculate. They can look at supply curves and demand curves and the available substitutions within the next decade. Do they see a significant supply/demand gap opening up? If the price of gas will be $7/gallon in six years (well within the lifespan of your next Ford F-250), is that enough of rate of return to justify holding products now?...

So here's my proposal for deciding if Peak Oil is on the way.

If the price of oil craters ($65) in the next 6 months then we're living in an energy bubble today and Peak Oil is more than 10-15 years away.

If the price of oil is above $105 a barrel in August of 2008 then Peak Oil is on the sooner rather than later, and the world I grew up in is shuffling away -- sooner than I'd expected.

So American Life may change in 2008 - not 2011.

Shocking news: incenting physicians towards one goal has negative impacts on other goals

I am so surprised by this shocking, impossible to predict, outcome:

AMNews: March 17, 2008. CMS metric may prompt excessive antibiotic use ... American Medical News

...A new study says physicians are 39% more likely to misdiagnose hospital patients as having community-acquired pneumonia due to the high-stakes environment fostered by mandatory public reporting of quality measures -- in this case, whether pneumonia patients got antibiotics within four hours of arriving at the hospital.

The results, published in the Feb. 25 Archives of Internal Medicine, are similar to those found in a Chest study published last year and echo many physicians' complaints about the measure of initial antibiotic timing, known as door-to-needle time. A February 2007 Infection Control and Hospital Epidemiology study tied excessive use of antibiotics encouraged by the performance metric to a severe outbreak of Clostridium difficile at a small rural hospital...

I trust my sarcasm is sufficiently dripping.

The CMS pay-for-performance programs will be eventually recognized as the most harmful health care innovation since Evaluation and Management coding killed primary care in the 1990s.

Alas, that recognition is still 18 months away -- and here I'm being atypically optimistic. E&M coding, for example, has now been a 13 year disaster.

There are many ways to improve health care quality that have been shown work and to be relatively free of perverse consequences. "Pay-for-performance", however, is an ideologically driven program that was reasonable to experiment with -- before the evidence of failure emerged. Now it needs to die -- but it won't until the Bush team leaves CMS.

How Homeland Security sets its priorities

Ever wonder how Homeland Security evaluates its security investments?

Maybe you imagine dozens of super-sharp analysts, veterans and geeks alike, weighing risk and assigning probabilities, preparing carefully reasoned analyses which their superiors review and confirm.

Oops. No, that a flash from the alternate reality where Gore became President, bin Laden and Zawahiri are dead, we're not in a recession, and we didn't commit ourselves to a 1.5 trillion dollar war in Iraq.

In the Bush administration it goes more like this ...

Airport passenger screenings to be reviewed - USATODAY.com

...Chertoff's department is about to issue requirements for crews and passengers of private jets to provide their names, birthdates and other information an hour before takeoff, so they can be checked against terrorist watch lists.

The next step could be requiring that private jets be scanned and passengers screened by U.S. Customs agents overseas, Chertoff said. The procedures might be "a little inconvenient," he said, but if a bomb got into the USA on a private jet, there would be calls to "shut all private aviation off."

Chertoff said he grew more concerned about the issue last year when a senior executive of a private-jet company told him, "I don't know who the heck gets on my planes, and it worries me."...

I'm imagining Chertoff is hitting up some GOP donor at one of those $2,000 a plate dinners, and somehow this comment lodges deep in his dormant brain. Maybe it was the fine Scotch. Who knows?

Fire.

Chertoff.

Now.

Please.

Then fire his boss.

iPhone developer response to Apple's 30% cut on iApp sales, and why I still won't order one.

iApp developers aren't too worried about Apple's 30% cute on all iPhone App sales -- "How about we make shitloads of money at 70% and ask questions later?"

Well said. The iPhones application distribution model is fantastic.

I almost ran out and bought an iPhone today. I had to tie myself to a chair and reread my August 2007 list of iPhone demands (rev Oct 2007). Of 9 non-negotiable demands, exactly 1 (a trivial one) was met in the past seven months.

Some of my demands will be met by iPhone developers - after June 2008. Some may be solved with the promised 2.0 firmware update. NONE of them have been met today. Gordon's third law of acquisition was written for this precise situation: "Don't buy on promises or potential. Acquire for real value now. Anything in the future is a plus (or, sometimes, a minus)."

So when the SDK is really available, and when I see the true state of the 2.0 firmware update, then I'll buy.

In the meantime, I've been abusing* the Aperture trial offer long enough. Instead of an iPhone I've ordered my copy of Aperture 2.01.

* If you delete the prefs you get another 30 days of trial. With 2.01 you have to swap a library in and out as well. It took me a long time to decide that Aperture's virtues outweigh its many flaws; I suspect Apple knows about the little quirk that extends the trial.

State of the universe: flat, 72% vacuum energy

CV provides the recipe for our universe from the most recent analysis of the echoes of the big bang:

WMAP 5-Year Results Released | Cosmic Variance:

...The WMAP folks have produced an elaborate cosmological parameters table that runs the numbers for different sets of assumptions (with and without spatial curvature, running spectral index, etc), and for different sets of data (not just WMAP but also supernovae, lensing, etc). Everything is basically consistent with a flat universe comprised of 72% vacuum energy, 23% dark matter, and 5% ordinary matter....

Of course the human brain is 70% water, so we shouldn't feel entirely bad that most of what we know is only 5% of the universe.

Here's what Wikipedia has on "vacuum energy":

... Two proposed forms for dark energy are the cosmological constant, a constant energy density filling space homogeneously,^[2] and scalar fields such as quintessence or moduli, dynamic quantities whose energy density can vary in time and space. In fact, contributions from scalar fields, which are constant in space, are usually also included in the cosmological constant. The cosmological constant is thought to arise from the vacuum energy...

and

...Vacuum energy is an underlying background energy that exists in space even when devoid of matter ...

So the recipe is basically definitional. Take away dark and ordinary matter and you get, by definition vacuum energy. Vacuum energy may arise largely from "smooth tension" (aka "dark energy"), but perhaps that's an interpretation of the results, not a statement of the results.

PS. Please note I'm not physicist in any form, I just like learning this stuff.

Update 3/8/2008: A little more detail on bad astronomy. Age - 13.73 billion years (middle aged in terms of a universe in which we can live). The average temperature of the universe is 2.725 degrees Kelvin -- just a smidgin above nothing.

Unintended consequences and accidental death from polypharmacy

Patients are empowered, but lack knowledge.

Health care providers have knowledge, but are stressed, disintegrated, and "disintermediated". Primary care, in particular, is near death (or dead).

The pharmaceutical industry is in a lesser known crisis. Chinese generics drive ferocious price competition, the discovery pipeline is dry, patents are expiring, and the last cash cow, the US, is running out of money. So the advertisement is getting desperate.

The GOP has stripped regulatory agencies of mission and funding.

Add it all up, and you have a storm of unintended consequences brewing. Larry Zaroff tells the story very well (emphases mine)...

Heath Ledger death |By Larry Zaroff, M.D., Ph.D. | Salon Life

...According to the Centers for Disease Control and Prevention, motor-vehicle crashes rank first among unintentional deaths in America. But poisoning is second, most commonly from the abuse of prescription and illegal drugs. Unintentional deaths from accidental drug ingestion rose significantly from 1999 to 2004. This trend is primarily due to increasing use of prescription opioid analgesics, and not heroin, methamphetamines or other illegal drugs...

...After leaving the drugstore, the patient realizes the wise doctor has given her only 30 pills, not enough, since one pill no longer gives her what she requires: deep, worry-free sleep or relief of pain or anxiety. If she has all three problems, she will need more pills or other kinds. She goes to another doctor and gets a second supply. She is set for the moment. But her work requires travel, sometimes out of the country. She can locate other doctors in other places who will prescribe. Now she has a fine stash both in her medicine cabinet and in her suitcase.

She is young, smart, well regarded by her associates. She is the opposite of careless. But she has no understanding of physiology, how the body works, what controls vital functions -- breathing, heartbeat, circulation -- and how drugs can affect these functions. How drugs work, their rate of absorption, their peak level of activity, is of no interest to her. She only wants relief of her insomnia, her pain, her worries. She has no idea that drugs have an optimum dose, that combinations of drugs might be like taking too much of a single drug, that often dissimilar medicines can affect the same organs and stop their activities. Unknown to her, she may even have a genetic abnormality that makes her more susceptible to the synergistic effects of the drugs.

The patient is not an addict and suicide is the last thing she would consider. But she has a tough day ahead of her. She needs her sleep. She decides to take two sleeping pills since one did not work well enough the previous night. Because she strained her back yesterday and feared the pain might keep her awake, she takes a narcotic, a single dose. She feels edgy despite the sleeping pills and the narcotic, and so she takes a tranquilizer. The witches' brew works. She dozes off but awakes in two hours, her mind jumbled. She must sleep. She slips into the bathroom and repeats the doses. She lies down, sleeps soon, too deeply. An hour later she stops breathing. She is alone, no one to aid her...

I don't agree with Dr. Zaroff's recommended solutions (read the article). I think we need to go back to the list I started this post with, and work each one independently. I think we also need a national education program. The modern patient is going to "play doctor" anyway, so they might as well start in on medical skill. "Drugs Kill" might be a good ad slogan, though it might be confused with anti-cocaine ads.