Community For Better Health Care

Vol V, No 15, Nov 14, 2006


In This Issue:

1.                  Featured Article: Mirrors in the Mind, Scientific American, November 2006

2.                  In the News: Climate Change: WSJ vs Scientific American, The Final Word?

3.                  International Medicine: From The Journal of Child Psychology and Psychiatry  

4.                  Medicare: Stethoscope Socialism By Deroy Murdock, Washington Times

5.                  Medical Gluttony: Gluttony Is Increasing System Inefficiency: This Is NOT Sustainable

6.                  Medical Myths: Rising to the Challenge

7.                  Overheard in the Medical Staff Lounge: Butcher of Baghdad Meets His Fate

8.                  Voices of Medicine: The Way We Were (And Will Be Again) by George Ingraham, M.D.

9.                  From the Physician Patient Bookshelf: TRUST BETRAYED - Inside the AARP

10.              Hippocrates & His Kin: Practice Guidelines Can Work in Two Ways

11.              Related Organizations: Restoring Accountability in HealthCare, Government and Society

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The Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. This year it was 50 percent, indicating open forums such as these are critically important. The 4th Annual World Health Congress has been scheduled for April 22-24, 2007, also in Washington, D.C. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2007. The World Health Care Congress - Middle East will be held in Dubai, United Arab Emirates, on November 12-14, 2007. World Health Care Congress - Europe 2007 will meet in Barcelona on March 26-28, 2007. For more information, visit 

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1.      Featured Article: Mirrors in the Mind, Scientific American, November 2006

Mirror neurons, a special class of cells in the brain, may mediate our ability to mimic, learn and understand the actions and intentions of others

A special class of brain cells reflects the outside world, revealing a new avenue for human understanding, connecting and learning By Giacomo Rizzolatti, Leonardo Fogassi and Vittorio Gallese

John watches Mary, who is grasping a flower. John knows what Mary is doing - she is picking up the flower - and he also knows why she is doing it. Mary is smiling at John, and he guesses that she will give him the flower as a present. The simple scene lasts just moments, and John's grasp of what is happening is nearly instantaneous. But how exactly does he understand Mary's action, as well as her intention, so effortlessly? 

A decade ago most neuroscientists and psychologists would have attributed an individual's understanding of someone else's actions and, especially, intentions to a rapid reasoning process not unlike that used to solve a logical problem: some sophisticated cognitive apparatus in John's brain elaborated on the information his senses took in and compared it with similar previously stored experiences, allowing John to arrive at a conclusion about what Mary was up to and why.

Although such complex deductive operations probably do occur in some situations, particularly when someone's behavior is difficult to decipher, the ease and speed with which we typically understand simple actions suggest a much more straightforward explanation. In the early 1990s our research group at the University of Parma in Italy, which at the time included Luciano Fadiga, found that answer somewhat accidentally in a surprising class of neurons in the monkey brain that fire when an individual performs simple goal-directed motor actions, such as grasping a piece of fruit. The surprising part was that these same neurons also fire when the individual sees someone else perform the same act. Because this newly discovered subset of cells seemed to directly reflect acts performed by another in the observer's brain, we named them mirror neurons.

Much as circuits of neurons are believed to store specific memories within the brain, sets of mirror neurons appear to encode templates for specific actions. This property may allow an individual not only to perform basic motor procedures without thinking about them but also to comprehend those acts when

they are observed, without any need for explicit reasoning about them. John grasps Mary's action because even as it s happening before his eyes, it is also happening, in effect, inside his head. It is interesting to note that philosophers in the phenomenological tradition long ago posited that one had to experience

something within oneself to truly comprehend it. But for neuroscientists, this finding of a physical basis for that idea in the mirror neuron system represents a dramatic change in the way we understand the way we understand.

Instant Recognition

Our research group was not seeking to support or refute one philosophical position or another when we first noticed mirror neurons. We were studying the brain's motor cortex, particularly an area called F5 associated with hand and mouth movements, to learn how commands to perform certain actions are encoded by the firing patterns of neurons. For this purpose, we were recording the activity of individual neurons in the brains of macaques. Our laboratory contained a rich repertoire of stimuli for the monkeys, and as they performed various actions, such as grasping for a toy or a piece of food, we could see that distinct sets of neurons discharged during the execution of specific motor acts.

Then we began to notice something strange: when one of us grasped a piece of food, the monkeys' neurons would fire in the same way as when the monkeys themselves grasped the food. At first we wondered whether this phenomenon could be the result of some trivial factor, such as the monkey performing an unnoticed movement while observing our actions. Once we managed to rule out this possibility and others, including food expectation by the monkeys, we realized that the pattern of neuron activity associated with the observed action was a true representation in the brain of the act itself, regardless of who was performing it.

Often in biological research, the most direct way to establish the function of a gene, protein or group of cells is simply to eliminate it and then look for deficits in the organism's health or behavior afterward. We could not use this technique to determine the role of mirror neurons, however, because we found them spread across important regions on both sides of the brain, including the premotor and parietal cortices. Destroying the entire mirror neuron system would have produced such broad general cognitive deficits in the monkeys that teasing out specific effects of the missing cells would have been impossible.

So we adopted a different strategy. To test whether mirror neurons play a role in understanding an action rather than just visually registering it, we assessed the neurons' responses when the monkeys could comprehend the meaning of an action without actually seeing it. If mirror neurons truly mediate understanding, we reasoned, their activity should reflect the meaning of the action rather than its visual features. We therefore carried out two series of experiments.

First we tested whether the F5 mirror neurons could "recognize" actions merely from their sounds. We recorded the mirror neurons while a monkey was Observing a hand motor act, such as ripping a sheet of paper or breaking a peanut shell, that is accompanied by a distinctive sound. Then we presented the monkey with the sound alone. We found that many F5 mirror neurons that had responded to the visual observation of acts accompanied by sounds also responded to the sounds alone, and we dubbed these cell subsets audiovisual mirror neurons.

Next we theorized that if mirror neurons are truly involved in understanding an action, they should also discharge when the monkey does not actually see the action but has sufficient clues to create a mental representation of it. Thus, we first showed a monkey an experimenter reaching for and grasping a piece of food. Next, a screen was positioned in front of the monkey so that it could not see the experimenter's hand grasping the food but could only guess the action's conclusion. Nevertheless, more than half the F5 mirror neurons also discharged when the monkey could just imagine what was happening behind the screen.

These experiments confirmed, therefore, that the activity of mirror neurons underpins understanding of motor acts: when comprehension of an action is possible on a nonvisual basis, such as sound or mental representation, mirror neurons do still discharge to signal the act's meaning.

Following these discoveries in the monkey brain, we naturally wondered whether a mirror neuron system also exists in humans. We first obtained strong evidence that it does through a series of experiments that employed various techniques for detecting changes in motor cortex activity. As volunteers observed an experimenter grasping objects or performing meaningless arm gestures, for example, increased neural activation in their hand and arm muscles that would be involved in the same movements suggested a mirror neuron response in the motor areas of their brains. Further investigations using different external measures of cortical activity, such as electroencephalography, also supported the existence of a mirror neuron system in humans. But none of the technologies we had used up to this point allowed us to identify the exact brain areas activated when the volunteers observed motor acts, so we set out to explore this question with direct brain-imaging techniques.

In those experiments, carried out at San Raffaele Hospital in Milan, we used positron-emission tomography (PET) to observe neuronal activity in the brains of human volunteers as they watched grasping actions performed with different hand grips and then, as a control, looked at stationary objects. In these situations, seeing actions performed by others activated three main areas of the brain's cortex. One of these, the superior temporal sulcus (STS), is known to contain neurons that respond to  observations of moving body parts. The other two - the inferior parietal lobule (IPL) and the inferior frontal gyrus (IFG) - correspond, respectively, to the monkey IPL and the monkey ventral premotor cortex, including F5, the areas where we had previously recorded mirror neurons.

These encouraging results suggested a mirror mechanism at work in the human brain as well but still did not fully reveal its scope. If mirror neurons permit an observed act to be directly understood by experiencing it, for example, we wondered to what extent the ultimate goal of the action is also a component of that "understanding."

On Purpose

RETURNING to our example of John and Mary, we said John knows both that Mary is picking up the flower and that she plans to hand it to him. Her smile gave him a contextual clue to her intention, and in this situation, John's knowledge of Mary's goal is fundamental to his understanding of her action, because giving him the flower is the completion of the movements that make up her act. . .

Connect and Learn

AS WITH ACTIONS, humans undoubtedly understand emotions in more than one way. Observing another person experiencing emotion can trigger a cognitive elaboration of that sensory information, which ultimately results in a logical conclusion about what the other is feeling. It may also, however, result in direct mapping of that sensory information onto the motor structures that would produce the experience of that emotion in the observer. These two means of recognizing emotions are profoundly different: with the first, the observer deduces the emotion but does not feel it; via the second, recognition is firsthand because the mirror mechanism elicits the same emotional state in the observer. Thus, when people use the expression "I feel your pain" to indicate both comprehension and empathy, they may not realize just how literally true their statement could be. . .

To read the entire article (subscription required), please go to

GIACOMO RIZZOLATTI, LEONARDO FOGASSI and VITTORIO GALLESE work together at the University of Parma in Italy, where Rizzolatti is director of the neurosciences department and Fogassi and Gallese are associate professors. In the early 1990s their studies of motor systems in the brains of monkeys and humans first revealed the existence of neurons with mirror properties. They have since continued to investigate those mirror neurons in both species as well as the role of the motor system in general cognition. They frequently collaborate with the many other research groups in Europe and the U.S. now also studying the breadth and functions of the mirror neuron system in humans and animals.

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2.      In the News: Climate Change: WSJ vs Scientific American, The Final Word?

Jeffrey D Sachs director of the Earth Institute at Columbia University, in his Scientific American column, Sustainable Developments, in October discusses "Fiddling while the Planet Burns" He asks: Will the Wall Street Journal's editorial writers accept a challenge to learn the truth about the science of global climate change? Sachs outlines his position at (subscription required)

Climate Non-Conformity, WSJ, November 2, 2006

Two scientific events of note occurred this week, but only one got any media coverage. Therein lies a story about modern politics and scientific priorities.

The report that received the headlines was Monday's 700-page jeremiad out of London on fighting climate change. Commissioned by the British government and overseen by former World Bank chief economist Nicholas Stern, the report made the intentionally shocking prediction that global warming could eliminate from 5% to 20% of world economic output "forever." Meanwhile, doing the supposedly virtuous thing and trying to forestall this catastrophe would cost merely an estimated 1% of world GDP. Thus we must act urgently and with new taxes and policies that go well beyond anything in the failed Kyoto Protocol.

The other event was a meeting at the United Nations organized by economist Bjorn Lomborg's Copenhagen Consensus Center. Ambassadors from 24 countries -- including Australia, China, India and the U.S. -- mulled which problems to address if the world suddenly found an extra $50 billion lying around. Mr. Lomborg's point is that, in a world with scarce resources, you need priorities. The consensus was that communicable diseases, sanitation and water, malnutrition and hunger, and education were all higher priorities than climate change.

We invited Mr. Lomborg to address the Stern report, and he takes apart its analysis brick-by-brick in the columns nearby. To our reading, there isn't much left of this politicized edifice. But we'd stress a couple of points ourselves. To read these points, please go to (subscription required) For Mr Lomborg's analysis, read on.

Stern Review on the Economics of Climate Change, WSJ, By BJORN LOMBORG November 2, 2006

The report on climate change by Nicholas Stern and the U.K. government has sparked publicity and scary headlines around the world. Much attention has been devoted to Mr. Stern's core argument that the price of inaction would be extraordinary and the cost of action modest.

Unfortunately, this claim falls apart when one actually reads the 700-page tome. Despite using many good references, the Stern Review on the Economics of Climate Change is selective and its conclusion flawed. Its fear-mongering arguments have been sensationalized, which is ultimately only likely to make the world worse off.

The review correctly points out that climate change is a real problem, and that it is caused by human greenhouse-gas emissions. Little else is right, however, and the report seems hastily put-together, with many sloppy errors. As an example, the cost of hurricanes in the U.S. is said to be both 0.13% of U.S. GDP and 10 times that figure.

The review is also one-sided, focusing almost exclusively on carbon-emission cuts as the solution to the problem of climate change. Mr. Stern sees increasing hurricane damage in the U.S. as a powerful argument for carbon controls. However, hurricane damage is increasing predominantly because there are more people with more goods to be damaged, settling in ever more risky habitats. Even if global warming does significantly increase the power of hurricanes, it is estimated that 95% to 98% of the increased damage will be due to demographics. The review acknowledges that simple initiatives like bracing and securing roof trusses and walls can cheaply reduce damage by more than 80%; yet its policy recommendations on expensive carbon reductions promise to cut the damages by 1% to 2% at best. That is a bad deal.

Mr. Stern is also selective, often seeming to cherry-pick statistics to fit an argument. This is demonstrated most clearly in the review's examination of the social damage costs of CO2 -- essentially the environmental cost of emitting each extra ton of CO2. The most well-recognized climate economist in the world is probably Yale University's William Nordhaus, whose "approach is perhaps closest in spirit to ours," according to the Stern review. Mr. Nordhaus finds that the social cost of CO2 is $2.50 per ton. Mr. Stern, however, uses a figure of $85 per ton. Picking a rate even higher than the official U.K. estimates -- that have themselves been criticized for being over the top -- speaks volumes. . .

Most economists were surprised by Mr. Stern's large economic estimates of damage from global warming. Mr. Nordhaus's model, for example, anticipates 3% will be wiped off global GDP if nothing is done over the coming century, taking into account the risk for catastrophes. The Stern review purports to show that the cost is "larger than many earlier studies suggested."

On the face of it, Mr. Stern actually accepts Mr. Nordhaus's figure: Even including risks of catastrophe and non-market costs, he agrees that an increase of four degrees Celsius will cost about 3% of GDP. But he assumes that we will continue to pump out carbon far into the 22nd century -- a rather unlikely scenario given the falling cost of alternative fuels, and especially if some of his predictions become clear to us toward the end of this century. Thus he estimates that the higher temperatures of eight degrees Celsius in the 2180s will be very damaging, costing 11% to 14% of GDP.

The Stern review then analyzes what the cost would be if everyone in the present and the future paid equally. Suddenly the cost estimate is not 0% now and 3% in 2100 -- but 11% of GDP right now and forever. If this seems like a trick, it is certainly underscored by the fact that the Stern review picks an extremely low discount rate, which makes the cost look much more ominous now.

But even 11% is not the last word. Mr. Stern suggests that there is a risk that the cost of global warming will be higher than the top end of the U.N. climate panel's estimates, inventing, in effect, a "worst-case scenario" even worse than any others on the table. Therefore, the estimated damage to GDP jumps to 15% from 11%. Moreover, Mr. Stern admonishes that poor people count for less in the economic calculus, so he then inflates 15% to 20%.

This figure, 20%, was the number that rocketed around the world, although it is simply a much-massaged reworking of the standard 3% GDP cost in 2100 -- a figure accepted among most economists to be a reasonable estimate. . .

The Stern review's cornerstone argument for immediate and strong action now is based on the suggestion that doing nothing about climate change costs 20% of GDP now, and doing something only costs 1%. However, this argument hinges on three very problematic assumptions. . .

Why does all this matter? It matters because, with clever marketing and sensationalist headlines, the Stern review is about to edge its way into our collective consciousness. The suggestion that flooding will overwhelm us has already been picked up by commentators, yet going back to the background reports properly shows declining costs from flooding and fewer people at risk. The media is now quoting Mr. Stern's suggestion that climate change will wreak financial devastation that will wipe 20% off GDP, explicitly evoking memories of past financial catastrophes such as the Great Depression or World War II; yet the review clearly tells us that costs will be 0% now and just 3% in 2100.

It matters because Gordon Brown, Tony Blair and Nicholas Stern all profess that one of the major reasons that they want to do something about climate change is because it will hit the world's poor the hardest. Using a worse-than-worst-case scenario, Mr. Stern warns that the wealth of South Asia and Sub-Saharan Africa will be reduced by 10% to 13% in 2100 and suggests that effect would lead to 145 million more poor people.

Faced with such alarmist suggestions, spending just 1% of GDP or $450 billion each year to cut carbon emissions seems on the surface like a sound investment. In fact, it is one of the least attractive options. Spending just a fraction of this figure -- $75 billion -- the U.N. estimates that we could solve all the world's major basic problems. We could give everyone clean drinking water, sanitation, basic health care and education right now. Is that not better?  . .

Last weekend in New York, I asked 24 U.N. ambassadors -- from nations including China, India and the U.S. -- to prioritize the best solutions for the world's greatest challenges, in a project known as Copenhagen Consensus. They looked at what spending money to combat climate change and other major problems could achieve. They found that the world should prioritize the need for better health, nutrition, water, sanitation and education, long before we turn our attention to the costly mitigation of global warning.

We all want a better world. But we must not let ourselves be swept up in making a bad investment, simply because we have been scared by sensationalist headlines.

Mr. Lomborg, author of "The Skeptical Environmentalist" (Cambridge, 2001), teaches at the Copenhagen Business School and is director of the Copenhagen Consensus Center.

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3.      International Medicine: From The Journal of Child Psychology and Psychiatry  

Research published in The Journal of Child Psychology and Psychiatry in January has shown that even women without past mental health problems are at risk of psychological ill-effects after abortion. Women who had had abortions had twice the level of mental health problems and three times the risk of major depressive illness as those who had given birth or never been pregnant.

This research has prompted the American Psychological Association to withdraw an official statement denying a link between abortion and psychological harm.

Since women having abortions can no longer be said to have a low risk of suffering from psychiatric conditions such as depression, doctors have a duty to advise about long-term adverse psychological consequences of abortion.

We suggest that the Royal College of Obstetricians and Gynaecologists and the Royal College of Psychiatrists revise their guidance, and that future abortion notifications clearly distinguish between physical and mental health grounds for abortion.

Emeritus Consultant Obstetrician and Gynaecologist, Bridgend

Professor of Psychiatry, University College, Dublin

Consultant Psychiatrist, London

To review the list of 15 prominent physicians who asked the Royal College of Obstetricians and Gynaecologists and the Royal College of Psychiatrists to revise their guidelines, please go to,,59-2423358.html.

To read about SUE HULBERT, 44, who had an abortion in May 2000 and is only now recovering from the depression and psychosis that followed, culminating in an overdose, please go to,,8122-2424033,00.html.

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4.      Medicare: Stethoscope socialism By Deroy Murdock, Washington Times, September 5, 2006

A national health-care system may be the Holy Grail of American liberalism. If only the government managed medicine, the argument goes, costs could be restrained, quality assured and access extended from the poshest beach house to the humblest shotgun shack.

On NBC's "Meet the Press" last fall, Rep. Rahm Emanuel, Illinois Democrat, advocated a "universal health-care system over the next 10 years." If Sen. Hillary Rodham Clinton, New York Democrat, reaches the Oval Office, she likely would take another crack at socialized medicine, as she did so disastrously in 1994.

Amy Ridenour of the National Center for Public Policy Research sees this model more as a poisoned chalice. Her Washington-based free-market think tank (with which I am a "distinguished fellow") has begun educating Americans on the massive belly flop that is state-sponsored health care. Wherever bureaucrats control medicine, the wise money says: "Don't get sick."

It would be bad enough if national health care merely offered patients low-quality treatment. Even worse, Ms. Ridenour finds, it kills them.    • Breast cancer is fatal to 25 percent of its American victims. In Great Britain and New Zealand, both socialized-medicine havens, breast cancer kills 46 percent of women it strikes.
    • Prostate cancer proves fatal to 19 percent of its American sufferers. In single-payer Canada, the National Center for Policy Analysis reports, this ailment kills 25 percent of such men and eradicates 57 percent of their British counterparts.
    • After major surgery, a 2003 British study found, 2.5 percent of American patients died in the hospital versus nearly 10 percent of similar Britons. Seriously ill U.S. hospital patients die at one-seventh the pace of those in the U.K.
    • "In usual circumstances, people over age 75 should not be accepted" for treatment of end-state renal failure, according to New Zealand's official guidelines. Unfortunately, for older Kiwis, government controls kidney dialysis.
    • According to a Populus survey, 98 percent of Britons want to reduce the time between diagnosis and treatment.

Unlike America's imperfect but more market-driven health-care industry, nationalized systems usually divide patients and caregivers. In America, patients and doctors often make medical decisions and thus demand the best-available diagnostic tools, procedures and drugs. Affordability obviously plays its part, but the fact that most Americans either pay for themselves or carry various levels of insurance guarantees a market whose profits reward medical innovators.

Under socialized medicine, public officials administer a single budget and usually ration care among a population whose sole choice is to take whatever therapies the state monopoly provides.

Medicrats often distribute resources based on politics rather than science. Government doctors and nurses frequently are unionized. As befalls American teachers in government schools, excellence rarely generates additional compensation - so why excel? Without incentives, such structures eventually breed mediocrity. Patients in universal-care systems get cheated even worse than do students in failing public schools. While their pupils suffer intellectually, politically driven health care jeopardizes patients' lives.

    • Emily Morely, 57, of Meath Park, Saskatchewan, discovered that cancer had invaded her liver, lungs, pancreas and spine. She also learned she had to wait at least three months to see an oncologist. In Canada, where private medicine is illegal, this could have meant death. However, Mrs. Morely saw a doctor after one month - once her children alerted Canada's legislature and mounted an international publicity campaign.

    • James Tyndale, 54, of Cambridge, England, wanted Velcade to stop his bone-marrow cancer. However, the government's so-called "postcode lottery" supplied this drug to some cities, but not Cambridge. The British health service finally relented after complaints from the Tories' shadow health secretary, MP Andrew Lansley.

   • Edward Atkinson, 75, of Norfolk, England, was deleted from a government hospital's hip-replacement-surgery waiting list after he mailed graphic anti-abortion literature to hospital employees. "We exercised our right to decline treatment to him for anything other than life-threatening conditions," said administrator Ruth May. She claimed her employees objected to Mr. Atkinson's materials. Despite a member of Parliament's pleas, Mr. Atkinson still awaits surgery.

For all its problems, America's more market-friendly health system offers patients better care and would deliver greater advancements if government adopted liability reform, interstate medical insurance sales, unhindered health savings accounts and other pro-market improvements. As for importing universal care, author P.J. O'Rourke said it best: "If you think health care is expensive now, just wait until it's free."
Deroy Murdock is a columnist with the Scripps Howard News Service and a senior fellow with the Atlas Economic Research Foundation in Arlington, Va.

Our thanks to MedicalTuesday member Gretchen Longcore for bringing this article and others to our attention.

 Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5.      Medical Gluttony is Increasing System Inefficiency: This is NOT Sustainable.

We were introduced to Jim Womack's Lean Marketing ( concepts by the CEO of Superfactory ( and have been following this idea over the past couple of years. We have been keeping our members informed of their medicinal application. This month, the editor of Superfactory, in commenting on their tremendous growth, emphasizes that lean manufacturing and lean enterprise methods are required to remain competitive in our global economy. So much of health care is moving in the opposite direction in the pursuit of cost control, when in fact it is increasing costs and decreasing efficiencies. The only problem is that the system is unable to measure many of these costs. Many doctors who weren't in tune to business practices were persuaded in giving up their formerly small, efficient business units. They were seduced by hospital PHOs, IPAs, Foundations, and managed care organizations (MCOs) into believing that the larger unit was required to be efficient. However, efficiency has been lost.

Let us look at the simple one-minute process of writing a prescription for the patient. This has created a nightmare of costs that is not recorded as medical costs. My front-office staff will spend up to 15 minutes on the phone before hand trying to determine which particular drug is covered by that patient's health plan. In several instances, the same prescription will generate three separate phone calls before the resolution. This, in effect, is more time in completing a one-minute prescription than the initial 20-minute office visit. The more than 100 percent increase in cost to the physician's office is not noted as a health-care cost.

This is not just an isolated instance. Caremark, Rx Solutions, Medco, and Express Scripts all have the same problem. My front-office assistant estimated that her time devoted to this task on two days last week exceeded three hours each day. (To see what pharmacy benefit managers' CEO's make, go to

At a Blue Cross Conference, one of these Pharmacy Benefit Managers extolled the efficiencies of their system. When the patient picks up his last refill, they immediately start faxing the doctor's office for renewals, sometimes daily. We pointed out that all of our patients get refill renewals on all their prescriptions until their next appointment, PLUS one month in case they have to reschedule. Hence, we would appreciate not getting 20 to 30 faxed requests for refills a day. My patients probably are already scheduled for their next visit before the current refill is used up. At that time, they will get new prescriptions with refills to last one year or until their next appointment. Unless I happen to get to the office before my staff so that I can put the 20 or 30 faxes through the shredder, it creates an office cost in processing all that unnecessary paper work.

Before answering the question, the speakers looked at each other for a moment and then replied that they had developed this super efficient system, and they would not consider making it less efficient. What they perceived as efficiency was not lean healthcare, but was actually gluttonous health care, which decreases efficiency and increases costs. Gluttonous health care cannot survive in the free market. It will die - unless the government takes over health care, in which event it will thrive and flourish.

The Free and Open Medical Market Place Will Make Health Care Lean and Affordable.

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6.      Medical Myths:  Rising to the Challenge by Donald W Fisher, PhD, President & CEO

Publisher's Comment: Group Practice Journal, American Medical Group Association

This issue features highlights from, our recently published 2006 Medical Group Compensation & financial Survey. According to findings, most specialties saw modest increases in compensation in 2005. Declining reimbursements, competition for specialists, the cost of new technology, and other factors are having a negative effect on revenues in most parts of the country, a situation that is clearly unsustainable.

The section of the survey that examines financial operations also found that medical groups were operating at an average loss of$1,264 s per physician (median performance per physician). It reports significant variation by region: groups in the Northern Region continue to operate at a significant loss, $8,111 per physician. Medical groups in the Eastern and Southern regions continue operating at a loss $3,494 and $1,539 per physician, respectively). Groups in the Western Region were performing better at 7,970 per physician.

In the face of the current economic climate, medical groups are rising to the challenge of delivering the highest quality, coordinated care to the patients they serve. One of the components contributing significantly to the trends in financial performance of medical groups is the current payment model. Most of the groups represented in the survey are large multispecialty groups that make substantial investments in technology, operations, and the most innovative care processes to best serve populations under their care, and are able to achieve remarkable results for their patients. Our current transaction based reimbursement system is indifferent to these results and to the efforts of medical groups to elevate the standard of care in the U.S.

lMGA's Results-Based Payment System (RPS) initiative seeks to design and implement a reimbursement system that rewards care quality and results. The RPS initiative seeks to develop a new model for reimbursement, based on improved healthcare delivery with regard to efficiency, timeliness, quality, appropriateness, and other factors. Results-based payment moves beyond today's pay-far-performance (P4P) models, and would promote coordinated care, technologic innovation, and continuous learning, as well as increase accountability for all stakeholders in health care. For more information, visit

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7.      Overheard in the Medical Staff Lounge: The Butcher of Baghdad Meets His Fate

There were three newspapers on the staff room dining tables: the Sacramento Bee, the SF Chronicle, and the Wall Street Journal. The WSJ had no headlines for the Saddam Hussein verdict. The other two highlighted the news in huge print.

Dr  Edwards: Yesterday's papers both said that the Saddam verdict will further divide Iraq. Today's headlines state that the Saddam verdict elicits hope. Which is it?

Dr Yancy: There can't be any more division than there is already. The Shiites and Kurds will be elated that the Butcher of Baghdad will meet his due reward.

Dr Ruth: But the Sunnis say that Saddam was a righteous man. They aren't going to take this.

Dr Edwards: But the division can't get any worse. The verdict should help bring closure.

Dr Ruth: But there has never been a trial and verdict in the Arab world such as this. What will be the fallout in the entire region?

Dr Yancy: The people of the mideast have been fighting and killing each other for thousands of years. Nothing is going to change that picture.

Dr Ruth: After the elections, there might be a greater push to leave them alone to let them do their killing in peace without our presence.

Dr Edwards: But many of our soldiers who are fighting for the cause are now saying, we can't leave. We need to stay. Doesn't that say something? Isn't that a bit more insightful than our congressmen who visit the battlescarred country and come back as experts after a few days?

Dr Yancy: You can't trust a congressman. They don't have an opinion until after they read the polls about what their constituents think.

Dr Rosen: It was Lew Rockwell who said that they don't have a brain. No one with a brain goes to Washington anymore. No one with a brain goes to a country and overnight considers himself an expert in their history and culture.

Dr Yancy: I spent four years of my training in Israel and know the area well. I'll be watching the hanging on TV with my family. I hope the cameras will be able to pick up the first Shiite or Kurd that puts a bullet through Saddam. After the first bullet, I'm sure there will be hundreds. The Arab world doesn't believe in gun control.  There may be thousands firing. That will be closure for a lot of folks.

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8.      Voices of Medicine: A Review of Regional Medical Journals from Rural California

The Bulletin, Published Monthly by the Humboldt-Del Norte County Medical Society, Sept 2006

IN MY OPINION: The Way We Were (And Will Be Again) by GEORGE INGRAHAM, M.D.

It was 1970: I had finished my residency and settled in Eureka. There were three hospitals in the city: Humboldt County Medical Center and the General Hospital, in addition to St Joseph. Each hospital staff met as a whole once a month. New docs needed to be on all three staffs if they wanted to build a referral practice. We had no neurologist, plastic surgeon, or neurosurgeon.  Emergency room physicians were unknown outside academia. We were all, on a rotating basis, on call to the hospital emergency rooms: ophthalmologists were called to deliver babies and internists were consulted for corneal abrasions. The hospital ERs were not staffed until a patient was brought in, at which point the nursing supervisor would unlock the Emergency Room and telephone the patient's family physician or whoever was on call for that day.

We had no scanners, much less computers, and no physician expanding FNP's, PA's, or CRNA's. We had only two female physicians, women having been felt by our predecessors not to be suited (I had a surgical mentor who proclaimed to our incredulous group that it was a waste of resources to let women into medical school at all) to the practice of medicine. More on this foolishness later.

What we did have; and it made up for many of the things the community lacked, was a very close-knit county medical society. The monthly meetings were held at OH's Town House (they still do a pretty good prime rib!) and with some exceptions every physician was there every month. Everyone knew the community's problems, which were discussed (not always dispassionately by those who had begun the evening at the bar) and dealt with as best we could. The medical society was an integral part of the mechanism of the community, and willingly accepted responsibility for seeing to it that the medical care part of the community was adequate and effective. Unfortunately, it was a men's club: it could get rowdy, and there were some outsize egos on parade. But by and large, flawed as it was, through the haze of bourbon fumes and cigarette smoke, angry exchanges, and the occasional abrupt and angry departures…it worked.  Some decades passed, and with them most of my hair, near vision, and svelte physique. We got a CAT scanner, Ted Loring bought a computer to do his billing, Russel Pardoe came to town, FNP's and PA's came on the scene, and ER docs became part of the herd, over the misgivings of the family practice docs who saw them as a threat and insisted on reassurances that they wouldn't be allowed to follow up on cases they had seen. The size and diversity of the medical community increased.  Hospital staffs, too large to meet as a whole, became departmentalized; and the medical community fragmented. You could actually pass another physician on the street and not recognize him or…good grief...her!  Attendance at the monthly meeting of the Society declined (largely due to an apathy which still confuses me) to the point that it was no longer felt to be worthwhile. The sense of community was largely lost. Fortunately the Medical Society remained intact.  The medical community now faces major changes in Eureka's one remaining hospital. The recruitment of new docs falls short of our need to replace the aging physician workforce. Falling reimbursements and intrusive management of care…but you know the list.

What's heartening is the resurgence of the Medical Society as the vehicle within which this loose collection of docs, unable to deal with these problems as individuals, may again become a de facto medical community with a real connection to the community we live in. With any luck, we will get back to where we were thirty odd years ago, minus the posturing and the verbal brawls. OK, most of the verbal brawls. For this we must largely thank Ellen Mahoney, whose willingness to take her time, that limited and irreplaceable gift, to organize and lead the troops, and Kate McCaffery, who is recruiting new members. The conventional wisdom is that psychologically women are better at finding consensus and organizing groups toward shared goals, and if so we are very lucky to have women leaders who can grab us by the ears and tell us "OK: we're going to deal with these problems; now sit down over there and start cooperating!"

Or maybe gender has nothing to do with it. After all, they're both Irish. §


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9.      Book Review: From our Archives: Inside the AARP

TRUST BETRAYED - Inside the AARP by Dale Van Atta. Regenery Publishing, Inc. Washington, DC: 1998, 208 pp, $25, ISBN 0-89526-485-4.

Dale Van Atta wrote a syndicated column with Jack Anderson that ran in more than 800 newspapers for over seven years. Today, he is a freelance author and journalist. He dedicates this volume to his aging mother, Vera Van Atta. We should alert our aging parents, even those under age 50, about this volume and the highly charged promotional campaign of the AARP.

The AARP is the second-largest organization in the United States, after the Catholic Church. It has thirty-three million members. Ethel Percy Andrus, a retired schoolteacher, was its founder. Steeped in the American ethos of God, country, and self-reliance, she explicitly stated that the "AARP is not a pressure group, petitioning for special privileges and exemptions because of age and numbers."

Today, the AARP supports higher taxes, disastrous health care legislation that threatens seniors, and other political causes such as attempting to defeat property tax reductions, the very thing that allows many retired seniors to keep their homes. The AARP has numerous business enterprises, including insurance and pharmaceuticals, that it claims are nonprofit services for seniors, but which are revenue engines for AARP causes and profit its business partners. Colonial Penn derives 80% of its profits from the AARP monopoly.

The AARP, with an income of more than $400 million a year, spent $83 million for salaries and benefits in 1994. Nineteen of the AARP's 1,732 employees earn more than $100,000 a year. The executive director, Horace Deets, headlined in a 1997 Fortune magazine profile as Washington's Second Most Powerful Man, making $357,000 a year in salary and benefits ($157,000 more than Washington's Most Powerful Man!) plus $49,000 in expenses. The block-long office building in DC, which some of its members call a Taj Mahal, reputedly cost $117 million. And in 1990, the AARP spent more than twice as much furnishing its posh headquarters than it spent on programs assisting the elderly. To read the entire review, go to

To read other reviews, please go to the Physician/Patient Bookshelf at

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10.  Hippocrates & His Kin: Practice Guidelines can work in two ways - neither of which are good.

At medical grand rounds this past week, the speaker addressed the guidelines that will rule medicine. He mentioned that shifting the guidelines on mammograms minimally could make a difference in saving billions of dollars in health-care costs. So let's see. If the radiology lobby gains ascendancy and changes the guidelines for mammograms to earlier than the current age or to obtain them more frequently, it could add billions of dollars to the radiologist's income?

Bureaucratic medicine will always favor the ones in power over the ones practicing good medicine.

It's a Relief to Know the Truth after All Those Conflicting Medical Studies

On two tables of stone, DIETS & DYING found on Mt Ararat, a short distance from Mt Sinai, the final word on nutrition and health were found. (We're researching the validity of the finding.)

The Japanese eat very little fat or red wine and suffer fewer heart attacks than the British or Americans. The French eat a lot of fat, drink a lot of red wine, and also suffer fewer heart attacks than the British or Americans. The Italians drink excessive amounts of red wine and a lot of cheese and also suffer fewer heart attacks than the British or Americans.

CONCLUSION: Eat and drink what you like. Speaking English is apparently what kills you.

During the course of the election campaigns, a San Franciscan didn't seem too worried that any Republican could or would get elected. He said San Francisco has the best politicians that money can buy.

Although some people think that things will be getting better after the elections, let's remember Yogi Berra: "Predictions are very difficult, especially about future events."

To read more vignettes, please go to

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11.  Organizations Restoring Accountability in HealthCare, Government and Society:


                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at and register to receive one or more of these reports. Be sure to review their new website for the latest on Consumer Directed Health Care at

                      Pacific Research Institute, ( Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may subscribe at or access their health page at Be sure to read Sally Pipes on the Mass Medical Mess at

                      The Mercatus Center at George Mason University ( is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government: This month, be sure to read Mr McTigue on Making a Difference Through Good Governance at

                      The National Association of Health Underwriters, The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business. Be sure to review the current articles listed on their table of contents at To see my recent columns, go to

                      The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at This month, be sure to read Massachusetts Health Plan is No Model for Other States at

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to To join, go to Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn at To read the current issue, go to

                      The Heartland Institute,, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care? at You may sign up for their health care email newsletter at

                      The Foundation for Economic Education,, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. This month be sure to read Dr Ebeling's The Misplaced Acceptance of Political Leaders at

                      The Council for Affordable Health Insurance,, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse." For a quick review of their news releases and recommendations, go to

                      The Health Policy Fact Checkers is a great resource to check the facts for accuracy in reporting and can be accessed from the preceding CAHI site or directly at Many of the articles are slightly dated, but the facts are real. This week, read the Daily Medical Follies: "Woeful Tales from the World of Nationalized Health Care" at

                      The Independence Institute,, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter at Read her latest newsletter at, which includes a section on PC Medicine and Euthanasia. To read the real story of the effects of minimum wage, please go to

                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read Martin Masse's editorial Sir John Cowperthwaite was the main figure responsible for Hong Kong's economic transformation, lifting millions of people out of poverty at Asked what is the key thing poor countries should do, Cowperthwaite once remarked: "They should abolish the Office of National Statistics." In Hong Kong, he refused to collect all but the most superficial statistics, believing that statistics were dangerous: they would led the state to to fiddle about remedying perceived ills, simultaneously hindering the ability of the market economy to work.

                      The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at for an overview of the extensive research articles that are available. You may want to go directly to their health research section at The Fraser Institute's sixteenth annual waiting list survey found that Canada-wide waiting times for surgical and other therapeutic treatments increased slightly in 2006. To read the report, go to

                      The Heritage Foundation,, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. This month read the CNN Poll: Majority believes government doing too much at

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at to obtain the foundation's daily reports. This month, be sure to read, Small States, Global Economy: Is Empire Necessary? at You may also log on to Lew's premier free-market site at to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see; or to find out why anyone would want to be an MD today, see

                      CATO. The Cato Institute ( was founded in 1977 by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio at This month be sure to read The American Way of War at

                      The Ethan Allen Institute,, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

                      The Free State Project, with a goal of Liberty in Our Lifetime,, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.] Be sure to read about their new Strategy in Our Lifetime at their opening page.

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. You may join them to explore the Roots of American Republicanism on a British Isles cruise on July 10-21, 2006. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read Dr Arnn on The Crisis and Politics of Higher Education The last ten years of Imprimis are archived at

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Del Meyer, MD, Editor & Founder

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Words of Wisdom

Good judgment comes from experience. Experience comes from making bad judgments. -Lillihei

There is nothing either good or bad, but thinking makes it so. -William Shakespeare

Life is not a matter of being dealt a good hand, but playing a poor hand well. -Robert Louis Stevenson

Some Recent Postings

October HPUSA Issue:

July HPUSA Issue:

In Memoriam

P.W. Botha: The "crocodile" slips away From The Economist, Nov 2nd 2006

Few mourn the death of an unrepentant symbol of apartheid

ANOTHER page of history has been turned in South Africa. P.W. Botha, who led the country from 1978 to 1989 at the height of the anti-apartheid struggle, died on October 31st at the age of 90. Listening to the messages of condolence to his family from his former adversary, Nelson Mandela, and President Thabo Mbeki, it may seem strange to recall that he was once utterly reviled in South Africa and abroad. An unrepentant hardliner of irascible temper, Mr Botha - known as the "great crocodile" - never apologised for the evils of apartheid. Yet Mr Mandela, faithful to his undying spirit of reconciliation, credits him for playing a critical role in bringing them to an end. . . He also never made any excuses for apartheid. . . In contrast to the conciliatory condolences from the ANC leadership, the Pro-Afrikaans Action Group, an outfit campaigning for Afrikaner rights and culture, which they consider under threat, said this week that Mr Botha may eventually be seen in a more benign light. . . For the present, however, few South Africans are shedding any tears over the symbol of an era that most are trying to forget. To read the entire Obit, go to

To read an additional obit from the London Times, please go to,,60-2431814,00.html.

On This Date in History - November 14

Nellie Bly, a newspaper reporter, was sent off on this date in 1889 by The New York World to try to travel around the world in less than 80 days. She made it in 72. There is so much to see in this world, that exploration has not stopped with Planet Earth. It will continue into the entire Universe. On the other hand, we travel so much faster that we see less and less of the world in which we live.

Moby Dick was published on this date in 1851. Herman Melville, who had written five books before Moby Dick, rates as one of our greater authors. It begins with the words, "Call me Ishmael" and goes on to say, "I love to sail forbidden seas, and land on barbarous coasts." There is much other imagery in Moby Dick, the great white whale, Captain Ahab's grim pursuit, and world of all the Ishmaels, disenchanted with what is around them, seeking forbidden seas. Within this realistic account of a whaling voyage, is set a symbolic account of the conflict between man and his fate.


In the U.S. a child is born every seven seconds, according to the U.S. Census Bureau. A person dies every 13 seconds. A migrant enters the country every 31 seconds. There's a net gain of one person every 11 seconds.

Since 1900 the U.S. has experienced just one population decline -- in 1918, because of World War I and a flu epidemic. 1950 saw the largest post-War growth -- 2.05% in that year.

An estimated 106 billion people have lived on planet Earth, according to the Population Reference Bureau. The current population is about 6.5 billion. That means about 6.1% of all people ever born are alive today.

Today foreign-born people make up 12% of the U.S. population, with Mexico as the leading country of origin. In 1967 they made up 5%, with Italy as the leader. In 1915 they made up 15%, with Germany as the leader.

By 2050 the world population is expected to increase to 9.1 billion from 6.5 billion today. Nine countries are expected to account for half the world's projected population increase: India, Pakistan, Nigeria, Dem. Rep. of Congo, Bangladesh, Uganda, U.S., Ethiopia and China.

The U.S. population officially hit 100 million in 1915. It hit 200 million in 1967. It hit 300 million [this year - 2006]. It is expected to hit 400 million in 2043.