On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health

Author: Dr. Jerome P. Kassirer

The profession of medicine encompasses a wide variety of ways in which a physician can dedicate his or her life within the traditional areas of clinical practice, research, education, and administration. In this book, Jerome Kassirer, a former editor-in-chief of the Journal, documents, with well-referenced examples, how conflicts of interest, primarily financial in nature, have infiltrated all areas of the profession. The audience for the book is clearly the U.S. public, who, the author writes, "must become involved if we are to change the greed culture that permeates medicine." I agree, in principle, with the author that there are substantial conflicts of interest within the medical profession. However, I question the potential effectiveness of this book as written for the public. The most obvious reason for a physician of Kassirer's stature as a clinician, academician, and former editor to write a book about conflicts of interest in medicine would be to continue his attempts to eliminate or at least decrease a problem that diminishes the profession. But is this book a good way to accomplish that goal? The book wavers between a scholarly work and a sensational expose. For example, the cover features a man wearing a white coat and a neat shirt and tie, with a stethoscope around his neck and a pricey pen and a few crisp $100 bills tucked in his pocket. I was taken aback by the image, which is clearly meant to depict a "fat cat doc" on the take. However, this jarring image is then tempered by the two opening sentences of the first chapter, which declare that most physicians are hard-working and dedicated to their patients and that perhaps even hundreds of thousands of physicians refuse to take any financial gift that might affect their clinical judgment. Then, aside from a few selected exceptions to that supposed rule, the rest of the book is dedicated to stories about physicians tainted by financial self-interest that altered how they cared for patients, how their research was conducted and reported, what they taught, and how they administered medical institutions, with evidence that all of these conflicts of interest led to the detriment of patient care. The final chapter discusses "what can be done," ending with a "possible roadmap" that includes 10 items for immediate implementation that would be possible primarily by legislation. The reader is asked to take a political stand to force the enactment of such legislation. If the reader were to take such action, the author would deserve a medal. However, if the reader's more likely reaction would be to view with distrust all physicians currently practicing in the United States, it would be unfortunate indeed and would undermine the very reason that the book was written. Catherine D. DeAngelis, M.D., M.P.H.

Dr Jerome Kassirer’s new book published for a general audience, On the Take: How Medicine’s Complicity With Big Business Can Endanger Your Health, chronicles the kind, extent, and consequences of collaborations between the medical profession and industry.¹ Adopting the style of an investigative reporter, this highly respected former editor of The New England Journal of Medicine relates, within 213 highly readable pages, a litany of well-referenced examples demonstrating that pernicious financial conflicts of interest are rife in medicine today and threaten to undermine the integrity of the profession. Although many of the incidents recounted in the book are already matters of public record, their inclusion in a single volume provides some sobering and most unsettling food for thought.

Beginning in Chapter 1 with the innocent free gifts, free meals, and free education many doctors receive, Dr Kassirer takes the reader through 8 revealing chapters to demonstrate that "trinkets bloom into meals at fine restaurants, meals grow into speaking fees, speaking fees morph into ongoing consultations and membership on drug company advisory boards, positions that can command up to six figures a year." He raises the question "Has all this money floating around medicine created a pattern of corruption?" By all indications, his answer to this question appears to be a resounding yes, with which we agree. The vis-à-tergo for this perfidy is attributed to the massive expansion of the highly profitable drug, device, biomedical, and commercial educational industries. This dramatic growth began to occur just after increased federal funding enhanced training and research programs in the 1960s, resulting in a flourishing of the academic medical enterprise within the United States. To further profits and remain competitive with the international market, so it reasoned, Congress passed legislation that provided financial incentives for academic medical centers and their investigators to patent their discoveries. As a result, leaders of major medical centers reaped the institutional rewards of licensing agreements, scientists were enriched by royalties, and industry profited from the resulting end product.

Under dramatic headings such as "Money-Warped Behavior," "Your Doctor’s Tainted Information," "Our Obliging Professional Organizations," "Can You Trust Your Doctor," and "Can We Trust Our Researchers," the reader is shown how pervasive conflicts of interest have spread up the professional food chain and have tainted multitudes of physicians and scientists along the way. This pool of professionals includes some who occupy our loftiest ivory towers, some within our federal agencies such as the National Institutes of Health and the Food and Drug Administration, some in our volunteer health agencies, many of our professional organizations and scientific societies, and even some of the panels of experts assembled to promulgate clinical practice guidelines. To be certain, the book also indicts those medical practitioners who are driven by greed. The exposé seems shocking in its extent and as distasteful as the jacket of the book must have been intended when designed, portraying as it does a $100 bill protruding from the breast pocket of an anonymous physician’s white coat.

In the main, Dr Kassirer’s theme strikes at the core of our conscience. There are incontrovertible dictums for the clinical practitioners that most would agree are to be avoided, such as meals at fancy restaurants; industry-sponsored trips, boondoggles that are usually promulgated under the guise of continuing medical education (CME); finder’s fees for enrolling patients in clinical trials; stipends for "pseudoconsulting"; and lavish fees for publishing articles favorable to industry in non–peer-reviewed journals. For the physician-investigator, there is always the possibility that the results of an industry-funded study will be negative or, worse, that the treatment may cause adverse effects. For this reason it must be considered axiomatic that the physician-investigator always remain therapeutically distant from his or her study subjects.

Not one to split hairs, Dr Kassirer stands clearly opposed to allowing editors, associate editors, editorialists, authors of review articles, guidelines developers, and principal investigators of large clinical trials to have any financial entanglements with industry whatsoever. He ingeniously develops such principles as "the fallacy of unique expertise" and "incestuous amplification." He mounts a compelling argument that all gifts from industry, however small (lunch included), are marketing ploys against which we have only limited resistance and that universally arouse a feeling of reciprocity in all of us. He argues that the practice of disclosure of conflicts within the profession is a hollow sanitation device that has failed because of little policing and no sanctions.

Unquestionably, this book is extremely effective at highlighting what is a powerful and well-organized effort by the pharmaceutical and device industries to co-opt vulnerable physicians. These efforts take many forms, but a particularly visible one is the major subsidization of CME programs. As an example, at the annual scientific sessions of both the American Heart Association and the American College of Cardiology, there are as many as 60 to 70 industry-sponsored satellite symposia, each featuring important and well-remunerated academic speakers, and many are accompanied by a free breakfast or dinner. Perhaps the most widespread tactic used to ingratiate the most vulnerable of physicians (overworked and debt-ridden trainees) to industry is the almost-daily practice of the "drug rep" providing meals at teaching conferences at most academic medical centers, community hospitals, and VA hospitals throughout the United States. For the key opinion leaders in a local community or specialty field, the attractions are more substantive, with lucrative appointments to company-funded speaker bureaus, consultantships, and advisory boards, each with its premium honorarium. Increasingly, medical investigators are becoming owners in part or in whole of patents and small companies and are offered stock or stock options in the sponsoring company; some have reaped enormous profits in the process.

In taking this instruction-by-example approach, however, Dr Kassirer does little to inform the reader of the precise magnitude of the problem, perhaps because the magnitude is in fact unknown. Even the informed reader may erroneously conclude that all physicians engage in these relationships and do so with the intent of deceiving their patients. The reader can only be impressed with Dr Kassirer’s unwavering ethic but is likely to be confused by his assertion that the pharmaceutical device–biomedical industry "is not the evil empire," when any remunerated interaction with industry is portrayed as a serious conflict of interest—so serious, in fact, that it should preclude the recipient from participation in any of a variety of professional activities ranging from clinical guidelines development, to writing editorials or review articles, to participating in analyses of many large databases. Such a policy would exclude many of the most qualified and distinguished members of the medical profession from participation in these vital activities. Perhaps it is more direct to state that Dr Kassirer has overlooked or underestimated the power of peer review and consensus development.

Dr Kassirer does acknowledge that his lexicon of egregious professional behavior in medicine did not come about in isolation, but rather that the abuses have paralleled "changes in the culture and the norms of society." We quite agree that practices such as excessively compensating CEOs undermine the nation’s trust in the corporate world and note that the huge salaries of many senior administrators in the healthcare industry are not far behind in this regard. We also hasten to add that, entirely apart from any influence exerted by the pharmaceutical and device industries, hyperbole is the grammar of our day, and sensationalism drives the expanded media coverage we now witness. Throughout all of society there has been an acknowledged decline in traditional morals. Examples of ethical compromises and flagrant greed abound in our culture and have tainted such icons as the New York Stock Exchange and many of its leading corporate members, the Olympic Organizing Committee, the FBI laboratories, government at almost every level, prominent philanthropies, and even organized religion.

Although we do not deny the perils that are associated with excessive interaction with industry that Dr Kassirer so clearly documents, we suggest the case is not presented with adequate balance. Surely one cannot accept the premise that all relationships between physicians and industry are pejorative. To the contrary, there are many physician-scientists who, working with the support of pharmaceutical companies, have identified the mechanism of a disease or devised a therapy that has ultimately demonstrated efficacy and safety and provided significant advances for the care of patients. Some of these individuals have even won Nobel prizes. Similarly, there are many overstretched practicing physicians who find it time-sparing and beneficial to receive early information about new drugs or new technologies from an industry representative, identifiably biased, who visits periodically to provide an incidental, inexpensive but convenient lunch. Physicians are trained to think critically, and they should be able to place the information in appropriate perspective with or without accompanying comestibles. As there are many examples of ethical and mutually beneficial liaisons among medical schools, hospitals, and professional societies, we maintain there is a need to be open-minded about these relationships and to assume that the intent of forming them is not always driven purely by unbridled greed and self-interest.

Fiscal pressures have created and will continue to create tensions among physicians, not-for-profit agencies, academic medical centers, and industry. Eliminating industry relationships is not only impractical but potentially financially detrimental for the organizations involved, particularly the academic medical centers.² Without fair and appropriate compensation from third-party payers for clinical services to hospitals and physicians, adequate support from the NIH, or sufficient philanthropy or institutional wealth, many are pushed to participate in commercial relationships when the opportunity presents itself. Although the relationships may be thorny, it is a choice that could be made for a greater good if there were "a practical, effective, clearly defined, and evenly applied process in place at each academic medical center to address key questions."³ Unfortunately, uniformly applicable guidelines do not exist for the medical profession, and it is difficult to find comparative guidelines from other professions or even the government that could serve as constructive examples of how to achieve this end. We feel strongly that this should be a primary goal of our profession and that every effort be made to find the solution in some pooling of the combined wisdom of our academic institutions and our many prestigious professional societies.

Before we arrive at how to manage conflicts of interest, however, we must fully disclose these potential conflicts without fear of shame or taint. Rather than being virtually meaningless, as Dr Kassirer claims, we view disclosure as an essential element for helping to mitigate the problem. Whenever a speaker or author reveals the existence of an industry relationship, physicians should be especially critical of the content and decide whether the presentation is unbiased science or a subtle endorsement of a product. Dr Kassirer rightly points out that as currently constituted, disclosures give no indication of the magnitude of physician-industry relationships. Rather than scrapping them, however, the medical profession should strive to make disclosures meaningful, perhaps by developing designations for categories of involvement that would signify whether the degrees of physician-industry relationships are major or minor.⁴

We applaud the incisive editorial mind and facile pen that bring to our attention the stretching of the moral fiber that threatens the tensile strength of the trust that binds us to our patients. We subscribe to the comments offered by the eminent individuals quoted on the back cover of Dr Kassirer’s book and to many of the commonsense suggestions for improving relationships between medicine and industry he offers in his concluding chapter. The most powerful is the call for an Institute of Medicine study, which would carry enormous weight in providing direction in this murky field. We do not feel the situation calls for draconian measures, although we can envision sending no more emphatic a message to industry, the medical profession, and the public than having the recognized leaders of medicine divest themselves promptly, publicly, and voluntarily of all recognizable conflicts of interest. Medical societies should suggest that their membership do likewise. We would do well to consider taking a page from the book of our students, who, at the 2002 meeting of the American Medical Student Association, approved a policy that urges physicians and trainees alike not to accept gifts from industry and to refuse honoraria for speaking or for token consulting, that opposes giving CME credits for drug company–sponsored events, and that urges hospitals to put an end to pharmaceutical company–funded lectures and lunches on and off site.⁵

Each physician, hospital, academic medical institution, or professional society must decide individually on the merits of any potential relationship with industry. The pros and cons must be weighed carefully. The pros are largely financial gain; the cons involve ethical risks that can potentially undermine the integrity of the individual, institution, or organization. In forging relationships between medicine and industry, 2 overriding principles seem self-evident. First, the rights and welfare of patients must transcend all other considerations. Second, the integrity of the involved parties must never be compromised. With this in mind, we also must recognize that the complexity of biomedical science, with its sophisticated and costly techniques, coupled with its dependency on academic innovation, is creating an ever-growing interdependence of universities and commercial entities. We strongly endorse those who propose developing new rules of engagement that would be universally applied in an open, informed, and timely manner and would be operative at each academic medical center to translate policy into practice.³ It is our conviction that full disclosure and transparency in medical-industry relationships should ultimately be the rule, not the exception.

Free Lunch: How the Wealthiest Americans Enrich Themselves at Government Expense (and Stick You With the Bill)

Author: David Cay Johnston

For its first 280 pages, the new exposé from this Pulitzer Prize-winning New York Times reporter is an engaging look at how the superrich consistently—and outrageously—rely on public handouts while preaching about free markets and wasteful entitlement programs all the way to the bank. The villains in David Cay Johnston's tales run the gamut from railroad executives to sports-franchise owners to hedge-fund managers, all joined by a willingness to take enormous sums from public coffers while providing little or nothing in return.

Take former Treasury Secretary John Snow, whose csx railroad saved billions by skimping on maintenance; when there was a fatal crash, taxpayers footed the bill. Before entering politics, George W. Bush ran a money-losing baseball team, but ended up millions of dollars richer by getting a government-funded sweetheart deal on a new stadium. Retail chains like Wal-Mart win property-tax breaks and then squeeze out local businesses that pay their fair share. The free ride has become business as usual, but Johnston sees it for what it really is: cheating.

Free Lunch fizzles in its final chapter, where Johnston lays out some unconvincing solutions. He proposes "politician finance reform"—giving members of Congress all the money they want for dining, travel, and entertainment so they can't be tempted by their wealthy friends. Yet the end of Abramoff-style golf junkets and free box seats would do little to curb the influence of major campaign donors. Johnston's final appeal to handout-hungry ceos to "ask themselves how much they are willing to sully their reputations" feels naive, too. It will take more than a call for self-restraint to derail this gravy train.

Free Lunch: How The Wealthiest Americans Enrich Themselves At Government Expense by David Cay Johnson will outrage the average American by showing how the super affluent publicly profess "free market" economics while covertly using government policy to insulate their companies from competition and pocket taxpayer dollars as subsidies.

Johnson explains that taxpayer subsidies steal from honest entrepreneurs to benefit the greedy who manipulate the government. He calls this "corporate socialism" and says: "Corporate socialism makes it possible for Wal-Mart to grab market share by undercutting the competition that did not get subsidies, while appearing to win because it was just more efficient."

Surprisingly, Johnson says a bigger recipient of direct corporate welfare than Wal-Mart (per company size) is Cabela's, the outdoor-sporting-goods store. Cabela's convinces local governments that its stores are "destinations" which will benefit the local economy by serving as tourist attractions (a claim Johnson smashes). Cabela's then seeks tax benefits and other compensation to build its stores.

Johnson writes: "The tribute Cabela's demanded from Hamburg [Pennsylvania] amounted to roughly $8,000 for each man, woman, and child in town." Johnson points out that between 2004 and 2006, Cabela's earned $223.4 million. During those years, it collected at least $293.7 million in subsidies, more than its reported profits. Meanwhile a family business selling fishing and hunting gear was driven out of business in Hamburg.

Success didn't go to the best competitor, but to the most skilled at getting government handouts. Johnson says it's morally unfair to use tax dollars paid by a small business to fund its rival, a larger corporation. Johnson says such subsidies are inefficient and place a drag on the American economy.

To explain how subsidy economics work, Johnson quotes Cabela's annual report: "Historically, we have been able to negotiate economic development arrangements relating to the construction of a number of our new destination retail stores, including free land, monetary grants and the recapture of incremental sales, property or other taxes through economic development bonds, with many local and state governments?"

Johnson tells us the consequences of America's economic policy favoring the exploitation of the middle class for the benefit of the super rich has very negative long-term economic consequences. For example, Johnson writes about how the Chinese got neodymium magnet research and manufacture moved out of the United States. These magnets are used in precision guided missiles. Johnson says that in the coming years, Americans could see 40 million jobs move overseas, because of the availability of low cost labor overseas and government policies designed to protect corporations, not American workers, nor even America's national security. Johnson says this could lead to an American economic plight that rivals the Great Depression. He asks us to contemplate a future where the great majority of Americans are reduced to "servant-level wages and jobs."

What about that hallmark of Americanism, pro sports? Unprofitable without subsidies, Johnson says. Of course, just taking other people's property is the simplest way for the politically powerful to enrich themselves at the expense of others.

Johnson explains how George W. Bush used eminent domain to seize land held by other Texans to build a new sports stadium and entertainment complex for his Texas Rangers investment. Taxpayers, via stadium bonds and an increase in the sales tax, paid for enriching Bush and his cronies. Bush's group got the right to purchase the stadium for less than one-third of the cost to build it. And, they got a rent-to-own deal, where every dollar paid in rent applied to the purchase price of the stadium. As Johnson observes, try getting that kind of rent-to-own deal from your local appliance store! These deals only occur because those negotiating for the government are really bought and paid for by the special interests negotiating on the other side.

Meanwhile, Texans were subjected to Enron's promotion of "market" electricity prices, which drove up electric energy prices by fifty percent in four years. Consumers will be shocked to learn how (in many states) they are now ripped off by electric companies. Free Lunch: How The Wealthiest Americans Enrich Themselves At Government Expense explains that while the costs to produce electricity haven't increased significantly, policies now allow energy companies to artificially bid up the cost consumers must pay for their electricity.

Enron's new "market" economics went to work in other states, where Johnson tells us consumers in those states paid $48 billion more in average energy costs in 2007 than consumers in states which retained traditional regulated utility rates. Johnson says this change in how utilities are allowed to price is a major reason legendary investor Warren Buffett has invested in more utilities.

These changes in electricity pricing are the direct result of large corporations buying political influence and lobbying to benefit themselves at the expense of citizens. One of the biggest supporters of this new government policy of transferring wealth from citizens to energy companies is Vice President Dick Cheney. When confronted with how California energy prices were artificially driven up because many producers were intentionally offline, Cheney quipped, "You know what? You just don't understand economics."

Johnson tells us America's high health care and exorbitant drug costs also stem from government policies designed to benefit HMOs and drug companies and to help them maximize their profits by soaking American citizens.

I think every American who wants to understand America's present economic plight should read Free Lunch: How The Wealthiest Americans Enrich Themselves At Government Expense by David Cay Johnson.

In Defense of Food: An Eater's Manifesto

Author: Michael Pollan

Food. There's plenty of it around, and we all love to eat it. So why should anyone need to defend it?

Because most of what we're consuming today is not food, and how we're consuming it -- in the car, in front of the TV, and increasingly alone -- is not really eating. Instead of food, we're consuming "edible foodlike substances" -- no longer the products of nature but of food science. Many of them come packaged with health claims that should be our first clue they are anything but healthy. In the so-called Western diet, food has been replaced by nutrients, and common sense by confusion. The result is what Michael Pollan calls the American paradox: The more we worry about nutrition, the less healthy we seem to become.

But if real food -- the sort of food our great grandmothers would recognize as food -- stands in need of defense, from whom does it need defending? From the food industry on one side and nutritional science on the other. Both stand to gain much from widespread confusion about what to eat, a question that for most of human history people have been able to answer without expert help. Yet the professionalization of eating has failed to make Americans healthier. Thirty years of official nutritional advice has only made us sicker and fatter while ruining countless numbers of meals.

Pollan proposes a new (and very old) answer to the question of what we should eat that comes down to seven simple but liberating words: Eat food. Not too much. Mostly plants. By urging us to once again eat food, he challenges the prevailing nutrient-by-nutrient approach -- what he calls nutritionism -- and proposes an alternative way of eating that is informed by the traditions and ecology of real, well-grown, unprocessed food. Our personal health, he argues, cannot be divorced from the health of the food chains of which we are part.

In Defense of Food shows us how, despite the daunting dietary landscape Americans confront in the modern supermarket, we can escape the Western diet and, by doing so, most of the chronic diseases that diet causes. We can relearn which foods are healthy, develop simple ways to moderate our appetites, and return eating to its proper context -- out of the car and back to the table. Michael Pollan's bracing and eloquent manifesto shows us how we can start making thoughtful food choices that will enrich our lives, enlarge our sense of what it means to be healthy, and bring pleasure back to eating.

Pollan's last book, The Omnivore's Dilemma, launched a national conversation about the American way of eating; now In Defense of Food shows us how to change it, one meal at a time.

LATIMES Review:

In a recent op-ed piece in the New York Times, Michael Pollan quotes Tom Harkin, chairman of the Senate Agriculture Committee, on the farm bill now before Congress: "This is not just a farm bill. It's a food bill, and Americans who eat want a stake in it." Pollan may be skeptical about whether American eaters can thwart passage of a bill that includes $42 billion in subsidies for the big cash crops -- corn, wheat, rice, soybeans and cotton -- but he firmly believes that "the eaters have spoken [and] a new politics has sprouted up."

That optimism fueled two of his earlier books: "The Botany of Desire," about our relationship with food, and "The Omnivore's Dilemma," which urged variety in our diet. It's most evident in the last of the trilogy, "In Defense of Food," whose simple message is "Eat food. Not too much. Mostly plants." The good news is, he thinks we can do it. Twenty years ago, it might have been difficult, but today organic, regionally grown food is more available than it has been since the food industry began controlling our consumption.

Pollan subtitles his new book "An Eater's Manifesto," but he's way too polite to tell us what to eat. Instead, he uses his familiar brand of carefully researched, common-sense journalism to persuade, providing guidelines and convincing arguments. "[W]hat other animal needs professional help in deciding what it should eat?" he asks. Once, we had culture ("just a fancy word for your mother"), but culture has been replaced by "scientists and food marketers (often an unhealthy alliance of the two)." Americans are "increasingly sick and fat. Four of the top ten causes of death today are chronic diseases with well-established links to diet: coronary heart disease, diabetes, stroke, and cancer."

We have been buffeted so often by conflicting studies that we've stopped thinking of food as food. We think of it as nutrition. (Recess at my children's schools in Santa Monica is no longer called recess, but "nutrition.") Pollan argues that food needs defending from "nutrition science on one side and from the food industry on the other -- and from the needless complications around eating that together they have fostered."

"In Defense of Food" is in three parts. The first explains the perils of "nutritionism," like most isms a reductionist, contextless ideology. Nutritionism divides our food into nutrients (Pollan shows the complexity involved by listing the astonishing number of antioxidants in thyme) and pits them against each other: fats versus carbs, carbs versus proteins. Moreover, it "has trouble discerning qualitative distinctions among foods," allowing marketers to avoid thorny issues of how food is grown and how humans process it. Nutritionism is a boon to food marketers, not only because it helps with splashy packaging but also because it lets them advise buyers to eat more of a particular food, exacerbating an already imbalanced, unvaried diet.

There's an all-too convenient relationship between the scientists and the marketers, he writes: "The food industry needs theories so it can better redesign specific processed foods; a new theory means a new line of products, allowing the industry to go on tweaking the Western diet instead of making any more radical change to its business model." The medical community also benefits; Pollan notes that as Americans spend less on food, they spend more on healthcare.

The second part, titled "The Western Diet and the Diseases of Civilization," begins with a 1982 study, in which a group of Aborigines who had left the bush, taken up a Western diet and developed Type-2 diabetes were returned to the bush and their native diet. The diabetic abnormalities all but disappeared. Pollan uses this and other studies to show how we can regain our own lost health. "What would happen," he asks, "if we were to start thinking about food as less of a thing and more of a relationship?" If we consume foods grown in degraded soils, or beef from cattle that have eaten grasses grown in such soils, or milk and cheese from those cattle, we won't get the nutrients we need. This is why processed food so often has to be fortified (something marketers trumpet as a bonus).

The third section offers rules (rather, gentle suggestions) for how to "escape the Western diet." Many are familiar, if you've spent any time paying attention to what you eat -- for example, don't eat packaged foods with lots of chemical ingredients. Some involve behavioral changes: Eat mostly plants, avoid supermarkets whenever possible, buy a freezer, "don't eat anything your great-grandmother wouldn't recognize as food," pay more to eat less and don't buy food where you buy gas. Some are more about how we eat than what we eat -- for example, do all your eating at a table, don't eat alone, eat slowly.

Here's the manifesto part. Pollan isn't just asking us to consider changing the way we eat. He's asking us to join a movement that's "renovating our food system in the name of health . . . in the very broadest sense of that word." By "health," he means avoiding diseases that kill us, but he also means happiness, pleasure, community -- factors ignored in studies or marketing plans or by government agencies such as the Senate Select Committee on Nutrition and Human Needs, chaired by George McGovern in the late 1970s, so vulnerable to free-market bullying. Government and business together can stand between human beings and their instincts. That pernicious link has been weakened, Pollan believes; it has certainly become a weak link in the food chain. We know what to eat. We just have to remember it.

IHT Review:

Not all scientific study of Mars is about extraterrestrial exploration. Some of it is about chocolate. Scientists at Mars Corporation have found evidence that the flavanols in cocoa have beneficial effects on the heart, thus allowing Mars to market products like its health-minded Rich Chocolate Indulgence Beverage.

In the same spirit, nutritionism has lately helped to justify vitamin-enriched Diet Coke, bread bolstered with the Omega-3 fatty acids more readily found in fish oil, and many other new improvements on what Michael Pollan calls "the tangible material formerly known as food."

Goaded by "the silence of the yams," Pollan wants to help old-fashioned edibles fight back. So he has written "In Defense of Food," a tough, witty, cogent rebuttal to the proposition that food can be reduced to its nutritional components without the loss of something essential. "We know how to break down a kernel of corn or grain of wheat into its chemical parts, but we have no idea how to put it back together again," he writes.

In this lively, invaluable book — which grew out of an essay Pollan wrote for The New York Times Magazine, for which he is a contributing writer — he assails some of the most fundamental tenets of nutritionism: that food is simply the sum of its parts, that the effects of individual nutrients can be scientifically measured, that the primary purpose of eating is to maintain health, and that eating requires expert advice. Experts, he says, often do a better job of muddying these issues than of shedding light on them. And it serves their own purposes to create confusion. In his opinion the industry-financed branch of nutritional science is "remarkably reliable in its ability to find a health benefit in whatever food it has been commissioned to study."

Some of this reasoning turned up in Pollan's best-selling "Omnivore's Dilemma." But "In Defense of Food" is a simpler, blunter and more pragmatic book, one that really lives up to the "manifesto" in its subtitle. Although he is not in the business of dispensing self-help rules, he incorporates a few McNuggets of plain-spoken advice: Don't eat things that your great-grandmother wouldn't recognize. Avoid anything that trumpets the word "healthy." Be as vitamin-conscious as the person who takes supplements, but don't actually take them. And in the soon to be exhaustively quoted words on the book's cover: "Eat food. Not too much. Mostly plants." An inspiring head of lettuce is the poster image for this mantra.

Do we really need such elementary advice? Well, two-thirds of the way through his argument Pollan points out something irrefutable. "You would not have bought this book and read this far into it if your food culture was intact and healthy," he says. Nor would you eat substances like Go-Gurt, eat them on the run or eat them at mealtimes that are so out of sync with friends and relatives that the real family dinner is an endangered ritual. Other writers on food, from Barbara Kingsolver to Marion Nestle, have expressed the same alarm, but "In Defense of Food" is an especially succinct and helpful summary.

Among the historical details that underscore a sense of food's downhill slide: the way a Senate Select Committee led by George McGovern was pressured in 1977 to reword a dietary recommendation. Its warning to "reduce consumption of meat" turned into "choose meats, poultry and fish that will reduce saturated fat intake."

When McGovern lost his seat three years later, Pollan says, the beef lobby "succeeded in rusticating the three-term senator, sending an unmistakable warning to anyone who would challenge the American diet, and in particular the big chunk of animal protein squatting in the middle of its plate."

Pollan shows how the story of nutritionism is "a history of macronutrients at war." If the conventional scientific wisdom has moved from demon (saturated fat) to demon (carbohydrates), creating irreconcilably different theories about the health benefits of various foods, it has also created an up-and-coming eating disorder: orthorexia.

"We are," he underscores, "people with an unhealthy obsession with healthy eating." This book is biliously entertaining about orthorexia's crazy extremes. A recent "qualified" FDA-approved health claim for corn oil makes sense, Pollan says, "as long as it replaces a comparable amount of, say, poison in your diet and doesn't increase the total number of calories you eat in a day."

Since a Western diet conducive to diabetes has led us not to improved eating habits but to a growing diabetes industry, complete with its own magazine (Diabetic Living), Pollan finds little wisdom from the medical establishment about food and its ramifications. "We'll know this has changed when doctors have kicked the fast-food franchises out of the hospitals," he says.

Until then he recommends that we pay more attention to the reductive effects of food science, recognize the fallibility of research studies (because to replicate the healthy effects of, say, the Mediterranean diet completely, you need to live like a villager on Crete) and dial back the clock. Pollan advocates a return to the local and the basic, even at the risk of elitism. He recommends that Americans spend more on food: not only more money but also more time. Eat less, and maybe you make up the financial difference. Trade fast food for cooking, and maybe you restore some civility to the traditional idea of the meal.

"No, a desk is not a table," he points out. Though he shouldn't have to tell us that, readers of "In Defense of Food" will be glad he did.

Our Daily Meds

How the Pharmaceutical Companies Transformed Themselves Into Slick Marketing Machines and Hooked the Nation on Prescription Drugs

By Melody Petersen

NYTIMES REVIEW
Petersen gets around to interviewing Iowa’s state nosologist near the end of “Our Daily Meds,” the facts that she cites don’t even sound that grim. The nosologist’s job is to catalog Iowa’s deceased according to cause of death. He processes about 27,000 death certificates a year. And by his reckoning there were only five deaths caused by adverse reactions to prescription drugs in 2002. That low figure is jarringly out of whack with Ms. Petersen’s investigative reporting in an angrily illuminating book on drug-related corporate malfeasance and patient peril.

“Could drugs be killing people but escaping all blame, leaving them to harm even more Americans until someone, finally, catches on?” Ms. Petersen asks. Given the information that her book uncovers, this a purely rhetorical question. Her study cites reckless and questionable behavior in all aspects of drug companies’ research and marketing ploys, even if much of this is familiar territory. It has been explored by earlier crusaders (notably Marcia Angell in “The Truth About the Drug Companies”) and in Ms. Petersen’s own journalism. She spent four years as a reporter covering the drug industry for The New York Times.

The newer and scarier material in “Our Daily Meds” concerns the increasingly serious consequences of Americans’ dependency on prescription drugs. Disagreeing with Iowa’s nosologist, Ms. Petersen says the lethal consequences of overprescribed or misprescribed drugs are too readily accepted as “natural” death. She cites the unwillingness of pathologists to question the wisdom with which doctors dispense medications. The reluctance of hospitals to perform autopsies, she says, has impeded medical research into what these interactions can do.

“Our Daily Meds” begins by illustrating the established drug-company practices that have led to this sorry juncture. There is the rigging of studies, so that to be deemed “effective” a drug need only perform better than a sugar pill. There are the promotional strategies that evade the need for F.D.A. warnings by, say, planting logos for the sexual enhancement drug Viagra and the antidepressant Wellbutrin on Nascar vehicles. There is the co-option of doctors and university researchers by aggressive, payola-dispensing drug company representatives.

Ms. Petersen, who has done much of her digging with the help of obscure but gratifying corporate documents, even finds feedback from doctors about the bribe-style amenities offered by drug company junkets. (“Hotel too cold inside,” one said, in an evaluation of a June 1998 drug company program, adding, “Resort places preferred.” From a different doctor, miffed at the lack of a chauffeur at another event: “Hired car would have been much preferable.”

But she moves to weightier matters in assessing the directions in which heavy drug dependence is leading Americans. First of all there are the business strategies that have created illnesses out of what used to be facts of life, labeled them as syndromes, and have hooked customers into long-term use of medication to cure them. (Detrol, the obnoxiously advertised cure for what its manufacturer calls “overactive bladder,” is a case in point, especially since it can cause hallucinations that resemble symptoms of Alzheimer’s disease.) Second, there are the economics of creating chronic consumers for marginally necessary drugs.

Irate as she is that in a period (1980-2003) when Americans doubled what they spent on cars they increased their spending on prescription drugs by 17 times, Ms. Petersen steps back to consider the long-term consequences of this shift in consumption. She notes that the first generation of children raised in front of ubiquitous, sunny drug-company advertisements (which became legal in 1997) has acquired the notions that prescription pills fix everything, and that they are less dangerous than street drugs. Then, looking to the elderly, she points out that increasing numbers of drugs are accumulating in these patients, with little regard for the consequences.

“As older patients move through time, often from physician to physician,” one doctor tells her, “they are at increasing risk of accumulating layer upon layer of drug therapy, as a reef accumulates layer upon layer of coral.” And when the side effects of sleeping pills or antidepressants mean more elderly people fall down, the solution is not likely to be the scaling back of such prescriptions. “Instead,” she writes, “the companies have used the statistics on falls to create a new blockbuster pharmaceutical market for drugs they claim will reduce the chances of breaking a bone.” The market for just two of these drugs, Fosamax and Actonel, is expected to be worth $10 billion by 2011.

Ms. Petersen compiles this data in anecdotal style, even though they would have hit harder in more crystallized, succinct form. But although she rambles and repeats herself at times, this material remains tough, cogent and disturbing enough to have a serious impact. So do her recommendations at the end of this chilling investigation.

Among them: Look at the pens and tissue boxes in your doctor’s office. If they feature drug ads, then a drug company representative has been courting your doctor, trying to influence the ways in which that doctor issues prescriptions. Don’t trust paid celebrity drug endorsements. Be aware that your symptoms may be caused not by illness but by medication, especially when more than one medication is involved. Ms. Petersen urges more study of these interactions, particularly on the part of police officers who can assess drunk drivers but not overmedicated ones.

“Our Daily Meds” also advocates more supervision of doctors’ research articles, many of which are ghostwritten by drug company spokesmen. It calls for drug watchdog agencies that are not overseen by the government, since government officials can so easily be lobbied. Most drastically, she advocates prison time for executives implicated in pharmaceutical crimes. But those crimes are part of a time-honored tradition. As a federal investigator put it in 1937, after a barely tested elixir killed as many as 30 percent of the people who took it: “Apparently they just throw drugs together and if they don’t explode they are placed on sale.”

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Once upon a time there was an industry called pharma that was interested in doing well and doing good. Run by doctors and chemists, drug companies employed battalions of researchers whose scientific efforts resulted by mid-century in a flood of life-saving drugs, including antibiotics, vaccines, tranquilizers, antihistamines and steroids. As George Merck, president of the company founded by his father, put it in 1950, "We try never to forget that medicine is for the people. It is not for the profits. The profits follow. . . ."

And how. Today, of course, drug companies are hugely profitable enterprises and the darlings of both Wall Street and K Street, having spent more on lobbying than any other industry between 1998 and 2004. Their transformation from small chemical manufacturers to marketing machines with sidelines in drug development is owed in large measure to blockbuster drugs. This is the term for any medication that generates more than $1 billion in sales annually. Such drugs as Nexium, Celebrex, Claritin and, of course, Viagra, whose brand names are household words, became blockbusters not because they save lives, or even because they are necessarily more effective than other remedies, but because their manufacturers employ some of the cleverest marketing on the planet.

Take the selling of Zantac, an anti-ulcer drug that came on the market in 1983 and paved the way for the blockbuster drugs that followed. First, Glaxo priced its new drug above its competitor, Tagamet -- a bold move, Melody Petersen writes in Our Daily Meds, that "like an underweight boxer trying to fool the prizefighter with his swagger . . . implied that Zantac was better." In reality, Zantac was a "me-too" drug, chemically almost identical to Tagamet and no more effective.

But it was the second half of Glaxo's strategy that was truly dazzling. Rather than plowing the revenue from Zantac back into R&D, as was then customary in the drug business, the company decided to invest in marketing the daylights out of its drug. Glaxo funded studies intended to show Zantac's superiority. It hired a battalion of sales reps, who flogged the drug relentlessly to doctors. Most brilliant of all, the company pioneered a ploy now used routinely in pharmaceutical marketing: It "condition branded" Zantac.

Glaxo's novel idea was to link its drug to the relief of a common but minor condition, then make consumers and doctors worry that the condition was a sign of a more worrisome disease. In this case, the minor condition was old-fashioned heartburn. Glaxo warned that heartburn was a sign of chronic reflux, which the company dubbed Gastro-Esophageal Reflux Disease, or GERD. Soon, millions of Americans were saying goodbye plop plop, fizz fizz, hello Zantac, an expensive prescription drug they started taking every day to ward off GERD, even though most episodes of reflux go away without treatment, and most heartburn can be relieved with an over-the-counter remedy.

Glaxo's strategy has become standard operating procedure in the pharmaceutical industry. Companies now routinely condition brand their drugs not only by linking minor symptoms to real diseases but sometimes by making up diseases out of whole cloth. Pharmacia marketed a drug named Detrol for a previously unknown condition dubbed "overactive bladder." Forrest Laboratories ran a study to see if its antidepressant Celexa could be used to treat "compulsive shopping disorder," a mental illness that has yet to be recognized by psychiatrists, but that some husbands and wives undoubtedly would like to invoke when confronted with a maxed out credit card.

Drug makers also have flooded the market with me-too drugs. We don't have just one anti-cholesterol medication, we have more than 10 to choose from. Nearly a dozen antidepressants act on the same neurotransmitters in the brain, and three different drugs target erectile dysfunction. That's not to say that multiple versions of a drug are necessarily a bad thing. Having several drugs does introduce some price competition, though not much, and certain drugs often work better for some people than for others. But as Petersen argues, there's a downside to this business model.

For one thing, in pursuing blockbusters, drug makers are neglecting research that could help people with less profitable diseases. Malaria continues to be a scourge of the third world, but patients with diseases that are rare in the United States get short shrift from the drug industry. Even antibiotics are in short supply in the industry's development pipelines, largely because no amount of creative marketing can lift an antibiotic to blockbuster status. An antibiotic might well save your life, but unlike Zantac or Lipitor or Claritin, it doesn't need to be taken for years on end, day in, day out. Even more troubling, the flow of truly innovative drugs has slowed to a trickle, at least in part because companies that were once science-driven now spend twice as much on marketing existing drugs as they do on developing new ones.

Worst of all, the marketing has had a demonstrably negative effect on many patients. Merck's painkiller Vioxx, which was heavily advertised for a wide variety of ailments, is estimated to have killed as many as 60,000 people before the company withdrew it from sale in 2004. "It's a Vietnam," the sister of one deceased Vioxx user told Petersen. Unnecessary drugs and dangerous interactions between drugs are a mounting problem, as one in six Americans now takes three or more drugs per day; many patients find themselves adding prescriptions to combat the side effects of other prescriptions. Petersen tells the story of a 5-year-old who was put on the stimulant Ritalin, which triggered seizures. His doctors were considering brain surgery until he was taken off the drug and the seizures stopped.

For those who know the history of drug marketing, much of this book will be familiar. Petersen draws on her years as a crackerjack business reporter at the New York Times, where her enterprising stories were eagerly awaited by those who follow the drug makers. She occasionally appears to forget that for all their hype and hucksterism, drug companies also produce many truly beneficial products. And in places, Our Daily Meds reads like MTV on paper, with too many jump-cuts and abrupt transitions from anecdote to anecdote without enough critical analysis. But for general readers, this is a fascinating introduction to one of the most powerful industries of our time.

It's hard to imagine what the endgame will be for the era of the blockbuster drug. Having built up Wall Street's thirst for the profits that blockbusters bring, drug makers are now in a sticky spot. Without investing more in R&D, companies don't have much hope of finding new blockbusters. But no company can abandon its marketing strategy and put its money back into research without jeopardizing the sales of its current drugs. Some drug company analysts foresee a day when the federal government will fund the clinical research that's necessary to get drugs approved, and companies will be reduced to manufacturing and selling them.

That might or might not be a good idea, but until pharma kicks its marketing habit, Petersen offers patients useful suggestions for avoiding harm. She recommends that before we head to the pharmacy, we ask our doctors if there is valid evidence that patients like us will benefit from taking a particular medication. We should always inquire about side effects. Better yet, we ought to be looking for ways to improve our health without a prescription. ·

Shannon Brownlee is a senior fellow at the New America Foundation and author of "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer."

The Post American World

Author: Fareed Zakaria

Americans are glum at the moment. No, I mean really glum. In April, a new poll revealed that 81 percent of the American people believe that the country is on the "wrong track." In the 25 years that pollsters have asked this question, last month's response was by far the most negative. Other polls, asking similar questions, found levels of gloom that were even more alarming, often at 30- and 40-year highs. There are reasons to be pessimistic—a financial panic and looming recession, a seemingly endless war in Iraq, and the ongoing threat of terrorism. But the facts on the ground—unemployment numbers, foreclosure rates, deaths from terror attacks—are simply not dire enough to explain the present atmosphere of malaise.

American anxiety springs from something much deeper, a sense that large and disruptive forces are coursing through the world. In almost every industry, in every aspect of life, it feels like the patterns of the past are being scrambled. "Whirl is king, having driven out Zeus," wrote Aristophanes 2,400 years ago. And—for the first time in living memory—the United States does not seem to be leading the charge. Americans see that a new world is coming into being, but fear it is one being shaped in distant lands and by foreign people.

Look around. The world's tallest building is in Taipei, and will soon be in Dubai. Its largest publicly traded company is in Beijing. Its biggest refinery is being constructed in India. Its largest passenger airplane is built in Europe. The largest investment fund on the planet is in Abu Dhabi; the biggest movie industry is Bollywood, not Hollywood. Once quintessentially American icons have been usurped by the natives. The largest Ferris wheel is in Singapore. The largest casino is in Macao, which overtook Las Vegas in gambling revenues last year. America no longer dominates even its favorite sport, shopping. The Mall of America in Minnesota once boasted that it was the largest shopping mall in the world. Today it wouldn't make the top ten. In the most recent rankings, only two of the world's ten richest people are American. These lists are arbitrary and a bit silly, but consider that only ten years ago, the United States would have serenely topped almost every one of these categories.

These factoids reflect a seismic shift in power and attitudes. It is one that I sense when I travel around the world. In America, we are still debating the nature and extent of anti-Americanism. One side says that the problem is real and worrying and that we must woo the world back. The other says this is the inevitable price of power and that many of these countries are envious—and vaguely French—so we can safely ignore their griping. But while we argue over why they hate us, "they" have moved on, and are now far more interested in other, more dynamic parts of the globe. The world has shifted from anti-Americanism to post-Americanism.

I. The End of Pax Americana
During the 1980s, when I would visit India—where I grew up—most Indians were fascinated by the United States. Their interest, I have to confess, was not in the important power players in Washington or the great intellectuals in Cambridge.

People would often ask me about … Donald Trump. He was the very symbol of the United States—brassy, rich, and modern. He symbolized the feeling that if you wanted to find the biggest and largest anything, you had to look to America. Today, outside of entertainment figures, there is no comparable interest in American personalities. If you wonder why, read India's newspapers or watch its television. There are dozens of Indian businessmen who are now wealthier than the Donald. Indians are obsessed by their own vulgar real estate billionaires. And that newfound interest in their own story is being replicated across much of the world.

How much? Well, consider this fact. In 2006 and 2007, 124 countries grew their economies at over 4 percent a year. That includes more than 30 countries in Africa. Over the last two decades, lands outside the industrialized West have been growing at rates that were once unthinkable. While there have been booms and busts, the overall trend has been unambiguously upward. Antoine van Agtmael, the fund manager who coined the term "emerging markets," has identified the 25 companies most likely to be the world's next great multinationals. His list includes four companies each from Brazil, Mexico, South Korea, and Taiwan; three from India, two from China, and one each from Argentina, Chile, Malaysia, and South Africa. This is something much broader than the much-ballyhooed rise of China or even Asia. It is the rise of the rest—the rest of the world.

We are living through the third great power shift in modern history. The first was the rise of the Western world, around the 15th century. It produced the world as we know it now—science and technology, commerce and capitalism, the industrial and agricultural revolutions. It also led to the prolonged political dominance of the nations of the Western world. The second shift, which took place in the closing years of the 19th century, was the rise of the United States. Once it industrialized, it soon became the most powerful nation in the world, stronger than any likely combination of other nations. For the last 20 years, America's superpower status in every realm has been largely unchallenged—something that's never happened before in history, at least since the Roman Empire dominated the known world 2,000 years ago. During this Pax Americana, the global economy has accelerated dramatically. And that expansion is the driver behind the third great power shift of the modern age—the rise of the rest.

At the military and political level, we still live in a unipolar world. But along every other dimension—industrial, financial, social, cultural—the distribution of power is shifting, moving away from American dominance. In terms of war and peace, economics and business, ideas and art, this will produce a landscape that is quite different from the one we have lived in until now—one defined and directed from many places and by many peoples.

The post-American world is naturally an unsettling prospect for Americans, but it should not be. This will not be a world defined by the decline of America but rather the rise of everyone else. It is the result of a series of positive trends that have been progressing over the last 20 years, trends that have created an international climate of unprecedented peace and prosperity.

I know. That's not the world that people perceive. We are told that we live in dark, dangerous times. Terrorism, rogue states, nuclear proliferation, financial panics, recession, outsourcing, and illegal immigrants all loom large in the national discourse. Al Qaeda, Iran, North Korea, China, Russia are all threats in some way or another. But just how violent is today's world, really?

A team of scholars at the University of Maryland has been tracking deaths caused by organized violence. Their data show that wars of all kinds have been declining since the mid-1980s and that we are now at the lowest levels of global violence since the 1950s. Deaths from terrorism are reported to have risen in recent years. But on closer examination, 80 percent of those casualties come from Afghanistan and Iraq, which are really war zones with ongoing insurgencies—and the overall numbers remain small. Looking at the evidence, Harvard's polymath professor Steven Pinker has ventured to speculate that we are probably living "in the most peaceful time of our species' existence."

Why does it not feel that way? Why do we think we live in scary times? Part of the problem is that as violence has been ebbing, information has been exploding. The last 20 years have produced an information revolution that brings us news and, most crucially, images from around the world all the time. The immediacy of the images and the intensity of the 24-hour news cycle combine to produce constant hype. Every weather disturbance is the "storm of the decade." Every bomb that explodes is BREAKING NEWS. Because the information revolution is so new, we—reporters, writers, readers, viewers—are all just now figuring out how to put everything in context.

We didn't watch daily footage of the two million people who died in Indochina in the 1970s, or the million who perished in the sands of the Iran-Iraq war ten years later. We saw little of the civil war in the Congo in the 1990s, where millions died. But today any bomb that goes off, any rocket that is fired, any death that results, is documented by someone, somewhere and ricochets instantly across the world. Add to this terrorist attacks, which are random and brutal. "That could have been me," you think. Actually, your chances of being killed in a terrorist attack are tiny—for an American, smaller than drowning in your bathtub. But it doesn't feel like that.

The threats we face are real. Islamic jihadists are a nasty bunch—they do want to attack civilians everywhere. But it is increasingly clear that militants and suicide bombers make up a tiny portion of the world's 1.3 billion Muslims. They can do real damage, especially if they get their hands on nuclear weapons. But the combined efforts of the world's governments have effectively put them on the run and continue to track them and their money. Jihad persists, but the jihadists have had to scatter, work in small local cells, and use simple and undetectable weapons. They have not been able to hit big, symbolic targets, especially ones involving Americans. So they blow up bombs in cafés, marketplaces, and subway stations. The problem is that in doing so, they kill locals and alienate ordinary Muslims. Look at the polls. Support for violence of any kind has dropped dramatically over the last five years in all Muslim countries.

Militant groups have reconstituted in certain areas where they exploit a particular local issue or have support from a local ethnic group or sect, most worryingly in Pakistan and Afghanistan where Islamic radicalism has become associated with Pashtun identity politics. But as a result, these groups are becoming more local and less global. Al Qaeda in Iraq, for example, has turned into a group that is more anti-Shiite than anti-American. The bottom line is this: since 9/11, Al Qaeda Central, the gang run by Osama bin Laden, has not been able to launch a single major terror attack in the West or any Arab country—its original targets. They used to do terrorism, now they make videotapes. Of course one day they will get lucky again, but that they have been stymied for almost seven years points out that in this battle between governments and terror groups, the former need not despair.

Some point to the dangers posed by countries like Iran. These rogue states present real problems, but look at them in context. The American economy is 68 times the size of Iran's. Its military budget is 110 times that of the mullahs. Were Iran to attain a nuclear capacity, it would complicate the geopolitics of the Middle East. But none of the problems we face compare with the dangers posed by a rising Germany in the first half of the 20th century or an expansionist Soviet Union in the second half. Those were great global powers bent on world domination. If this is 1938, as some neoconservatives tell us, then Iran is Romania, not Germany.

Others paint a dark picture of a world in which dictators are on the march. China and Russia and assorted other oil potentates are surging. We must draw the battle lines now, they warn, and engage in a great Manichean struggle that will define the next century. Some of John McCain's rhetoric has suggested that he adheres to this dire, dyspeptic view. But before we all sign on for a new Cold War, let's take a deep breath and gain some perspective. Today's rising great powers are relatively benign by historical measure. In the past, when countries grew rich they've wanted to become great military powers, overturn the existing order, and create their own empires or spheres of influence. But since the rise of Japan and Germany in the 1960s and 1970s, none have done this, choosing instead to get rich within the existing international order. China and India are clearly moving in this direction. Even Russia, the most aggressive and revanchist great power today, has done little that compares with past aggressors. The fact that for the first time in history, the United States can contest Russian influence in Ukraine—a country 4,800 miles away from Washington that Russia has dominated or ruled for 350 years—tells us something about the balance of power between the West and Russia.

Compare Russia and China with where they were 35 years ago. At the time both (particularly Russia) were great power threats, actively conspiring against the United States, arming guerrilla movement across the globe, funding insurgencies and civil wars, blocking every American plan in the United Nations. Now they are more integrated into the global economy and society than at any point in at least 100 years. They occupy an uncomfortable gray zone, neither friends nor foes, cooperating with the United States and the West on some issues, obstructing others. But how large is their potential for trouble? Russia's military spending is $35 billion, or 1/20th of the Pentagon's. China has about 20 nuclear missiles that can reach the United States. We have 830 missiles, most with multiple warheads, that can reach China. Who should be worried about whom? Other rising autocracies like Saudi Arabia and the Gulf states are close U.S. allies that shelter under America's military protection, buy its weapons, invest in its companies, and follow many of its diktats. With Iran's ambitions growing in the region, these countries are likely to become even closer allies, unless America gratuitously alienates them.

II. The Good News
In July 2006, I spoke with a senior member of the Israeli government, a few days after Israel's war with Hezbollah had ended. He was genuinely worried about his country's physical security. Hezbollah's rockets had reached farther into Israel than people had believed possible. The military response had clearly been ineffectual: Hezbollah launched as many rockets on the last day of the war as on the first. Then I asked him about the economy—the area in which he worked. His response was striking. "That's puzzled all of us," he said. "The stock market was higher on the last day of the war than on the first! The same with the shekel." The government was spooked, but the market wasn't.

Or consider the Iraq War, which has produced deep, lasting chaos and dysfunction in that country. Over two million refugees have crowded into neighboring lands. That would seem to be the kind of political crisis guaranteed to spill over. But as I've traveled in the Middle East over the last few years, I've been struck by how little Iraq's troubles have destabilized the region. Everywhere you go, people angrily denounce American foreign policy. But most Middle Eastern countries are booming. Iraq's neighbors—Turkey, Jordan, and Saudi Arabia—are enjoying unprecedented prosperity. The Gulf states are busy modernizing their economies and societies, asking the Louvre, New York University, and Cornell Medical School to set up remote branches in the desert. There's little evidence of chaos, instability, and rampant Islamic fundamentalism.

The underlying reality across the globe is of enormous vitality. For the first time ever, most countries around the world are practicing sensible economics. Consider inflation. Over the past 20 years hyperinflation, a problem that used to bedevil large swaths of the world from Turkey to Brazil to Indonesia, has largely vanished, tamed by successful fiscal and monetary policies. The results are clear and stunning. The share of people living on $1 a day has plummeted from 40 percent in 1981 to 18 percent in 2004 and is estimated to drop to 12 percent by 2015. Poverty is falling in countries that house 80 percent of the world's population. There remains real poverty in the world—most worryingly in 50 basket-case countries that contain 1 billion people—but the overall trend has never been more encouraging. The global economy has more than doubled in size over the last 15 years and is now approaching $54 trillion! Global trade has grown by 133 percent in the same period. The expansion of the global economic pie has been so large, with so many countries participating, that it has become the dominating force of the current era. Wars, terrorism, and civil strife cause disruptions temporarily but eventually they are overwhelmed by the waves of globalization. These circumstances may not last, but it is worth understanding what the world has looked like for the past few decades.

III. A New Nationalism
Of course, global growth is also responsible for some of the biggest problems in the world right now. It has produced tons of money—what businesspeople call liquidity—that moves around the world. The combination of low inflation and lots of cash has meant low interest rates, which in turn have made people act greedily and/or stupidly. So we have witnessed over the last two decades a series of bubbles—in East Asian countries, technology stocks, housing, subprime mortgages, and emerging market equities. Growth also explains one of the signature events of our times—soaring commodity prices. $100 oil is just the tip of the barrel. Almost all commodities are at 200-year highs. Food, only a few decades ago in danger of price collapse, is now in the midst of a scary rise. None of this is due to dramatic fall-offs in supply. It is demand, growing global demand, that is fueling these prices. The effect of more and more people eating, drinking, washing, driving, and consuming will have seismic effects on the global system. These may be high-quality problems, but they are deep problems nonetheless.

The most immediate effect of global growth is the appearance of new economic powerhouses on the scene. It is an accident of history that for the last several centuries, the richest countries in the world have all been very small in terms of population. Denmark has 5.5 million people, the Netherlands has 16.6 million. The United States is the biggest of the bunch and has dominated the advanced industrial world. But the real giants—China, India, Brazil—have been sleeping, unable or unwilling to join the world of functioning economies. Now they are on the move and naturally, given their size, they will have a large footprint on the map of the future. Even if people in these countries remain relatively poor, as nations their total wealth will be massive. Or to put it another way, any number, no matter how small, when multiplied by 2.5 billion becomes a very big number. (2.5 billion is the population of China plus India.)

The rise of China and India is really just the most obvious manifestation of a rising world. In dozens of big countries, one can see the same set of forces at work—a growing economy, a resurgent society, a vibrant culture, and a rising sense of national pride. That pride can morph into something uglier. For me, this was vividly illustrated a few years ago when I was chatting with a young Chinese executive in an Internet café in Shanghai. He wore Western clothes, spoke fluent English, and was immersed in global pop culture. He was a product of globalization and spoke its language of bridge building and cosmopolitan values. At least, he did so until we began talking about Taiwan, Japan, and even the United States. (We did not discuss Tibet, but I'm sure had we done so, I could have added it to this list.) His responses were filled with passion, bellicosity, and intolerance. I felt as if I were in Germany in 1910, speaking to a young German professional, who would have been equally modern and yet also a staunch nationalist.

As economic fortunes rise, so inevitably does nationalism. Imagine that your country has been poor and marginal for centuries. Finally, things turn around and it becomes a symbol of economic progress and success. You would be proud, and anxious that your people win recognition and respect throughout the world.

In many countries such nationalism arises from a pent-up frustration over having to accept an entirely Western, or American, narrative of world history—one in which they are miscast or remain bit players. Russians have long chafed over the manner in which Western countries remember World War II. The American narrative is one in which the United States and Britain heroically defeat the forces of fascism. The Normandy landings are the climactic highpoint of the war—the beginning of the end. The Russians point out, however, that in fact the entire Western front was a sideshow. Three quarters of all German forces were engaged on the Eastern front fighting Russian troops, and Germany suffered 70 percent of its casualties there. The Eastern front involved more land combat than all other theaters of World War II put together.

Such divergent national perspectives always existed. But today, thanks to the information revolution, they are amplified, echoed, and disseminated. Where once there were only the narratives laid out by The New York Times, Time, Newsweek, the BBC, and CNN, there are now dozens of indigenous networks and channels—from Al Jazeera to New Delhi's NDTV to Latin America's Telesur. The result is that the "rest" are now dissecting the assumptions and narratives of the West and providing alternative views. A young Chinese diplomat told me in 2006, "When you tell us that we support a dictatorship in Sudan to have access to its oil, what I want to say is, 'And how is that different from your support of a medieval monarchy in Saudi Arabia?' We see the hypocrisy, we just don't say anything—yet."

The fact that newly rising nations are more strongly asserting their ideas and interests is inevitable in a post-American world. This raises a conundrum—how to get a world of many actors to work together. The traditional mechanisms of international cooperation are fraying. The U.N. Security Council has as its permanent members the victors of a war that ended more than 60 years ago. The G8 does not include China, India or Brazil—the three fastest-growing large economies in the world—and yet claims to represent the movers and shakers of the world economy. By tradition, the IMF is always headed by a European and the World Bank by an American. This "tradition," like the segregated customs of an old country club, might be charming to an insider. But to the majority who live outside the West, it seems bigoted. Our challenge is this: Whether the problem is a trade dispute or a human rights tragedy like Darfur or climate change, the only solutions that will work are those involving many nations. But arriving at solutions when more countries and more non-governmental players are feeling empowered will be harder than ever.

IV. The Next American Century
Many look at the vitality of this emerging world and conclude that the United States has had its day. "Globalization is striking back," Gabor Steingart, an editor at Germany's leading news magazine, Der Spiegel, writes in a best-selling book. As others prosper, he argues, the United States has lost key industries, its people have stopped saving money, and its government has become increasingly indebted to Asian central banks. The current financial crisis has only given greater force to such fears.

But take a step back. Over the last 20 years, globalization has been gaining depth and breadth. America has benefited massively from these trends. It has enjoyed unusually robust growth, low unemployment and inflation, and received hundreds of billions of dollars in investment. These are not signs of economic collapse. Its companies have entered new countries and industries with great success, using global supply chains and technology to stay in the vanguard of efficiency. U.S. exports and manufacturing have actually held their ground and services have boomed.

The United States is currently ranked as the globe's most competitive economy by the World Economic Forum. It remains dominant in many industries of the future like nanotechnology, biotechnology, and dozens of smaller high-tech fields. Its universities are the finest in the world, making up 8 of the top ten and 37 of the top fifty, according to a prominent ranking produced by Shanghai Jiao Tong University. A few years ago the National Science Foundation put out a scary and much-discussed statistic. In 2004, the group said, 950,000 engineers graduated from China and India, while only 70,000 graduated from the United States. But those numbers are wildly off the mark. If you exclude the car mechanics and repairmen—who are all counted as engineers in Chinese and Indian statistics—the numbers look quite different. Per capita, it turns out, the United States trains more engineers than either of the Asian giants.

But America's hidden secret is that most of these engineers are immigrants. Foreign students and immigrants account for almost 50 percent of all science researchers in the country. In 2006 they received 40 percent of all PhDs. By 2010, 75 percent of all science PhDs in this country will be awarded to foreign students. When these graduates settle in the country, they create economic opportunity. Half of all Silicon Valley start-ups have one founder who is an immigrant or first generation American. The potential for a new burst of American productivity depends not on our education system or R&D spending, but on our immigration policies. If these people are allowed and encouraged to stay, then innovation will happen here. If they leave, they'll take it with them.

More broadly, this is America's great—and potentially insurmountable—strength. It remains the most open, flexible society in the world, able to absorb other people, cultures, ideas, goods, and services. The country thrives on the hunger and energy of poor immigrants. Faced with the new technologies of foreign companies, or growing markets overseas, it adapts and adjusts. When you compare this dynamism with the closed and hierarchical nations that were once superpowers, you sense that the United States is different and may not fall into the trap of becoming rich, and fat, and lazy.

American society can adapt to this new world. But can the American government? Washington has gotten used to a world in which all roads led to its doorstep. America has rarely had to worry about benchmarking to the rest of the world—it was always so far ahead. But the natives have gotten good at capitalism and the gap is narrowing. Look at the rise of London. It's now the world's leading financial center—less because of things that the United States did badly than those London did well, like improving regulation and becoming friendlier to foreign capital. Or take the U.S. health care system, which has become a huge liability for American companies. U.S. carmakers now employ more people in Ontario, Canada, than Michigan because in Canada their health care costs are lower. Twenty years ago, the United States had the lowest corporate taxes in the world. Today they are the second-highest. It's not that ours went up. Those of others went down.

American parochialism is particularly evident in foreign policy. Economically, as other countries grow, for the most part the pie expands and everyone wins. But geopolitics is a struggle for influence: as other nations become more active internationally, they will seek greater freedom of action. This necessarily means that America's unimpeded influence will decline. But if the world that's being created has more power centers, nearly all are invested in order, stability and progress. Rather than narrowly obsessing about our own short-term interests and interest groups, our chief priority should be to bring these rising forces into the global system, to integrate them so that they in turn broaden and deepen global economic, political, and cultural ties. If China, India, Russia, Brazil all feel that they have a stake in the existing global order, there will be less danger of war, depression, panics, and breakdowns. There will be lots of problems, crisis, and tensions, but they will occur against a backdrop of systemic stability. This benefits them but also us. It's the ultimate win-win.

To bring others into this world, the United States needs to make its own commitment to the system clear. So far, America has been able to have it both ways. It is the global rule-maker but doesn't always play by the rules. And forget about standards created by others. Only three countries in the world don't use the metric system—Liberia, Myanmar, and the United States. For America to continue to lead the world, we will have to first join it.

Americans—particularly the American government—have not really understood the rise of the rest. This is one of the most thrilling stories in history. Billions of people are escaping from abject poverty. The world will be enriched and ennobled as they become consumers, producers, inventors, thinkers, dreamers, and doers. This is all happening because of American ideas and actions. For 60 years, the United States has pushed countries to open their markets, free up their politics, and embrace trade and technology. American diplomats, businessmen, and intellectuals have urged people in distant lands to be unafraid of change, to join the advanced world, to learn the secrets of our success. Yet just as they are beginning to do so, we are losing faith in such ideas. We have become suspicious of trade, openness, immigration, and investment because now it's not Americans going abroad but foreigners coming to America. Just as the world is opening up, we are closing down.

Generations from now, when historians write about these times, they might note that by the turn of the 21st century, the United States had succeeded in its great, historical mission—globalizing the world. We don't want them to write that along the way, we forgot to globalize ourselves.

Inventing Niagara: Beauty, Power, and Lies

Author: Ginger Strand


In a new history of Niagara Falls, a natural wonder is reshaped by man—and its surroundings become a toxic wasteland.
David Gates
NEWSWEEK


The first European to see Niagara falls didn't enjoy it. "When one stands near the Fall," wrote Father Louis Hennepin (who did so in 1678), "and looks down into this most dreadful Gulph, one is seized with Horror." If you've ever been there, you may know the feeling. Mount Everest or the Grand Canyon may also inspire that sense of mingled awe, terror and human insignificance the Romantics called the sublime. But unlike those places, Niagara Falls is unceasing, deafening, destructive motion—one of these centuries, in fact, it will destroy itself.

Assuming, to be sure, that humans would let nature take its course. But of all the world's natural wonders, Niagara Falls may be the most artificial. Upriver, technicians turn up the falls for the tourist season, by diverting less water for hydropower. From April through mid-September, 8 a.m. to 10 p.m., they let 100,000 cubic feet per second go over the falls—double the usual 50,000, but still only half the natural volume. Starting as early as the 1830s, the topography has been tweaked, even rebuilt. The falls straddle the border between New York state and Ontario province near Buffalo: the American Falls on the U.S. side, the Horseshoe Falls in Canada, with the smaller Bridal Veil (also in the United States) between them. The U.S. Army Corps of Engineers has blasted and excavated, filled and graded; it has added eight acres to Goat Island, between the Bridal Veil and Horseshoe Falls, implanted sensors to detect rocks coming loose and reshaped the Horseshoe's American edge; the Canadian falls is now 400 feet narrower than it used to be. And, as every tourist knows, colored lights tart up the enfeebled falls by night.

Ginger Strand, who writes for Harper's and The Believer, is obsessed with this strange and contradictory place—so badly, she says, that her boyfriend "did a search for Niagara Falls on the Internet Movie Database and banned any resulting films from our Netflix queue." In her new book, "Inventing Niagara: Beauty, Power, and Lies," she admits that she first considered the falls "no more than a kitschy spectacle, a chance to soak in a heart-shaped Jacuzzi"—the falls long predates the Poconos as a honeymoon destination—"and get some really awful souvenirs for my irony-adoring pals." She now sees Niagara as "a monument to the ways America falsifies its relationship to nature, reshaping its contours, redirecting its force, claiming to submit to its will while imposing our own upon it." Strand sometimes sounds like an environmental scold—spending time in the city of Niagara Falls with its 10 active Superfund sites can do that to you—but she's actually a hybrid of cultural historian and indefatigable roving reporter, who can't help taking quirky pleasure sometimes in what ought to be an utterly grim story.

Even in the early 1800s, entrepreneurs recognized Niagara Falls' potential for providing cheap power and for drawing tourists—and the latter enterprise was tacky from the first. In 1827, hotelkeepers sent an old schooner called the Michigan over the falls, with two bears, a buffalo, two foxes, a raccoon, an eagle, a dog and 15 geese onboard, along with a human crew in effigy, flying an American flag, a Union Jack and a Jolly Roger. (One goose survived, along with a bear who'd jumped ship above the falls.) The Maid of the Mist boat tours began in 1846—below the falls, thankfully—though not until 1996 did the recorded audio stop telling the fabricated myth of an Indian woman sent over the brink as a human sacrifice. In 1859 and 1860, the French aerialist Blondin made trips across the gorge on a tightrope—on which he did headstands, drank champagne, even cooked omelets; twice, he carried his manager on his shoulders. Later came the barrel riders—the first to succeed was a 63-year-old woman, in 1901—and the promotion of the Niagara Falls honeymoon as an almost obligatory American tradition, which has persisted in popular culture from "Shuffle Off to Buffalo" (from the 1933 film "42nd Street") through the 1952 movie "Niagara," which made Marilyn Monroe a star, all the way to—as Strand is not alone in suspecting—the vigorously evocative trade name for the virility drug sildenafil citrate.

After the Civil War, a movement called Free Niagara—guided by the landscape architect Frederick Law Olmsted—sought to get rid of the falls' honky-tonk attractions in favor of a re-engineered nature both picturesque and spiritually elevating. Strand grants his sincerity, but calls him a snob for whom "the aristocrat's taste was the right taste, and ought to be taught to the common man." The movement, she says, misdirected the public's gaze away from the industrialization of the area. Olmsted's artificial nature played into the tycoons' hands "by helping to create the division of purpose—over here is nature, over there, behind that hedge, is industry—that enabled the full industrial exploitation of the Falls to begin."

We know how that story ends—with failing companies leaving behind unemployed workers and such environmental disasters as Love Canal, where 82 different chemicals contaminated the area: residents began getting sick, and there was an increase in miscarriages and birth defects. "A baby was born with two rows of teeth," Strand writes, "another with three ears." You have to be impressed by the scale and variety of the contamination: not just from chemicals with sci-fi names (dodecyl mercaptan, hexachloroethane) but also radiation from former nuclear-weapons plants. The Army Corps of Engineers has identified "seven radioactively contaminated sites within ten miles of America's waterfall." And Strand is frankly awed by the giant mound that's the city of Niagara Falls' other most visible landmark: "It takes twenty minutes just to circumnavigate this beast … It covers 385 acres and includes one operating landfill, ten closed landfills, a wastewater treatment facility and container storage … It hulks there, green and gargantuan—in winter, white as a ski slope—as if humans had tried to outdo the Falls in reshaping the landscape." When she brings a video-artist friend there, he calls it "the most beautiful earthwork I have ever seen."

Of course this take seems as out of keeping as Hennepin's reaction to the falls: isn't "horror" the proper response here? I suppose that someone will accuse Strand, or at least her friend, of estheticizing human misery: how many people died from the toxins in this earthwork? But after a certain point, what else is a writer to do? That's the job description. Strand doesn't try to hide devastation behind a hedge, she's done more than her share of raking the chemical-infused muck and she's drawn from her story appropriately solemn (if vague) lessons about the relationship between humanity and nature. "Environmentalism is a way of seeing. It's time to look the world squarely in the face and try to understand our role in it … We are [nature] and it is us … We must consider the natural world not as merely waiting to be of service or to be saved, but must respect it as an equal partner in shaping the future of our planet."

But writing, too, is a way of seeing, and Strand can't help seeing gratuitous marvels in her ruined and dying landscape: electrical transmission towers resembling "broad-shouldered and narrow-hipped, metal linebackers striding across the Mohawk Valley," two abandoned shopping carts "stuck together as if mating," a squirrel in a brownfield "with two racing stripes of mange down its back." Unlike the Olmsteds of the world, she doesn't confuse beauty with prettying-up, and finds in nature no inherent moral or spiritual uplift: "What does the waterfall say? The world stands for nothing. The waterfall says just that: water, falling. Water, falling." Coleridge said it in his 1802 "Dejection" ode: "In our life alone does nature live." That is, we humans bring the beauty, whether to the waterfall or the transmission tower; nature just brings the nature. On the other hand, in nature alone can we live. And as the planet heats up, Niagara Falls, where both man and nature are about to go over the edge, is Everywhere.

Doubt is Their Product: How Industry's Assault on Science Threatens Your Health

Author: David Michaels

This book will shock anyone who still believes that 'science' and 'integrity' are soulmates.


If anyone remakes "Erin Brockovich," this is a scene I want to see. A scientist launches a study to determine the toxicity of hexavalent chromium, the drinking-water contaminant at the center of the lawsuits Brockovich spearheaded. The study will be a meta-analysis, combining existing individual studies to, he says, produce more-authoritative conclusions. Some of the earlier studies measured rates of lung cancer among pigment-factory workers exposed to airborne chromium, so it makes sense to include them. But the scientist is working for industry, so he chooses his other studies carefully: he includes those that assessed all forms of cancer among residents who drank chromium-laced water. Only the workers, not the residents, had increased rates of lung cancer. No surprise there: only inhaled—not ingested—chromium can cause lung cancer. Since there are many more residents than factory workers, the data showing no rise in lung cancer swamp the large numbers of lung cancers in the workers. Thanks to this sleight of hand, the study—which happened in real life, not a movie—concludes that chromium "is only weakly carcinogenic for the lungs," giving the chemical a nice coat of whitewash.

That science can be bought is hardly news to anyone who knows about tobacco "scientists." But how pervasive, effective and stealthy this science-for-hire is—as masterfully documented by David Michaels of George Washington University in his new book, "Doubt Is Their Product: How Industry's Assault on Science Threatens Your Health"—will shock anyone who still believes that "science" and "integrity" are soulmates. In studies of how toxic chemicals affect human health, Michaels told me, "It's quite easy to take a positive result [showing harmful effects] and turn it falsely negative. This epidemiological alchemy is used widely."

The alchemy is all in how you design your study and massage the data. Want to show that chemical x does not raise the risk of cancer? Then follow the exposed population for only a few years, since the cancers that most chemicals cause take 20 or 30 years to show up. Since workers are healthier than the general population, they start with a lower death rate; only by comparing rates of something the chemical is specifically suspected of causing—a particular lung disease, perhaps—can you detect a problem. Or, combine data on groups who got a lot of the suspect chemical, such as factory workers, with those who got little or none, perhaps their white-collar bosses. The low disease rates in the latter will dilute the high rates in the former, making it seem that x isn't that toxic. All these ruses have been used, delaying government action on chemicals including benzene, vinyl chloride, asbestos, chromium, beryllium and a long list of others that cause cancer in humans. "Any competent epidemiologist can employ particular tricks of the trade when certain results are desired," Michaels writes.

The strategy of manufacturing doubt was pioneered, of course, by the tobacco industry. Tobacco-funded studies threw up enough red herrings—"Psychosocial, Familial Factors May Have Role in Lung Cancer," "Lung Cancer Rare in Bald Men"—to confuse consumers and delay the warning label on cigarettes. Doubt is still a crucial product for any industry fighting regulations that would protect workers and consumers from exposure to toxic compounds. Now some industries argue that it would be wrong to reduce allowable exposure limits until science can prove exactly what level is safe. Better to keep the limit at, say, 50—even though that level kills workers—than cut it to 10, when 12 might be OK.

This is all very big business. "Product-defense firms" have sprung up to spin the science and manufacture doubt—proudly. One boasted on its Web site of persuading the Food and Drug Administration to let an unnamed drug stay on the market for "10 additional years of sales" before the FDA banned it for harming people. This science-for-hire is aided and abetted by what Michaels calls "vanity journals," established by the firms. By naming like-minded consultants as the journal's peer reviewers (who decide what gets published), they can get anything that advances their cause into "a peer-reviewed journal"—magic words to jurors, regulators and reporters.

Make no mistake: raising doubt has run up the body count. By the early 1980s, for instance, studies had shown that children who took aspirin when they had a viral infection such as chickenpox were at greater risk of developing Reye's syndrome, which damages the brain and liver and is fatal in about one case in three. Desperate to protect their market, aspirin makers claimed the science was flawed, called for more research (a constant refrain), and ran public-service announcements assuring parents, "We do know that no medication has been proven to cause Reye's." The campaign delayed by years the requirement that aspirin carry a warning label about children and Reye's. In the interim, thousands of kids developed Reye's. Hundreds died.

Michaels's argument would be stronger if he included cases in which early studies overstated risk, to show that industry is sometimes right about how dangerous a compound is. (Sodium nitrite in hot dogs?) Still, his book should leave no doubt that science, and scientists, can be bought—the public welfare be damned.

BETTER TOGETHER: Restoring the American Community

Author : Robert Putnam

In his national best-seller Bowling Alone, Robert Putnam decried the collapse of America’s social institutions. But while traveling to promote the book, one question came up at every appearance: what can we do to end the atrophy of America’s civic vitality. What can bring us together again?

Seeking an answer to this question, Putnam, a professor of public policy at Harvard, with the assistance of coauthor Lewis Feldstein, who has a long and distinguished career in civic activism, visited places across the country where individuals and groups are engaged in unusual forms of social activism and civic renewal. These are people who are renewing their communities and investing in new forms of “social capital.” Better Together describes a dozen innovative organizations from east to west and north to south that are re-weaving the social fabric of our country, and brings the hopeful news that our civic institutions are taking new forms to adapt to new times and new needs.

Examples:
* A mentoring and reading program in Philadelphia that brings together retirees and elementary school children to the benefit of both – the children get help reading and the retirees have a richer, more purposeful life
* A group of sixth-grade activists in a small Wisconsin town who managed to persuade local authorities to improve safety at a railroad crossing and in doing so learned a valuable lesson in civic activism
* A neighborhood in Boston that has been revitalized by a civic association that overcame ethnic differences and now plays an ongoing role in the neighborhood
* A community effort in the impoverished Rio Grande Valley, one of the poorest regions in the U.S., that brought such basic services as electricity, roads, and health care to the mostly Spanish-speaking residents
* A successful small business initiative in Tupelo, Mississippi, that began sixty years ago with the purchase of a prize bull
* Chicago public libraries that have broadened their mission and have become true community centers
* Two huge and rapidly growing churches in Los Angeles that are making people feel connected to other church members and their community
* The city of Portland, Oregon, where the anti-war movement of the sixties actually changed the institutions so that now there is a remarkably high level of civic engagement in government and politics (more so than in other cities, even other cities on the west coast).

All across America such organizations are starting up and thriving, giving hope that the message of Bowling Alone has reached people and that our civic institutions are improving and adapting to the changing world around us. And the timing of Better Together could not be more perfect -- in the wake of 9/11 the subjects of civic spirit, community renewal, and social capital have been high on everyone’s agenda as Americans ask again what makes us uniquely American and what values do we want to pass on to the next generations.

Book Review:

Has America's civic life lost the vitality it once had? Over the past decade there has been an explosion of essays, books, reports, and academic projects on this topic that has resulted in, for the social sciences, a surprisingly definitive answer: Yes. Americans today are less likely to vote, be involved in civic groups, participate in public affairs, or even spend time with neighbors than in past generations (particularly the "Greatest Generation," which fought in World War II). Having spent much of the 1990s documenting this decline, academics, policymakers, and political commentators have shifted to a stickier question: What might it take to reverse this trend and bring more Americans together as active participants in their own communities?

While Robert D. Putnam, a professor at Harvard University, and New Hampshire Charitable Foundation President Lewis M. Feldstein were putting the finishing touches on their new book, Better Together: Restoring the American Community, some Internet-savvy youth were busy providing an answer of their own: flash mobs.

Communicating through email, flash mob organizers helped bring together hundreds of people to briefly interact in a public space -- and just as quickly depart. The first such flash mob was held in June in New York City; 200 people amassed for 10 minutes on the ninth floor of Macy's department store to discuss the merits of the store's carpets. Soon afterward, flash mobs appeared in other cities. In San Francisco, for example, hundreds gathered for a game of duck-duck-goose on the Golden Gate Bridge. As one participant described the gathering: "We have protests in San Francisco all the time. The whole point of this is that there is no point."

In their own ridiculous way, these flash mobs drive home a critical point: In the search for a revival of America's civic life, what people do in the public sphere is as important as the fact that they are doing it together.

Readers will not find stories of flash mobs playing duck-duck-goose in Putnam and Feldstein's Better Together, but they will find a surprisingly eclectic mix of organizations that the authors present as examples of an overall effort to create "new forms of community, adapted to the conditions and needs of our time."

Each of the book's 12 chapters is devoted to the story of a different exercise in community building. In Los Angeles, an evangelical Christian mega-church turns its crowd of 45,000 visitors into a congregation of committed members through the organization of hundreds of small study groups focused on encouraging social interaction. In Boston, organizers succeed in unionizing Harvard's research assistants through the use of one-on-one conversations and the patient development of personal relationships. In Portsmouth, N.H., a two-year effort seeks to lower the social barriers between shipyard workers and the community's artists through an interpretive dance festival that integrates the various actions of building a ship -- and the shipbuilders themselves -- into the performances.

As a guide for using community-building techniques to improve one's organization or civic project, this book serves its purpose well -- it offers readers a dozen well-researched and well-written examples of how to encourage the formation of productive social ties. However, read in the larger context of the effort to restore the vitality of American civic life, the book falls a bit short.

Like the flash mobs of 2003, Putnam and Feldstein's overriding focus on novel ways to generate social connections ends up making the creation of these social ties an end in itself. Indeed, the authors seem to lose sight of an essential point about the Greatest Generation, which they and others have identified as the high-water mark for civic engagement -- that the strong sense of community held by that generation was created by working together as citizens to accomplish great things.

That insight raises some key questions for public officials and policymakers. Rather than Putnam and Feldstein's self-conscious strategy for investing in greater levels of social connectedness, why not work toward increasing the involvement of citizens in the key public challenges their country and their communities face, knowing that a revitalized civic spirit could be the happy byproduct of such an effort?

This approach would point toward a set of civic projects overlooked by Putnam and Feldstein in Better Together. With U.S. Armed Forces stretched thin in Afghanistan and Iraq, America's national leadership could take advantage of the military's new 18-month enlistment program to bring a new generation of citizen soldiers into service to share the burden of self-defense. With international terrorists determined to put America's communities on the front lines, national, state, and local authorities could scale up the fledgling AmeriCorps homeland security efforts to bring community members together in emergency preparedness education programs, Citizen Emergency Response Teams (CERT), police and fire department support projects, and disaster emergency planning. Finally, as policymakers confront other public challenges, such as the coming wave of baby boomer retirements, they could look first to civic programs that expand the opportunities for citizens themselves to work together to solve critical public problems.

In his 1995 article, "Bowling Alone," and the 2000 book of the same name, Putnam played a crucial role in lifting the veil on the huge social and political problem of declining civic engagement. However, in the shift from documenting the decline to highlighting ways to reverse this trend, Putnam and Feldstein's Better Together serves mostly as a cautionary tale for how much more difficult the latter can be. By ignoring the most compelling reasons Americans have to work together as citizens in favor of more deliberative community building strategies, they end up defining down the civic agenda they profess to support. That weakens the case for a public policy focused on the civic health of the nation.

Marc Magee is the director of the Center for Civic Enterprise at the Progressive Policy Institute.