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Objective: Relatively little is known about the intergenerational mechanisms that lead to social disparities in child health. We examined whether the association between low socioeconomic status (SES) and child behavior problems is mediated by maternal health conditions and behavior.

Methods: Prospective cohort data (1979-1998) on 2,677 children and their mothers were obtained from the National Longitudinal Survey of Youth. SES, the Child Behavior Problems Index (BPI), and maternal smoking, depressive symptoms, and alcohol use before, during, and after pregnancy were examined.

Results: Lower income and lower maternal education were associated with increased child BPI scores. Adjustment for maternal smoking, depressive symptoms, and alcohol use attenuated the associations between SES and child BPI by 26% to 49%. These maternal health conditions often occurred together, persisted over time, and were associated with the mother's own childhood SES and pre-pregnancy health.

Conclusions: Social disparities in women's health conditions may help shape the

likelihood of behavior problems in the subsequent generation. Improved public

health programs and services for disadvantaged women across the lifecourse may

not only address their own urgent health needs, but reduce social disparities in the health and well-being of their children.

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Public Health Reports
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Paul H. Wise
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In 1920, the Irish Republican Army reportedly considered a terrifying new weapon: typhoid-contaminated milk. Reading from an IRA memo he claimed had been captured in a recent raid, Sir Hamar Greenwood described to Parliament the ease with which "fresh and virulent cultures" could be obtained and introduced into milk served to British soldiers. Although the plot would only target the military, the memo expressed concern that the disease might spread to the general population.

Although the IRA never used this weapon, the incident illustrates that poisoning a nation's milk supply with biological agents hardly ranks as a new concept. Yet just two weeks ago, the National Academy of Sciences' journal suspended publication of an article analyzing the vulnerability of the U.S. milk supply to botulinum toxin, because the Department of Health and Human Services warned that information in the article provided a "road map for terrorists."

That approach may sound reasonable, but the effort to suppress scientific information reflects a dangerously outdated attitude. Today, information relating to microbiology is widely and instantly available, from the Internet to high school textbooks to doctoral theses. Our best defense against those who would use it as a weapon is to ensure that our own scientists have better information. That means encouraging publication.

The article in question, written by Stanford University professor Lawrence Wein and graduate student Yifan Liu, describes a theoretical terrorist who obtains a few grams of botulinum toxin on the black market and pours it into an unlocked milk tank. Transferred to giant dairy silos, the toxin contaminates a much larger supply. Because even a millionth of a gram may be enough to kill an adult, hundreds of thousands of people die. (Wein summarized the article in an op-ed he wrote for the New York Times.) The scenario is frightening, and it is meant to be -- the authors want the dairy industry and its federal regulators to take defensive action.

The national academy's suspension of the article reflects an increasing concern that publication of sensitive data can provide terrorists with a how-to manual, but it also brings to the fore an increasing anxiety in the scientific community that curbing the dissemination of research may impair our ability to counter biological threats. This dilemma reached national prominence in fall 2001, when 9/11 and the anthrax mailings drew attention to another controversial article. This one came from a team of Australian scientists.

Approximately every four years, Australia suffers a mouse infestation. In 1998, scientists in Canberra began examining the feasibility of using a highly contagious disease, mousepox, to alter the rodents' ability to reproduce. Their experiments yielded surprising results. Researchers working with mice naturally resistant to the disease found that combining a gene from the rodent's immune system (interleukin-4) with the pox virus and inserting the pathogen into the animals killed them -- all of them. Plus 60 percent of the mice not naturally resistant who had been vaccinated against mousepox.

In February 2001 the American SocietyforMicrobiologists' (ASM) Journal of Virology reported the findings. Alarm ensued. The mousepox virus is closely related to smallpox -- one of the most dangerous pathogens known to humans. And the rudimentary nature of the experiment demonstrated how even basic, inexpensive microbiology can yield devastating results.

When the anthrax attacks burst into the news seven months later, the mousepox case became a lightning rod for deep-seated fears about biological weapons. The Economist reported rumors about the White House pressuring American microbiology journals to restrict publication of similar pieces. Samuel Kaplan, chair of the ASM publications board, convened a meeting of the editors in chief of the ASM's nine primary journals and two review journals. Hoping to head off government censorship, the organization -- while affirming its earlier decision -- ordered its peer reviewers to take national security and the society's code of ethics into account.

Not only publications came under pressure, but research itself. In spring 2002 the newly formed Department of Homeland Security developed an information-security policy to prevent certain foreign nationals from gaining access to a range of experimental data. New federal regulations required that particular universities and laboratories submit to unannounced inspections, register their supplies and obtain security clearances. Legislation required that all genetic engineering experiments be cleared by the government.

On the mousepox front, however, important developments were transpiring. Because the Australian research had entered the public domain, scientists around the world began working on the problem. In November 2003, St. Louis University announced an effective medical defense against a pathogen similar to -- but even more deadly than -- the one created in Australia. This result would undoubtedly not have been achieved, or at least not as quickly, without the attention drawn by the ASM article.

The dissemination of nuclear technology presents an obvious comparison. The 1946 Atomic Energy Act classifies nuclear information "from birth." Strong arguments can be made in favor of such restrictions: The science involved in the construction of the bomb was complex and its application primarily limited to weapons. A short-term monopoly was possible. Secrecy bought the United States time to establish an international nonproliferation regime. And little public good would have been achieved by making the information widely available.

Biological information and the issues surrounding it are different. It is not possible to establish even a limited monopoly over microbiology. The field is too fundamental to the improvement of global public health, and too central to the development of important industries such as pharmaceuticals and plastics, to be isolated. Moreover, the list of diseases that pose a threat ranges from high-end bugs, like smallpox, to common viruses, such as influenza. Where does one draw the line for national security?

Experience suggests that the government errs on the side of caution. In 1951, the Invention Secrecy Act gave the government the authority to suppress any design it deemed detrimental to national defense. Certain areas of research-- atomic energy and cryptography -- consistently fell within its purview. But the state also placed secrecy orders on aspects of cold fusion, space technology, radar missile systems, citizens band radio voice scramblers, optical engineering and vacuum technology. Such caution, in the microbiology realm, may yield devastating results. It is not in the national interest to stunt research into biological threats.

In fact, the more likely menace comes from naturally occurring diseases. In 1918 a natural outbreak of the flu infected one-fifth of the world's population and 25 percent of the United States'. Within two years it killed more than 650,000 Americans, resulting in a 10-year drop in average lifespan. Despite constant research into emerging strains, the American Lung Association estimates that the flu and related complications kill 36,000 Americans each year. Another 5,000 die annually from food-borne pathogens -- an extraordinarily large number of which have no known cure. The science involved in responding to these diseases is incremental, meaning that small steps taken by individual laboratories around the world need to be shared for larger progress to be made.

The idea that scientific freedom strengthens national security is not new. In the early 1980s, a joint Panel on Scientific Communication and National Security concluded security by secrecywasuntenable. Its report called instead for security by accomplishment -- ensuring strength through advancing research. Ironically, one of the three major institutions participating was the National Academy of Sciences -- the body that suspended publication of the milk article earlier this month.

The government has a vested interest in creating a public conversation about ways in which our society is vulnerable to attack. Citizens are entitled to know when their milk, their water, their bridges, their hospitals lack security precautions. If discussion of these issues is censored, the state and private industry come under less pressure to alter behavior; indeed, powerful private interests may actively lobby against having to install expensive protections. And failure to act may be deadly.

Terrorists will obtain knowledge. Our best option is to blunt their efforts to exploit it. That means developing, producing and stockpiling effective vaccines. It means funding research into biosensors -- devices that detect the presence of toxic substances in the environment -- and creating more effective reporting requirements for early identification of disease outbreaks. And it means strengthening our public health system.

For better or worse, the cat is out of the bag -- something brought home to me last weekend when I visited the Tech Museum of Innovation in San Jose. One hands-on exhibit allowed children to transfer genetic material from one species to another. I watched a 4-year-old girl take a red test tube whose contents included a gene that makes certain jellyfish glow green. Using a pipette, she transferred the material to a blue test tube containing bacteria. She cooled the solution, then heated it, allowing the gene to enter the bacteria. Following instructions on a touch-screen computer, she transferred the contents to a petri dish, wrote her name on the bottom, and placed the dish in an incubator. The next day, she could log on to a Web site to view her experiment, and see her bacteria glowing a genetically modified green.

In other words, the pre-kindergartener (with a great deal of help from the museum) had conducted an experiment that echoed the Australian mousepox study. Obviously, this is not something the child could do in her basement. But just as obviously, the state of public knowledge is long past anyone's ability to censor it.

Allowing potentially harmful information to enter the public domain flies in the face of our traditional way of thinking about national security threats. But we have entered a new world. Keeping scientists from sharing information damages our ability to respond to terrorism and to natural disease, which is more likely and just as devastating. Our best hope to head off both threats may well be to stay one step ahead.

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We compared the cost-effectiveness of a free nicotine replacement therapy (NRT) program with a statewide smoke-free workplace policy in Minnesota. We conducted 1-year simulations of costs and benefits. The number of individuals who quit smoking and the quality-adjusted life years (QALYs) were the measures of benefits. After 1 year, a NRT program generated 18,500 quitters at a cost of 7020 dollars per quitter (4440 dollars per QALY), and a smoke-free workplace policy generated 10,400 quitters at a cost of 799 dollars per quitter (506 dollars per QALY). Smoke-free work-place policies are about 9 times more cost-effective per new nonsmoker than free NRT programs are. Smoke-free workplace policies should be a public health funding priority, even when the primary goal is to promote individual smoking cessation.

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American Journal of Public Health
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Background: An increase in the incidence of esophageal adenocarcinoma has coincided with a decrease in the prevalence of Helicobacter pylori infection. Whether these 2 phenomena are associated is unknown.

Methods: We conducted a nested case-control study of 128,992 members of an integrated health care system who had participated in a multiphasic health checkup (MHC) during 1964-1969. During follow-up, 52 patients developed esophageal adenocarcinoma. Three randomly chosen control subjects from the MHC cohort were matched to each case subject, on the basis of age at the MHC, sex, race, and the date and site of the MHC. Data on cigarette smoking, alcohol consumption, body mass index (BMI), and education level were obtained at the MHC. Serum samples collected at the MHC were tested for IgG antibodies to H. pylori and to the H. pylori CagA protein.

Results: Subjects with H. pylori infections were less likely than uninfected subjects to develop esophageal adenocarcinoma (odds ratio [OR], 0.37 [95% confidence interval (CI), 0.16-0.88]). This significant association was restricted to case subjects and control subjects 50 years old at the MHC (OR, 0.20 [95% CI, 0.06-0.68]). In patients with H. pylori infections, the OR for those who tested positive for IgG antibodies to the CagA protein was similar to that for those who tested negative for it. BMI >/=25 and cigarette smoking were strong independent risk factors for development of esophageal adenocarcinoma.

Conclusion: The absence of H. pylori infection, independent of cigarette smoking and BMI, is associated with a markedly increased risk of development of esophageal adenocarcinoma.

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Journal of Infectious Diseases
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Julie Parsonnet
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Mortality rates in the United States fell more rapidly during the late nineteenth and early twentieth centuries than in any other period in American history. This decline coincided with an epidemiological transition and the disappearance of a mortality "penalty" associated with living in urban areas. There is little empirical evidence and much unresolved debate about what caused these improvements, however. In this article, we report the causal influence of clean water technologies -- filtration and chlorination -- on mortality in major cities during the early twentieth century. Plausibly exogenous variation in the timing and location of technology adoption was used to identify these effects, and the validity of this identifying assumption is examined in detail. We found that clean water was responsible for nearly half the total mortality reduction in major cities, three quarters of the infant mortality reduction, and nearly two thirds of the child mortality reduction. Rough calculations suggest that the social rate of return to these technologies was greater than 23 to 1, with a cost per person-year saved by clean water of about $500 in 2003 dollars. Implications for developing countries are briefly considered.

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Demography
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Grant Miller
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Imagine that Israel never existed. Would the economic malaise and political repression that drive angry young men to become suicide bombers vanish? Would the Palestinians have an independent state? Would the United States, freed of its burdensome ally, suddenly find itself beloved throughout the Muslim world? Wishful thinking. Far from creating tensions, Israel actually contains more antagonisms than it causes.

Since World War II, no state has suffered so cruel a reversal of fortunes as Israel. Admired all the way into the 1970s as the state of "those plucky Jews" who survived against all odds and made democracy and the desert bloom in a climate hostile to both liberty and greenery, Israel has become the target of creeping delegitimization. The denigration comes in two guises. The first, the soft version, blames Israel first and most for whatever ails the Middle East, and for having corrupted U.S. foreign policy. It is the standard fare of editorials around the world, not to mention the sheer venom oozing from the pages of the Arab-Islamic press. The more recent hard version zeroes in on Israel's very existence. According to this dispensation, it is Israel as such, and not its behavior, that lies at the root of troubles in the Middle East. Hence the "statocidal" conclusion that Israel's birth, midwifed by both the United States and the Soviet Union in 1948, was a grievous mistake, grandiose and worthy as it may have been bat the time.

The soft version is familiar enough. One motif is the "wagging the dog" theory. Thus, in the United States, the "Jewish lobby" and a cabal of neoconservatives have bamboozled the Bush administration into a mindless pro-Israel policy inimical to the national interest. This view attributes, as has happened so often in history, too much clout to the Jews. And behind this charge lurks a more general one-that it is somehow antidemocratic for subnational groups to throw themselves into the hurly-burly of politics when it comes to foreign policy. But let us count the ways in which subnational entities battle over the national interest: unions and corporations clamor for tariffs and tax loopholes; nongovernmental organizations agitate for humanitarian intervention; and Cuban Americans keep us from smoking cheroots from the Vuelta Abajo. In previous years, Poles militated in favor of Solidarity, African Americans against Apartheid South Africa, and Latvians against the Soviet Union. In other words, the democratic melee has never stopped at the water's edge.

Another soft version is the "root-cause" theory in its many variations.

Because the "obstinate" and "recalcitrant" Israelis are the main culprits, they must be punished and pushed back for the sake of peace. "Put pressure on Israel"; "cut economic and military aid"; "serve them notice that we will not condone their brutalities"-these have been the boilerplate homilies, indeed the obsessions, of the chattering classes and the foreign-office establishment for decades. Yet, as Sigmund Freud reminded us, obsessions tend to spread. And so there are ever more creative addenda to the well-wrought root-cause theory. Anatol Lieven of the Carnegie Endowment for International Peace argues that what is happening between Israelis and Palestinians is a "tremendous obstacle to democratization because it inflames all the worst, most regressive aspects of Arab nationalism and Arab culture." In other words, the conflict drives the pathology, and not the other way around-which is like the streetfighter explaining to the police: "It all started when this guy hit back."

The problem with this root cause argument is threefold: It blurs, if not reverses, cause and effect. It ignores a myriad of conflicts unrelated to Israel. And it absolves the Arabs of culpability, shifting the blame to you know whom. If one believes former U.N. weapons inspector Scott Ritter, the Arab-Islamic quest for weapons of mass destruction, and by extension the war against Iraq, are also Made in Israel. "[A]s long as Israel has nuclear weapons," Ritter opines, "it has chosen to take a path that is inherently confrontational....Now the Arab countries, the Muslim world, is not about to sit back and let this happen, so they will seek their own deterrent. We saw this in Iraq, not only with a nuclear deterrent but also with a biological weapons deterrent...that the Iraqis were developing to offset the Israeli nuclear superiority."

This theory would be engaging if it did not collide with some inconvenient facts. Iraqis didn't use their weapons of mass destruction against the Israeli usurper but against fellow Muslims during the Iran-Iraq War, and against fellow Iraqis in the poison-gas attack against Kurds in Halabja in 1988-neither of whom were brandishing any nuclear weapons. As for the Iraqi nuclear program, we now have the "Duelfer Report," based on the debriefing of Iraqi regime loyalists, which concluded: "Iran was the preeminent motivator of this policy. All senior-level Iraqi officials considered Iran to be Iraq's principal enemy in the region. The wish to balance Israel and acquire status and influence in the Arab world were also considerations, but secondary."

Now to the hard version. Ever so subtly, a more baleful tone slips into this narrative: Israel is not merely an unruly neighbor but an unwelcome intruder. Still timidly uttered outside the Arab world, this version's proponents in the West bestride the stage as truth sayers who dare to defy taboo. Thus, the British writer A.N. Wilson declares that he has reluctantly come to the conclusion that Israel, through its own actions, has proven it does not have the right to exist. And, following Sept. 11, 2001, Brazilian scholar Jose Arthur Giannotti said: "Let us agree that the history of the Middle East would be entirely different without the State of Israel, which opened a wound between Islam and the West. Can you get rid of Muslim terrorism without getting rid of this wound which is the source of the frustration of potential terrorists?"

The very idea of a Jewish state is an "anachronism," argues Tony Judt, a professor and director of the Remarque Institute at New York University. It resembles a "late-nineteenth-century separatist project" that has "no place" in this wondrous new world moving toward the teleological perfection of multiethnic and multicultural togetherness bound together by international law. The time has come to "think the unthinkable," hence, to ditch this Jewish state for a binational one, guaranteed, of course, by international force.

So let us assume that Israel is an anachronism and a historical mistake without which the Arab-Islamic world stretching from Algeria to Egypt, from Syria to Pakistan, would be a far happier place, above all because the original sin, the establishment of Israel, never would have been committed. Then let's move from the past to the present, pretending that we could wave a mighty magic wand, and "poof," Israel disappears from the map.

Civilization of Clashes

Let us start the what-if procession in 1948, when Israel was born in war.

Would stillbirth have nipped the Palestinian problem in the bud? Not quite. Egypt, Transjordan (now Jordan), Syria, Iraq, and Lebanon marched on Haifa and Tel Aviv not to liberate Palestine, but to grab it. The invasion was a textbook competitive power play by neighboring states intent on acquiring territory for themselves. If they had been victorious, a Palestinian state would not have emerged, and there still would have been plenty of refugees. (Recall that half the population of Kuwait fled Iraqi dictator Saddam Hussein's "liberation" of that country in 1990.) Indeed, assuming that Palestinian nationalism had awakened when it did in the late 1960s and 1970s, the Palestinians might now be dispatching suicide bombers to Egypt, Syria, and elsewhere.

Let us imagine Israel had disappeared in 1967, instead of occupying the West Bank and the Gaza Strip, which were held, respectively, by Jordan's King Hussein and Egypt's President Gamal Abdel Nasser. Would they have relinquished their possessions to Palestinian leader Yasir Arafat and thrown in Haifa and Tel Aviv for good measure? Not likely. The two potentates, enemies in all but name, were united only by their common hatred and fear of Arafat, the founder of Fatah (the Palestine National Liberation Movement) and rightly suspected of plotting against Arab regimes. In short, the "root cause" of Palestinian statelessness would have persisted, even in Israel's absence.

Let us finally assume, through a thought experiment, that Israel goes "poof" today. How would this development affect the political pathologies of the Middle East? Only those who think the Palestinian issue is at the core of the Middle East conflict would lightly predict a happy career for this most dysfunctional region once Israel vanishes. For there is no such thing as "the" conflict. A quick count reveals five ways in which the region's fortunes would remain stunted-or worse:

States vs. States Israel's elimination from the regional balance would hardly bolster intra-Arab amity. The retraction of the colonial powers, Britain and France, in the mid-20th century left behind a bunch of young Arab states seeking to redraw the map of the region. From the very beginning, Syria laid claim to Lebanon. In 1970, only the Israeli military deterred Damascus from invading Jordan under the pretext of supporting a Palestinian uprising. Throughout the 1950s and 1960s, Nasser's Egypt proclaimed itself the avatar of pan-Arabism, intervening in Yemen during the 1960s. Nasser's successor, President Anwar Sadat, was embroiled in on-and-off clashes with Libya throughout the late 1970s. Syria marched into Lebanon in 1976 and then effectively annexed the country 15 years later, and Iraq launched two wars against fellow Muslim states: Iran in 1980, Kuwait in 1990. The war against Iran was the longest conventional war of the 20th century. None of these conflicts is related to the Israeli-Palestinian one. Indeed, Israel's disappearance would only liberate military assets for use in such internal rivalries.

Believers vs. Believers: Those who think that the Middle East conflict is a "Muslim-Jewish thing" had better take a closer look at the score card: 14 years of sectarian bloodshed in Lebanon; Saddam's campaign of extinction against the Shia in the aftermath of the first Gulf War; Syria's massacre of 20,000 people in the Muslim Brotherhood stronghold of Hama in 1982; and terrorist violence against Egyptian Christians in the 1990s. Add to this tally intraconfessional oppression, such as in Saudi Arabia, where the fundamentalist Wahhabi sect wields the truncheon of state power to inflict its dour lifestyle on the less devout.

Ideologies vs. Ideologies: Zionism is not the only "ism" in the region, which is rife with competing ideologies. Even though the Baathist parties in Syria and Iraq sprang from the same fascist European roots, both have vied for precedence in the Middle East. Nasser wielded pan-Arabism-cumsocialism against the Arab nation-state. And both Baathists and Nasserites have opposed the monarchies, such as in Jordan. Khomeinist Iran and Wahhabite Saudi Arabia remain mortal enemies. What is the connection to the Arab-Israeli conflict? Nil, with the exception of Hamas, a terror army of the faithful once supported by Israel as a rival to the Palestine Liberation Organization and now responsible for many suicide bombings in Israel. But will Hamas disband once Israel is gone? Hardly Hamas has bigger ambitions than eliminating the "Zionist entity." The organization seeks nothing less than a unified Arab state under a regime of God.

Reactionary Utopia vs. Modernity: A common enmity toward Israel is the only thing that prevents Arab modernizers and traditionalists from tearing their societies apart. Fundamentalists vie against secularists and reformist Muslims for the fusion of mosque and state under the green flag of the Prophet. And a barely concealed class struggle pits a minuscule bourgeoisie and millions of unemployed young men against the power structure, usually a form of statist cronyism that controls the means of production. Far from creating tensions, Israel actually contains the antagonisms in the world around it.

Regimes vs. Peoples: The existence of Israel cannot explain the breadth and depth of the Mukhabarat states (secret police states) throughout the Middle East. With the exceptions of Jordan, Morocco, and the Gulf sheikdoms, which gingerly practice an enlightened monarchism, all Arab countries (plus Iran and Pakistan) are but variations of despotism-from the dynastic dictatorship of Syria to the authoritarianism of Egypt. Intranational strife in Algeria has killed nearly 100,000, with no letup in sight. Saddam's victims are said to number 300,000. After the Khomeinists took power in 1979, Iran was embroiled not only in the Iran-Iraq War but also in barely contained civil unrest into the 1980s. Pakistan is an explosion waiting to happen. Ruthless suppression is the price of stability in this region.

Again, it would take a florid imagination to surmise that factoring Israel out of the Middle East equation would produce liberal democracy in the region. It might be plausible to argue that the dialectic of enmity somehow favors dictatorship in "frontline states" such as Egypt and Syria-governments that invoke the proximity of the "Zionist threat" as a pretext to suppress dissent. But how then to explain the mayhem in faraway Algeria, the bizarre cult-of-personality regime in Libya, the pious kleptocracy of Saudi Arabia, the clerical despotism of Iran, or democracy's enduring failure to take root in Pakistan? Did Israel somehow cause the various putsches that produced the republic of fear in Iraq? If Jordan, the state sharing the longest border with Israel, can experiment with constitutional monarchy, why not Syria?

It won't do to lay the democracy and development deficits of the Arab world on the doorstep of the Jewish state. Israel is a pretext, not a cause, and therefore its dispatch will not heal the self-inflicted wounds of the Arab-Islamic world. Nor will the mild version of "statocide," a binational state, do the trick-not in view of the "civilization of clashes" (to borrow a term from British historian Niall Ferguson) that is the hallmark of Arab political culture. The mortal struggle between Israelis and Palestinians would simply shift from the outside to the inside.

My Enemy, Myself

Can anybody proclaim in good conscience that these dysfunctionalities of the Arab world would vanish along with Israel? Two U.N. "Arab Human Development Reports," written by Arab authors, say no. The calamities are homemade. Stagnation and hopelessness have three root causes. The first is lack of freedom. The United Nations cites the persistence of absolute autocracies, bogus elections, judiciaries beholden to executives, and constraints on civil society. Freedom of expression and association are also sharply limited. The second root cause is lack of knowledge: Sixty-five million adults are illiterate, and some 10 million children have no schooling at all. As such, the Arab world is dropping ever further behind in scientific research and the development of information technology. Third, female participation in political and economic life is the lowest in the world. Economic growth will continue to lag as long as the potential of half the population remains largely untapped.

Will all of this right itself when that Judeo-Western insult to Arab pride finally vanishes? Will the millions of unemployed and bored young men, cannon fodder for the terrorists, vanish as well-along with one-party rule, corruption, and closed economies? This notion makes sense only if one cherishes single-cause explanations or, worse, harbors a particular animus against the Jewish state and its refusal to behave like Sweden.(Come to think of it, Sweden would not be Sweden either if it lived in the Hobbesian world of the Middle East.)

Finally, the most popular what-if issue of them all: Would the Islamic world hate the United States less if Israel vanished? Like all what-if queries, this one, too, admits only suggestive evidence. To begin, the notion that 5 million Jews are solely responsible for the rage of 1 billion or so Muslims cannot carry the weight assigned to it. Second, Arab-Islamic hatreds of the United States preceded the conquest of the West Bank and Gaza. Recall the loathing left behind by the U.S.-managed coup that restored the shah's rule in Tehran in 1953, or the U.S. intervention in Lebanon in 1958. As soon as Britain and France left the Middle East, the United States became the dominant power and the No. 1 target. Another bit of suggestive evidence is that the fiercest (unofficial) anti-Americanism emanates from Washington's self-styled allies in the Arab Middle East, Egypt and Saudi Arabia. Is this situation because of Israel-or because it is so convenient for these regimes to "busy giddy minds with foreign quarrels" (as Shakespeare's Henry IV put it) to distract their populations from their dependence on the "Great Satan"?

Take the Cairo Declaration against "U.S. hegemony," endorsed by 400 delegates from across the Middle East and the West in December 2002. The lengthy indictment mentions Palestine only peripherally. The central condemnation, uttered in profuse variation, targets the United States for monopolizing power "within the framework of capitalist globalization," for reinstating "colonialism," and for blocking the "emergence of forces that would shift the balance of power toward multi-polarity." In short, Global America is responsible for all the afflictions of the Arab world, with Israel coming in a distant second.

This familiar tale has an ironic twist: One of the key signers is Nader Fergany, lead author of the 2002 U.N. Arab Human Development Report. So even those who confess to the internal failures of the Arab world end up blaming "the Other." Given the enormity of the indictment, ditching Israel will not absolve the United States. Iran's Khomeinists have it right, so to speak, when they denounce America as the "Great Satan" and Israel only as the "Little Satan," a handmaiden of U.S. power. What really riles America-haters in the Middle East is Washington's intrusion into their affairs, be it for reasons of oil, terrorism, or weapons of mass destruction. This fact is why Osama bin Laden, having attached himself to the Palestinian cause only as an afterthought, calls the Americans the new crusaders, and the Jews their imperialist stand-ins.

None of this is to argue in favor of Israel's continued occupation of the West Bank and Gaza, nor to excuse the cruel hardship it imposes on the Palestinians, which is pernicious, even for Israel's own soul. But as this analysis suggests, the real source of Arab angst is the West as a palpable symbol of misery and an irresistible target of what noted Middle East scholar Fouad Ajami has called "Arab rage." The puzzle is why so many Westerners, like those who signed the Cairo Declaration, believe otherwise. Is this anti-Semitism, as so many Jews are quick to suspect? No, but denying Israel's legitimacy bears an uncanny resemblance to some central features of this darkest of creeds. Accordingly, the Jews are omnipotent, ubiquitous, and thus responsible for the evils of the world.

Today, Israel finds itself in an analogous position, either as handmaiden or manipulator of U.S. might. The soft version sighs: "If only Israel were more reasonable..." The semihard version demands that "the United States pull the rug out from under Israel" to impose the pliancy that comes from impotence. And the hard-hard version dreams about salvation springing from Israel's disappearance.

Why, sure-if it weren't for that old joke from Israel's War of Independence: While the bullets were whistling overhead and the two Jews in their foxhole were running out of rounds, one griped, "If the Brits had to give us a country not their own, why couldn't they have given us Switzerland?" Alas, Israel is just a strip of land in the world's most noxious neighborhood, and the cleanup hasn't even begun.

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Background:

The withdrawal of rofecoxib has highlighted concerns regarding the safety of cyclooxygenase-2 (COX-2) inhibitors. In some patients COX-2 inhibitors may be safer than nonselective nonsteroidal anti-inflammatory drugs (NSAIDs); however, the public health benefit of COX-2 inhibitors depends on their use in patients at higher than normal risk from NSAIDs. We examined trends in COX-2 inhibitor use based on risk for adverse events from NSAIDs.

Methods:

We analyzed data from the National Ambulatory Medical Care Survey (1999-2002) and National Hospital Ambulatory Medical Care Survey (1999-2001), nationally representative surveys of community and hospital-based outpatient practices. The main outcome measure was the proportion of patient visits in which COX-2 inhibitors were prescribed, stratified by risk of adverse gastrointestinal (GI) events from NSAIDs.

Results:

Of the visits in which either a COX-2 inhibitor or NSAID was prescribed, the frequency of COX-2 inhibitor use increased from 35% (1999) to 55% (2000) to 61% (2001 and 2002). Among patients with the lowest risk for adverse events from NSAIDs, the proportion receiving a COX-2 inhibitor increased from 12% in 1999 to 35% in 2002. Overall, increases in COX-2 inhibitor use among patients in whom NSAIDs could be used accounted for more than 63% of the growth in COX-2 inhibitor use during the period examined.

Conclusions:

Marked increases in COX-2 inhibitor use have occurred since their release, primarily among patients at low risk for adverse events from NSAIDs. These findings demonstrate the challenge of limiting innovative therapies to the settings in which they are initially targeted and maximally beneficial.

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PURPOSE:

The cost-effectiveness of cardiopulmonary resuscitation (CPR) and defibrillation training for laypersons unselected for risk of encountering cases of cardiac arrest is not known. We compared the costs and health benefits of alternative resuscitation training strategies for adults without professional first-responder duties who are at average risk of encountering cases of out-of-hospital cardiac arrest.

METHODS:

We constructed a cost-effectiveness analytic model. Data on cardiac arrest epidemiology and the effectiveness of CPR/defibrillation training were obtained from the medical literature. Instructional costs were determined from a survey of training programs. Downstream cardiac arrest survivor quality-adjusted life expectancy and long-term health care costs were derived from prior studies. We compared three strategies for training unselected laypersons: CPR/defibrillation training alone, training combined with home defibrillator purchase, and no training. The main outcome measures were total instructional costs for trainees combined with health care costs for additional cardiac arrest survivors, and quality-adjusted survival for additional patients resuscitated by trainees.

RESULTS:

CPR/defibrillation training yielded 2.7 quality-adjusted hours of life at a cost of 62 US dollars per trainee (202,400 US dollars per quality-adjusted life-year [QALY] gained). Training laypersons in CPR/defibrillation with subsequent defibrillator purchase cost 2,489,700 US dollars per QALY. In contrast, CPR/defibrillation training cost less than 75,000 US dollars per QALY if trainees lived with persons older than 75 years or with persons who had cardiac disease, or if total training costs were less than 10 US dollars.

CONCLUSION:

Training unselected laypersons in CPR/defibrillation is costly compared with other public health initiatives. Conversely, training laypersons selected by occupation, low training costs, or having high-risk household companions is substantially more efficient.

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American Journal of Medicine
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Douglas K. Owens
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Adolescent smokers (N = 211) were randomized to 1 of 2 groups: (a) nicotine patch plus bupropion SR (sustained release; 150 mg per day) or (b) nicotine patch plus placebo. Group skills training sessions were conducted each week by research staff. Abstinence rates at Weeks 10 and 26 were as follows: (a) patch plus bupropion, 23% and 8%, (b) patch plus placebo, 28% and 7%. Despite the lack of a treatment effect, a large majority of adolescents in both treatment groups reduced their consumption to a few cigarettes per day or less and maintained this reduction over time. Similarly, an examination of survival curves revealed that by the end of treatment many had managed to avoid a return to daily smoking. These findings are encouraging and suggest new avenues for research. For example, treatments of the kind examined in this report, augmented by extended maintenance therapies, may yield higher long-term success rates.

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Journal of Consulting and Clinical Psychology
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