Wednesday, September 26, 2007
“Rules for Aging” by Roger Rosenblatt
excerpted from Modern Maturity, May-June, 1999
Since older people are as close to perfection as human beings get, I thought it would be generous, from time to time, to use this space to offer guidelines for living to those less old to help them age successfully, or at all. The art of aging requires NOT doing things more than taking positive action, so this is essentially a list of “nots” and “don’ts.”
1. IT DOESN’T MATTER. Whatever you think matters, doesn’t. This guideline is absolutely reliable and adhering to it will add decades to your life. It does not matter if you are late for anything; if you’re having a bad hair day, or a no hair day; if your car won’t start; if you boss looks at you cockeyed; if your girlfriend or boyfriend looks at you cockeyed; if you are cockeyed; if you don’t get promotions; if you do; if you have spinach in your teeth or if you lose your teeth in your spinach. It doesn’t matter.
2. NOBODY IS THINKING ABOUT YOU. Yes, I know, You are certain that your friends are becoming your enemies; that your enemies are acquiring nuclear weapons; that your grocer, garbage man, clergyperson, sister-in-law, and dog are all of the opinion that you have put on weight; furthermore, that everyone spends two-thirds of every day commenting on your disintegration, denigrating your work, plotting your murder. I promise you: Nobody is thinking about you. They are thinking about themselves, just like you.
3. DO NOT GO TO YOUR LEFT. Going to one’s left, or working on going to one’s left, is a basketball term for strengthening one’s weaknesses. A right-handed player will improve his game considerably if he learns to dribble and shoot with his left hand, and to move to his left on the court. But this is true only for basketball not for living. In life, if you attempt to strengthen a weakness, you will grow weaker. If, on the other hand (the right), you keep playing to your strength, people will not notice that you have weaknesses. Of course, you do not believe me. You will go ahead and take singing lessons or write that novel anyway. Trust me.
4. GIVE HONEST, FRANK, AND OPEN CRITICISM TO NOBODY, NEVER. The following situation will present itself to you over and over: There is a friend, a relative, an employee, an employer, a colleague, whose behavior flaws are so evident to everyone but themselves, you just know that a straightforward, no-punches-pulled conversation with them will show them the error of their ways. They will see the light at once, and forever be grateful that only as good and candid a person as yourself would have sufficient kindness and courage to confront them. Better still: From the moment you inform them about their bad table manners, their poor choices in clothing, their hygiene, their loudness, their deafness, their paranoia, they will reform on the spot. Their lives will be redeemed, and they will owe their renewed selves and all future happiness to you—honest, frank, and open you.
I implore you: FORGET ABOUT IT. When the muse of candor whispers in your ear, swat it…take a long walk, a cold shower, and clear your head. This guideline relates to guideline number two. Nobody is thinking about you, unless you tell them about their faults. Then you can be sure they are thinking about you. They are thinking of killing you.
That’s enough wisdom for now. I know younger people will not heed my advice anyway. So the guideline I offer them is: Don’t. Go ahead and stay awake worrying what people are thinking about you, work on your weaknesses, and criticize friends. It doesn’t matter.
excerpted from Modern Maturity, May-June, 1999
Since older people are as close to perfection as human beings get, I thought it would be generous, from time to time, to use this space to offer guidelines for living to those less old to help them age successfully, or at all. The art of aging requires NOT doing things more than taking positive action, so this is essentially a list of “nots” and “don’ts.”
1. IT DOESN’T MATTER. Whatever you think matters, doesn’t. This guideline is absolutely reliable and adhering to it will add decades to your life. It does not matter if you are late for anything; if you’re having a bad hair day, or a no hair day; if your car won’t start; if you boss looks at you cockeyed; if your girlfriend or boyfriend looks at you cockeyed; if you are cockeyed; if you don’t get promotions; if you do; if you have spinach in your teeth or if you lose your teeth in your spinach. It doesn’t matter.
2. NOBODY IS THINKING ABOUT YOU. Yes, I know, You are certain that your friends are becoming your enemies; that your enemies are acquiring nuclear weapons; that your grocer, garbage man, clergyperson, sister-in-law, and dog are all of the opinion that you have put on weight; furthermore, that everyone spends two-thirds of every day commenting on your disintegration, denigrating your work, plotting your murder. I promise you: Nobody is thinking about you. They are thinking about themselves, just like you.
3. DO NOT GO TO YOUR LEFT. Going to one’s left, or working on going to one’s left, is a basketball term for strengthening one’s weaknesses. A right-handed player will improve his game considerably if he learns to dribble and shoot with his left hand, and to move to his left on the court. But this is true only for basketball not for living. In life, if you attempt to strengthen a weakness, you will grow weaker. If, on the other hand (the right), you keep playing to your strength, people will not notice that you have weaknesses. Of course, you do not believe me. You will go ahead and take singing lessons or write that novel anyway. Trust me.
4. GIVE HONEST, FRANK, AND OPEN CRITICISM TO NOBODY, NEVER. The following situation will present itself to you over and over: There is a friend, a relative, an employee, an employer, a colleague, whose behavior flaws are so evident to everyone but themselves, you just know that a straightforward, no-punches-pulled conversation with them will show them the error of their ways. They will see the light at once, and forever be grateful that only as good and candid a person as yourself would have sufficient kindness and courage to confront them. Better still: From the moment you inform them about their bad table manners, their poor choices in clothing, their hygiene, their loudness, their deafness, their paranoia, they will reform on the spot. Their lives will be redeemed, and they will owe their renewed selves and all future happiness to you—honest, frank, and open you.
I implore you: FORGET ABOUT IT. When the muse of candor whispers in your ear, swat it…take a long walk, a cold shower, and clear your head. This guideline relates to guideline number two. Nobody is thinking about you, unless you tell them about their faults. Then you can be sure they are thinking about you. They are thinking of killing you.
That’s enough wisdom for now. I know younger people will not heed my advice anyway. So the guideline I offer them is: Don’t. Go ahead and stay awake worrying what people are thinking about you, work on your weaknesses, and criticize friends. It doesn’t matter.
The New York Times
September 26, 2007
Economic Scene
He’s Happier, She’s Less So
By DAVID LEONHARDT
Last year, a team of researchers added a novel twist to something known as a time-use survey. Instead of simply asking people what they had done over the course of their day, as pollsters have been doing since the 1960s, the researchers also asked how people felt during each activity. Were they happy? Interested? Tired? Stressed?
Not surprisingly, men and women often gave similar answers about what they liked to do (hanging out with friends) and didn’t like (paying bills). But there were also a number of activities that produced very different reactions from the two sexes — and one of them really stands out: Men apparently enjoy being with their parents, while women find time with their mom and dad to be slightly less pleasant than doing laundry.
Alan Krueger, a Princeton economist working with four psychologists on the time-use research team, figures that there is a simple explanation for the difference. For a woman, time with her parents often resembles work, whether it’s helping them pay bills or plan a family gathering. “For men, it tends to be sitting on the sofa and watching football with their dad,” said Mr. Krueger, who, when not crunching data, enjoys watching the New York Giants with his father.
This intriguing — if unsettling — finding is part of a larger story: there appears to be a growing happiness gap between men and women.
Two new research papers, using very different methods, have both come to this conclusion. Betsey Stevenson and Justin Wolfers, economists at the University of Pennsylvania (and a couple), have looked at the traditional happiness data, in which people are simply asked how satisfied they are with their overall lives. In the early 1970s, women reported being slightly happier than men. Today, the two have switched places.
Mr. Krueger, analyzing time-use studies over the last four decades, has found an even starker pattern. Since the 1960s, men have gradually cut back on activities they find unpleasant. They now work less and relax more.
Over the same span, women have replaced housework with paid work — and, as a result, are spending almost as much time doing things they don’t enjoy as in the past. Forty years ago, a typical woman spent about 23 hours a week in an activity considered unpleasant, or 40 more minutes than a typical man. Today, with men working less, the gap is 90 minutes.
These trends are reminiscent of the idea of “the second shift,” the name of a 1989 book by the sociologist Arlie Hochschild, arguing that modern women effectively had to hold down two jobs. The first shift was at the office, and the second at home.
But researchers who have looked at time-use data say the second-shift theory misses an important detail. Women are not actually working more than they were 30 or 40 years ago. They are instead doing different kinds of work. They’re spending more time on paid work and less on cleaning and cooking.
What has changed — and what seems to be the most likely explanation for the happiness trends — is that women now have a much longer to-do list than they once did (including helping their aging parents). They can’t possibly get it all done, and many end up feeling as if they are somehow falling short.
Mr. Krueger’s data, for instance, shows that the average time devoted to dusting has fallen significantly in recent decades. There haven’t been any dust-related technological breakthroughs, so houses are probably just dirtier than they used to be. I imagine that the new American dustiness affects women’s happiness more than men’s.
Ms. Stevenson was recently having drinks with a business school graduate who came up with a nice way of summarizing the problem. Her mother’s goals in life, the student said, were to have a beautiful garden, a well-kept house and well-adjusted children who did well in school. “I sort of want all those things, too,” the student said, as Ms. Stevenson recalled, “but I also want to have a great career and have an impact on the broader world.”
It’s telling that there is also a happiness gap between boys and girls in high school. As life has generally gotten better over the last generation — less crime, longer-living grandparents and much cooler gadgets — male high school seniors have gotten happier. About 25 percent say they are very satisfied with their lives, up from 16 percent in 1976. Roughly 22 percent of senior girls now give that answer, unchanged from the 1970s.
When Ms. Stevenson and I were talking last week about possible explanations, she mentioned her “hottie theory.” It’s based on an April article in this newspaper by Sara Rimer, about a group of incredibly impressive teenage girls in Newton, Mass. The girls were getting better grades than the boys, playing varsity sports, helping to run the student government and doing community service. Yet one girl who had gotten a perfect 2,400 on her college entrance exams noted that she and her friends still felt pressure to be “effortlessly hot.”
As Ms. Stevenson, who’s 36, said: “When I was in high school, it was clear being a hottie was the most important thing, and it’s not that it’s any less important today. It’s that other things have become more important. And, frankly, people spent a lot of time trying to be a hottie when I was in high school. So I don’t know where they find the time today.”
The two new papers — Mr. Krueger’s will be published in the Brookings Papers on Economic Activity and the Stevenson-Wolfers one is still in draft form — are part of a burst of happiness research in recent years. There is no question that the research has its limitations. Happiness, of course, is highly subjective.
A big reason that women reported being happier three decades ago — despite far more discrimination — is probably that they had narrower ambitions, Ms. Stevenson says. Many compared themselves only to other women, rather than to men as well. This doesn’t mean they were better off back then.
But it does show just how incomplete the gender revolution has been. Although women have flooded into the work force, American society hasn’t fully come to grips with the change. The United States still doesn’t have universal preschool, and, in contrast to other industrialized countries, there is no guaranteed paid leave for new parents.
Government policy isn’t the only problem, either. Inside of families, men still haven’t figured out how to shoulder their fair share of the household burden. Instead, we’re spending more time on the phone and in front of the television.
This weekend, I think I may volunteer to do a little dusting.
E-mail: Leonhardt@nytimes.com
September 26, 2007
Economic Scene
He’s Happier, She’s Less So
By DAVID LEONHARDT
Last year, a team of researchers added a novel twist to something known as a time-use survey. Instead of simply asking people what they had done over the course of their day, as pollsters have been doing since the 1960s, the researchers also asked how people felt during each activity. Were they happy? Interested? Tired? Stressed?
Not surprisingly, men and women often gave similar answers about what they liked to do (hanging out with friends) and didn’t like (paying bills). But there were also a number of activities that produced very different reactions from the two sexes — and one of them really stands out: Men apparently enjoy being with their parents, while women find time with their mom and dad to be slightly less pleasant than doing laundry.
Alan Krueger, a Princeton economist working with four psychologists on the time-use research team, figures that there is a simple explanation for the difference. For a woman, time with her parents often resembles work, whether it’s helping them pay bills or plan a family gathering. “For men, it tends to be sitting on the sofa and watching football with their dad,” said Mr. Krueger, who, when not crunching data, enjoys watching the New York Giants with his father.
This intriguing — if unsettling — finding is part of a larger story: there appears to be a growing happiness gap between men and women.
Two new research papers, using very different methods, have both come to this conclusion. Betsey Stevenson and Justin Wolfers, economists at the University of Pennsylvania (and a couple), have looked at the traditional happiness data, in which people are simply asked how satisfied they are with their overall lives. In the early 1970s, women reported being slightly happier than men. Today, the two have switched places.
Mr. Krueger, analyzing time-use studies over the last four decades, has found an even starker pattern. Since the 1960s, men have gradually cut back on activities they find unpleasant. They now work less and relax more.
Over the same span, women have replaced housework with paid work — and, as a result, are spending almost as much time doing things they don’t enjoy as in the past. Forty years ago, a typical woman spent about 23 hours a week in an activity considered unpleasant, or 40 more minutes than a typical man. Today, with men working less, the gap is 90 minutes.
These trends are reminiscent of the idea of “the second shift,” the name of a 1989 book by the sociologist Arlie Hochschild, arguing that modern women effectively had to hold down two jobs. The first shift was at the office, and the second at home.
But researchers who have looked at time-use data say the second-shift theory misses an important detail. Women are not actually working more than they were 30 or 40 years ago. They are instead doing different kinds of work. They’re spending more time on paid work and less on cleaning and cooking.
What has changed — and what seems to be the most likely explanation for the happiness trends — is that women now have a much longer to-do list than they once did (including helping their aging parents). They can’t possibly get it all done, and many end up feeling as if they are somehow falling short.
Mr. Krueger’s data, for instance, shows that the average time devoted to dusting has fallen significantly in recent decades. There haven’t been any dust-related technological breakthroughs, so houses are probably just dirtier than they used to be. I imagine that the new American dustiness affects women’s happiness more than men’s.
Ms. Stevenson was recently having drinks with a business school graduate who came up with a nice way of summarizing the problem. Her mother’s goals in life, the student said, were to have a beautiful garden, a well-kept house and well-adjusted children who did well in school. “I sort of want all those things, too,” the student said, as Ms. Stevenson recalled, “but I also want to have a great career and have an impact on the broader world.”
It’s telling that there is also a happiness gap between boys and girls in high school. As life has generally gotten better over the last generation — less crime, longer-living grandparents and much cooler gadgets — male high school seniors have gotten happier. About 25 percent say they are very satisfied with their lives, up from 16 percent in 1976. Roughly 22 percent of senior girls now give that answer, unchanged from the 1970s.
When Ms. Stevenson and I were talking last week about possible explanations, she mentioned her “hottie theory.” It’s based on an April article in this newspaper by Sara Rimer, about a group of incredibly impressive teenage girls in Newton, Mass. The girls were getting better grades than the boys, playing varsity sports, helping to run the student government and doing community service. Yet one girl who had gotten a perfect 2,400 on her college entrance exams noted that she and her friends still felt pressure to be “effortlessly hot.”
As Ms. Stevenson, who’s 36, said: “When I was in high school, it was clear being a hottie was the most important thing, and it’s not that it’s any less important today. It’s that other things have become more important. And, frankly, people spent a lot of time trying to be a hottie when I was in high school. So I don’t know where they find the time today.”
The two new papers — Mr. Krueger’s will be published in the Brookings Papers on Economic Activity and the Stevenson-Wolfers one is still in draft form — are part of a burst of happiness research in recent years. There is no question that the research has its limitations. Happiness, of course, is highly subjective.
A big reason that women reported being happier three decades ago — despite far more discrimination — is probably that they had narrower ambitions, Ms. Stevenson says. Many compared themselves only to other women, rather than to men as well. This doesn’t mean they were better off back then.
But it does show just how incomplete the gender revolution has been. Although women have flooded into the work force, American society hasn’t fully come to grips with the change. The United States still doesn’t have universal preschool, and, in contrast to other industrialized countries, there is no guaranteed paid leave for new parents.
Government policy isn’t the only problem, either. Inside of families, men still haven’t figured out how to shoulder their fair share of the household burden. Instead, we’re spending more time on the phone and in front of the television.
This weekend, I think I may volunteer to do a little dusting.
E-mail: Leonhardt@nytimes.com
Sunday, September 23, 2007
The New York Times
September 23, 2007
Op-Ed Contributor
Who’s Your Daddy?
By MARK EDMUNDSON
Batesville, Va.
SIGMUND Freud died 68 years ago today, and it remains uncertain whether he is what W. H. Auden called him, “a whole climate of opinion / Under whom we conduct our differing lives,” or whether he is completely passé. It’s still not clear whether Freud was the genius of the 20th century, a comprehensive absurdity or something in between.
Our confusion about Freud is something he predicted — and also provoked — particularly in his later work, now largely unread, which is preoccupied with the question of authority. It sheds light on our confused attitudes toward Freud, who always strove for cultural authority. But more important, books like “Totem and Taboo” and “Group Psychology and the Analysis of the Ego” illuminate our collective difficulties with power and particularly with the two scourges of today’s world, fundamentalist religion and tyrannical politics.
Probably the best way to understand Freud’s take on authority is to consider the mode of therapy that he settled on midway through his career. We might call it “transference therapy.” Over time, Freud came to see that his patients were transferring feelings and hopes from other phases of their lives onto him.
Frequently they sought from him what they’d sought from their parents when they were children. They wanted perfect love, and even more fervently, it seems, they wanted perfect truth. They became obsessed with Freud as what Jacques Lacan, the French psychoanalytic theorist, liked to call “the subject who is supposed to know.” Patients saw Freud as an all-knowing figure who had the wisdom to solve all their problems and make them genuinely happy and whole.
Freud’s objective as a therapist was to help his patients dismantle their idealized image of him. He taught them to see how the love they demanded from him was love that they had once demanded (and of course never received) from fathers and mothers and other figures of authority. Over time, the patients might come to view the doctor — Freud — as another suffering, striving mortal, not unlike themselves.
The man sitting at the foot of the couch had to be revealed as neither a Merlin nor a Gandalf, but as a rather short, bespectacled fellow who smoked too many cigars and had a deep fondness for his dog Jo-Fi, the chow who sat beside him while he worked and to whom he occasionally addressed stray remarks. Once the patient could do that much, he was in a better position to treat other important figures in his life realistically. He’d be less prone to assault them with demands, to ask them for everything.
One of Freud’s key beliefs was that there is no sharp division between the psychologically healthy and the unwell. His patients longed for authoritative fathers — and so did Freud. In the early phase of his career, he embraced a sequence of mentors (among them Jean Charcot, the French neurologist; Wilhelm Fliess, a German doctor; and Josef Breuer, an Austrian doctor) who had nothing like his mental powers, but whom he vastly esteemed nonetheless. Freud said we all seek such figures, in both political and personal life.
In “Group Psychology,” Freud wrote about the qualities that a leader-figure, in his most extreme guise, possesses. “His intellectual acts,” said Freud, “were strong and independent even in isolation and his will needed no reinforcement from others.”
He also “loved no one but himself, or other people only insofar as they served his needs.” The leader’s confidence is absolute, for he possesses what everyone most wants, truth. His allure is as powerful as it is pernicious.
Well, you might say, it takes one to know one. Freud himself was drawn to authority. He liked to lord it over his disciples; he liked to make pronouncements; he liked — as schoolchildren say at recess — to act big. When Freud presented himself to the public, he almost never forgot the lessons that he had learned about authority in his consulting room and through his studies of the church, the army and tribal societies. “The autocratic pose” clung to him, said Auden.
Freud still manifests himself to us as a grand patriarch. Collectively we have thought about him as the father, as the one who is supposed to know. We have hoped he’d confer the truth — make us whole and happy. Of course, he cannot. But he has been different from all the other aspiring masters in that he has taught nothing so insistently as the need to dissolve our illusions about masters, and to be responsive to more moderate, subtle and humane sources of authority.
Such a figure — authoritarian and anti-authoritarian at the same time — cannot help but be confusing. But once we understand our confusion, Freud can also be quite illuminating. Among other things, his ideas about authority help us understand (and in some measure sympathize with) the hunger for absolute leaders and absolute truth that probably besets us all, but that has overwhelmed many of our fellow humans who find themselves living under tyrannical governments and fundamentalist faiths.
But the best of Freud will not be available to us until we can work through the transference he provoked. We need to see him as a great patriarch, yes, but as one who struggled for nothing so much as for the abolition of patriarchy.
Mark Edmundson, a professor of English at the University of Virginia, is the author, most recently, of “The Death of Sigmund Freud: The Legacy of His Last Days.”
September 23, 2007
Op-Ed Contributor
Who’s Your Daddy?
By MARK EDMUNDSON
Batesville, Va.
SIGMUND Freud died 68 years ago today, and it remains uncertain whether he is what W. H. Auden called him, “a whole climate of opinion / Under whom we conduct our differing lives,” or whether he is completely passé. It’s still not clear whether Freud was the genius of the 20th century, a comprehensive absurdity or something in between.
Our confusion about Freud is something he predicted — and also provoked — particularly in his later work, now largely unread, which is preoccupied with the question of authority. It sheds light on our confused attitudes toward Freud, who always strove for cultural authority. But more important, books like “Totem and Taboo” and “Group Psychology and the Analysis of the Ego” illuminate our collective difficulties with power and particularly with the two scourges of today’s world, fundamentalist religion and tyrannical politics.
Probably the best way to understand Freud’s take on authority is to consider the mode of therapy that he settled on midway through his career. We might call it “transference therapy.” Over time, Freud came to see that his patients were transferring feelings and hopes from other phases of their lives onto him.
Frequently they sought from him what they’d sought from their parents when they were children. They wanted perfect love, and even more fervently, it seems, they wanted perfect truth. They became obsessed with Freud as what Jacques Lacan, the French psychoanalytic theorist, liked to call “the subject who is supposed to know.” Patients saw Freud as an all-knowing figure who had the wisdom to solve all their problems and make them genuinely happy and whole.
Freud’s objective as a therapist was to help his patients dismantle their idealized image of him. He taught them to see how the love they demanded from him was love that they had once demanded (and of course never received) from fathers and mothers and other figures of authority. Over time, the patients might come to view the doctor — Freud — as another suffering, striving mortal, not unlike themselves.
The man sitting at the foot of the couch had to be revealed as neither a Merlin nor a Gandalf, but as a rather short, bespectacled fellow who smoked too many cigars and had a deep fondness for his dog Jo-Fi, the chow who sat beside him while he worked and to whom he occasionally addressed stray remarks. Once the patient could do that much, he was in a better position to treat other important figures in his life realistically. He’d be less prone to assault them with demands, to ask them for everything.
One of Freud’s key beliefs was that there is no sharp division between the psychologically healthy and the unwell. His patients longed for authoritative fathers — and so did Freud. In the early phase of his career, he embraced a sequence of mentors (among them Jean Charcot, the French neurologist; Wilhelm Fliess, a German doctor; and Josef Breuer, an Austrian doctor) who had nothing like his mental powers, but whom he vastly esteemed nonetheless. Freud said we all seek such figures, in both political and personal life.
In “Group Psychology,” Freud wrote about the qualities that a leader-figure, in his most extreme guise, possesses. “His intellectual acts,” said Freud, “were strong and independent even in isolation and his will needed no reinforcement from others.”
He also “loved no one but himself, or other people only insofar as they served his needs.” The leader’s confidence is absolute, for he possesses what everyone most wants, truth. His allure is as powerful as it is pernicious.
Well, you might say, it takes one to know one. Freud himself was drawn to authority. He liked to lord it over his disciples; he liked to make pronouncements; he liked — as schoolchildren say at recess — to act big. When Freud presented himself to the public, he almost never forgot the lessons that he had learned about authority in his consulting room and through his studies of the church, the army and tribal societies. “The autocratic pose” clung to him, said Auden.
Freud still manifests himself to us as a grand patriarch. Collectively we have thought about him as the father, as the one who is supposed to know. We have hoped he’d confer the truth — make us whole and happy. Of course, he cannot. But he has been different from all the other aspiring masters in that he has taught nothing so insistently as the need to dissolve our illusions about masters, and to be responsive to more moderate, subtle and humane sources of authority.
Such a figure — authoritarian and anti-authoritarian at the same time — cannot help but be confusing. But once we understand our confusion, Freud can also be quite illuminating. Among other things, his ideas about authority help us understand (and in some measure sympathize with) the hunger for absolute leaders and absolute truth that probably besets us all, but that has overwhelmed many of our fellow humans who find themselves living under tyrannical governments and fundamentalist faiths.
But the best of Freud will not be available to us until we can work through the transference he provoked. We need to see him as a great patriarch, yes, but as one who struggled for nothing so much as for the abolition of patriarchy.
Mark Edmundson, a professor of English at the University of Virginia, is the author, most recently, of “The Death of Sigmund Freud: The Legacy of His Last Days.”
Thursday, September 20, 2007
The New York Times
September 18, 2007
Personal Health
The ‘Poisonous Cocktail’ of Multiple Drugs
By JANE E. BRODY
A 78-year-old woman was found unconscious on the floor of her apartment by a neighbor who checked on her. The woman could not remember falling but told doctors that before going to bed she had abdominal pain and nausea and had produced a black stool, after which she had palpitations and felt lightheaded.
Her medical history included high blood pressure, coronary artery disease, atrial fibrillation, congestive heart failure and osteoarthritis. She also had a cold with a productive cough. For each condition, she had been prescribed a different drug, and she was taking a few over-the-counter remedies on her own. These were the medications:
¶Lopressor to control high blood pressure.
¶Digitalis to help the heart pump and control its rhythm.
¶Coumadin to prevent a stroke caused by blood clots.
¶Furosemide, a potent diuretic to lower blood pressure.
¶Lipitor to lower serum cholesterol.
¶Baby aspirin to reduce cardiac risk from blood clots.
¶Celebrex for arthritis pain.
¶Paxil for depression and anxiety.
¶Valium, as needed, to help her sleep.
¶Levofloxacin, an antibiotic for the cough.
¶Ibuprofen for body aches.
¶Cough medicine.
This is what doctors call polypharmacy, otherwise known as a “poisonous cocktail” of many drugs that can interact in dangerous ways and cause side effects that can be far worse than the diseases they are treating. Elderly people are especially vulnerable because they often have several medical problems for which they see different doctors, each prescribing drugs, often without knowing what else the patient is taking.
The woman described above passed out because she had a bleeding stomach ulcer from a combination of drugs that irritate the stomach, Celebrex, ibuprofen and aspirin, and thin the blood, coumadin and aspirin, made worse by an antibiotic that raises blood levels of coumadin.
She recovered after a transfusion of two units of packed red blood cells and was sent home with strict instructions to stop the Celebrex, ibuprofen and aspirin and advice to “contact her internist and psychiatrist regarding possible medication changes that might decrease the risk for future adverse events,” Dr. Michael Stern reported in the June issue of Emergency Medicine.
Dr. Stern, a specialist in geriatric emergency medicine at New York Presbyterian Hospital/Weill Cornell Medical Center, noted that the elderly took about 40 percent of prescribed drugs, roughly twice what younger adults take, and that they suffered twice as many adverse drug reactions as younger people.
“The average community-dwelling older adult takes 4.5 prescription drugs and 2.1 over-the-counter medications,” Dr. Stern reported. Polypharmacy is responsible for up to 28 percent of hospital admissions and, he added, if it were classified as such, it would be the fifth leading cause of death in the United States.
The Effects of Aging
Various drugs taken by the elderly can interact dangerously. Some drugs use the same metabolic pathway and, thus, compete with one another, which can result in hazardous blood levels of one or more drugs. Some drugs cause effects like dehydration that reduce kidney function and the ability to eliminate drug metabolites. The combined effects of some drugs can be more potent than the prescriber intended.
In addition to seeing several doctors, many older people use multiple pharmacies to buy prescriptions. There may be no single health professional who knows what they are taking and could alert them to dangerous combinations. This is especially true in places where chain stores have replaced independent pharmacies or when the patient’s drug plan requires that medications be ordered by mail.
It is not just the number of diseases, drugs or doctors that is the problem. Age-related changes in physiology can worsen matters significantly, even if just two or three drugs are being taken. Just as a child is not the same as a small adult, pharmacologically speaking, an elderly person is not just an older young adult.
Major organ systems function less efficiently in older people. The heart’s ability to pump blood declines with age, as does absorption by the gut, the breakdown of drugs by the liver and the ability of the kidneys to excrete them. With aging, the percentage of lean body mass declines, and body fat increases. Thus, aging affects how much of a drug reaches the bloodstream, how well it is distributed in the body and how effectively it is cleared from the system.
Drugs like digitalis and coumadin, which are primarily distributed in lean tissues, are likely to reach higher blood levels in people older than 65. So the prescribed dosages should be lowered to reduce the risk of toxic side effects. Other drugs, like Valium and barbiturates, that are distributed in fatty tissue can accumulate in the elderly body and remain active longer, increasing side effects like sedation.
Aging also results in fewer protein binding sites for drugs, resulting in a higher blood level of the drug that loses the competition for sites.
Furthermore, aging can affect the responses to certain medications. This is especially true for those that influence blood pressure and the brain. Drugs like Valium, antidepressants and antihistamines can cause effects like delirium, agitation, sleepiness, depression and worsening dementia in older people, Dr. Stern wrote.
Preventing Problems
Keep a list of all medications you take and their dosages and dosing schedules. This should include prescription drugs, over-the-counter and herbal remedies and vitamin and mineral supplements. Take the list whenever you go to the doctor, and make sure that the doctor reviews it before prescribing something else. In addition, because doctors are not always familiar with the actions of all drugs, take the list to the pharmacy when ordering a new prescription and ask the pharmacist to review it for potential interactions.
It also helps to order all medications from the same pharmacy, which should keep a computerized record of everything you take. That way, a possible hazard will not be missed if different pharmacists are on duty.
Never take an over-the-counter or herbal remedy without checking with your doctor. If your doctor is hard to reach or ill informed, ask the pharmacist whether the remedy is safe in view of the other drugs you take.
Carefully review and abide by all dosing directions, especially those that say, “Take with food,” “Take one hour before meals,” “Do not consume alcohol while on this drug,” or, “Do not take this medicine if you are also taking ...”
Ask the prescribing doctor what side effects to expect and what should prompt an immediate call to the doctor. Do not assume that a decline in well-being is caused by a disease or age. It could be a drug side effect.
September 18, 2007
Personal Health
The ‘Poisonous Cocktail’ of Multiple Drugs
By JANE E. BRODY
A 78-year-old woman was found unconscious on the floor of her apartment by a neighbor who checked on her. The woman could not remember falling but told doctors that before going to bed she had abdominal pain and nausea and had produced a black stool, after which she had palpitations and felt lightheaded.
Her medical history included high blood pressure, coronary artery disease, atrial fibrillation, congestive heart failure and osteoarthritis. She also had a cold with a productive cough. For each condition, she had been prescribed a different drug, and she was taking a few over-the-counter remedies on her own. These were the medications:
¶Lopressor to control high blood pressure.
¶Digitalis to help the heart pump and control its rhythm.
¶Coumadin to prevent a stroke caused by blood clots.
¶Furosemide, a potent diuretic to lower blood pressure.
¶Lipitor to lower serum cholesterol.
¶Baby aspirin to reduce cardiac risk from blood clots.
¶Celebrex for arthritis pain.
¶Paxil for depression and anxiety.
¶Valium, as needed, to help her sleep.
¶Levofloxacin, an antibiotic for the cough.
¶Ibuprofen for body aches.
¶Cough medicine.
This is what doctors call polypharmacy, otherwise known as a “poisonous cocktail” of many drugs that can interact in dangerous ways and cause side effects that can be far worse than the diseases they are treating. Elderly people are especially vulnerable because they often have several medical problems for which they see different doctors, each prescribing drugs, often without knowing what else the patient is taking.
The woman described above passed out because she had a bleeding stomach ulcer from a combination of drugs that irritate the stomach, Celebrex, ibuprofen and aspirin, and thin the blood, coumadin and aspirin, made worse by an antibiotic that raises blood levels of coumadin.
She recovered after a transfusion of two units of packed red blood cells and was sent home with strict instructions to stop the Celebrex, ibuprofen and aspirin and advice to “contact her internist and psychiatrist regarding possible medication changes that might decrease the risk for future adverse events,” Dr. Michael Stern reported in the June issue of Emergency Medicine.
Dr. Stern, a specialist in geriatric emergency medicine at New York Presbyterian Hospital/Weill Cornell Medical Center, noted that the elderly took about 40 percent of prescribed drugs, roughly twice what younger adults take, and that they suffered twice as many adverse drug reactions as younger people.
“The average community-dwelling older adult takes 4.5 prescription drugs and 2.1 over-the-counter medications,” Dr. Stern reported. Polypharmacy is responsible for up to 28 percent of hospital admissions and, he added, if it were classified as such, it would be the fifth leading cause of death in the United States.
The Effects of Aging
Various drugs taken by the elderly can interact dangerously. Some drugs use the same metabolic pathway and, thus, compete with one another, which can result in hazardous blood levels of one or more drugs. Some drugs cause effects like dehydration that reduce kidney function and the ability to eliminate drug metabolites. The combined effects of some drugs can be more potent than the prescriber intended.
In addition to seeing several doctors, many older people use multiple pharmacies to buy prescriptions. There may be no single health professional who knows what they are taking and could alert them to dangerous combinations. This is especially true in places where chain stores have replaced independent pharmacies or when the patient’s drug plan requires that medications be ordered by mail.
It is not just the number of diseases, drugs or doctors that is the problem. Age-related changes in physiology can worsen matters significantly, even if just two or three drugs are being taken. Just as a child is not the same as a small adult, pharmacologically speaking, an elderly person is not just an older young adult.
Major organ systems function less efficiently in older people. The heart’s ability to pump blood declines with age, as does absorption by the gut, the breakdown of drugs by the liver and the ability of the kidneys to excrete them. With aging, the percentage of lean body mass declines, and body fat increases. Thus, aging affects how much of a drug reaches the bloodstream, how well it is distributed in the body and how effectively it is cleared from the system.
Drugs like digitalis and coumadin, which are primarily distributed in lean tissues, are likely to reach higher blood levels in people older than 65. So the prescribed dosages should be lowered to reduce the risk of toxic side effects. Other drugs, like Valium and barbiturates, that are distributed in fatty tissue can accumulate in the elderly body and remain active longer, increasing side effects like sedation.
Aging also results in fewer protein binding sites for drugs, resulting in a higher blood level of the drug that loses the competition for sites.
Furthermore, aging can affect the responses to certain medications. This is especially true for those that influence blood pressure and the brain. Drugs like Valium, antidepressants and antihistamines can cause effects like delirium, agitation, sleepiness, depression and worsening dementia in older people, Dr. Stern wrote.
Preventing Problems
Keep a list of all medications you take and their dosages and dosing schedules. This should include prescription drugs, over-the-counter and herbal remedies and vitamin and mineral supplements. Take the list whenever you go to the doctor, and make sure that the doctor reviews it before prescribing something else. In addition, because doctors are not always familiar with the actions of all drugs, take the list to the pharmacy when ordering a new prescription and ask the pharmacist to review it for potential interactions.
It also helps to order all medications from the same pharmacy, which should keep a computerized record of everything you take. That way, a possible hazard will not be missed if different pharmacists are on duty.
Never take an over-the-counter or herbal remedy without checking with your doctor. If your doctor is hard to reach or ill informed, ask the pharmacist whether the remedy is safe in view of the other drugs you take.
Carefully review and abide by all dosing directions, especially those that say, “Take with food,” “Take one hour before meals,” “Do not consume alcohol while on this drug,” or, “Do not take this medicine if you are also taking ...”
Ask the prescribing doctor what side effects to expect and what should prompt an immediate call to the doctor. Do not assume that a decline in well-being is caused by a disease or age. It could be a drug side effect.
Monday, September 17, 2007
The New York Times
September 17, 2007
Op-Ed Contributor
This Is Your (Father’s) Brain on Drugs
By MIKE MALES
Santa Cruz, Calif.
A SPATE of news reports have breathlessly announced that science can explain why adults have such trouble dealing with teenagers: adolescents possess “immature,” “undeveloped” brains that drive them to risky, obnoxious, parent-vexing behaviors. The latest example is a study out of Temple University that found that the “temporal gap between puberty, which impels adolescents toward thrill seeking, and the slow maturation of the cognitive-control system, which regulates these impulses, makes adolescence a time of heightened vulnerability for risky behavior.”
We know the rest of the script: Commentators brand teenagers as stupid, crazy, reckless, immature, irrational and even alien, then advocate tough curbs on youthful freedoms. Jay Giedd, who heads the brain imaging project at the National Institutes of Health, argues that the voting and drinking ages should be raised to 25. Deborah Yurgelun-Todd, a psychiatrist at Harvard Medical School, asks whether we should allow teenagers to be lifeguards or to enlist in the military. And state legislators around the country have proposed raising driving ages.
But the handful of experts and officials making these claims are themselves guilty of reckless overstatement. More responsible brain researchers — like Daniel Siegel of the University of California at Los Angeles and Kurt Fischer at Harvard’s Mind, Brain and Education Program — caution that scientists are just beginning to identify how systems in the brain work.
“People naturally want to use brain science to inform policy and practice, but our limited knowledge of the brain places extreme limits on that effort,” Dr. Siegel told me. “There can be no ‘brain-based education’ or ‘brain-based parenting’ at this early point in the history of neuroscience.”
Why, then, do many pundits and policy makers rush to denigrate adolescents as brainless? One troubling possibility: youths are being maligned to draw attention from the reality that it’s actually middle-aged adults — the parents — whose behavior has worsened.
Our most reliable measures show Americans ages 35 to 54 are suffering ballooning crises:
•
18,249 deaths from overdoses of illicit drugs in 2004, up 550 percent per capita since 1975, according to data from the National Center for Health Statistics.
•
46,925 fatal accidents and suicides in 2004, leaving today’s middle-agers 30 percent more at risk for such deaths than people aged 15 to 19, according to the national center.
•
More than four million arrests in 2005, including one million for violent crimes, 500,000 for drugs and 650,000 for drinking-related offenses, according to the F.B.I. All told, this represented a 200 percent leap per capita in major index felonies since 1975.
•
630,000 middle-agers in prison in 2005, up 600 percent since 1977, according to the Bureau of Justice Statistics.
•
21 million binge drinkers (those downing five or more drinks on one occasion in the previous month), double the number among teenagers and college students combined, according to the government’s National Household Survey on Drug Use and Health.
•
370,000 people treated in hospital emergency rooms for abusing illegal drugs in 2005, with overdose rates for heroin, cocaine, pharmaceuticals and drugs mixed with alcohol far higher than among teenagers.
•
More than half of all new H.I.V./AIDS diagnoses in 2005 were given to middle-aged Americans, up from less than one-third a decade ago, according to the Centers for Disease Control.
What experts label “adolescent risk taking” is really baby boomer risk taking. It’s true that 30 years ago, the riskiest age group for violent death was 15 to 24. But those same boomers continue to suffer high rates of addiction and other ills throughout middle age, while later generations of teenagers are better behaved. Today, the age group most at risk for violent death is 40 to 49, including illegal-drug death rates five times higher than for teenagers.
Strangely, the experts never mention even more damning new “discoveries” about the middle-aged brain, like the 2004 study of scans by Harvard researchers revealing declines in key memory and learning genes that become significant by age 40. In reality, human brains are highly adaptive. Both teenagers and adults display a wide variety of attitudes and behaviors derived from individual conditions and choices, not harsh biological determinism. There’s no “typical teenager” any more than there’s a “typical” 45-year-old.
Commentators slandering teenagers, scientists misrepresenting shaky claims about the brain as hard facts, 47-year-olds displaying far riskier behaviors than 17-year-olds, politicians refusing to face growing middle-aged crises ... if grown-ups really have superior brains, why don’t we act as if we do?
Mike Males is a senior researcher for the Center on Juvenile and Criminal Justice and a founder of Youthfacts.org.
September 17, 2007
Op-Ed Contributor
This Is Your (Father’s) Brain on Drugs
By MIKE MALES
Santa Cruz, Calif.
A SPATE of news reports have breathlessly announced that science can explain why adults have such trouble dealing with teenagers: adolescents possess “immature,” “undeveloped” brains that drive them to risky, obnoxious, parent-vexing behaviors. The latest example is a study out of Temple University that found that the “temporal gap between puberty, which impels adolescents toward thrill seeking, and the slow maturation of the cognitive-control system, which regulates these impulses, makes adolescence a time of heightened vulnerability for risky behavior.”
We know the rest of the script: Commentators brand teenagers as stupid, crazy, reckless, immature, irrational and even alien, then advocate tough curbs on youthful freedoms. Jay Giedd, who heads the brain imaging project at the National Institutes of Health, argues that the voting and drinking ages should be raised to 25. Deborah Yurgelun-Todd, a psychiatrist at Harvard Medical School, asks whether we should allow teenagers to be lifeguards or to enlist in the military. And state legislators around the country have proposed raising driving ages.
But the handful of experts and officials making these claims are themselves guilty of reckless overstatement. More responsible brain researchers — like Daniel Siegel of the University of California at Los Angeles and Kurt Fischer at Harvard’s Mind, Brain and Education Program — caution that scientists are just beginning to identify how systems in the brain work.
“People naturally want to use brain science to inform policy and practice, but our limited knowledge of the brain places extreme limits on that effort,” Dr. Siegel told me. “There can be no ‘brain-based education’ or ‘brain-based parenting’ at this early point in the history of neuroscience.”
Why, then, do many pundits and policy makers rush to denigrate adolescents as brainless? One troubling possibility: youths are being maligned to draw attention from the reality that it’s actually middle-aged adults — the parents — whose behavior has worsened.
Our most reliable measures show Americans ages 35 to 54 are suffering ballooning crises:
•
18,249 deaths from overdoses of illicit drugs in 2004, up 550 percent per capita since 1975, according to data from the National Center for Health Statistics.
•
46,925 fatal accidents and suicides in 2004, leaving today’s middle-agers 30 percent more at risk for such deaths than people aged 15 to 19, according to the national center.
•
More than four million arrests in 2005, including one million for violent crimes, 500,000 for drugs and 650,000 for drinking-related offenses, according to the F.B.I. All told, this represented a 200 percent leap per capita in major index felonies since 1975.
•
630,000 middle-agers in prison in 2005, up 600 percent since 1977, according to the Bureau of Justice Statistics.
•
21 million binge drinkers (those downing five or more drinks on one occasion in the previous month), double the number among teenagers and college students combined, according to the government’s National Household Survey on Drug Use and Health.
•
370,000 people treated in hospital emergency rooms for abusing illegal drugs in 2005, with overdose rates for heroin, cocaine, pharmaceuticals and drugs mixed with alcohol far higher than among teenagers.
•
More than half of all new H.I.V./AIDS diagnoses in 2005 were given to middle-aged Americans, up from less than one-third a decade ago, according to the Centers for Disease Control.
What experts label “adolescent risk taking” is really baby boomer risk taking. It’s true that 30 years ago, the riskiest age group for violent death was 15 to 24. But those same boomers continue to suffer high rates of addiction and other ills throughout middle age, while later generations of teenagers are better behaved. Today, the age group most at risk for violent death is 40 to 49, including illegal-drug death rates five times higher than for teenagers.
Strangely, the experts never mention even more damning new “discoveries” about the middle-aged brain, like the 2004 study of scans by Harvard researchers revealing declines in key memory and learning genes that become significant by age 40. In reality, human brains are highly adaptive. Both teenagers and adults display a wide variety of attitudes and behaviors derived from individual conditions and choices, not harsh biological determinism. There’s no “typical teenager” any more than there’s a “typical” 45-year-old.
Commentators slandering teenagers, scientists misrepresenting shaky claims about the brain as hard facts, 47-year-olds displaying far riskier behaviors than 17-year-olds, politicians refusing to face growing middle-aged crises ... if grown-ups really have superior brains, why don’t we act as if we do?
Mike Males is a senior researcher for the Center on Juvenile and Criminal Justice and a founder of Youthfacts.org.
Sunday, September 16, 2007
The New York Times
September 16, 2007
Op-Ed Contributor
Toys for Saps
By GARY CROSS
University Park, Pa.
THE chief executive of Mattel, Robert Eckert, has just apologized to America’s parents for allowing hundreds of thousands of Chinese-made toys decorated with leaded paint or containing powerful magnets into the country, exposing children to danger. This is admirable, as is the recall of these toys and the toy industry’s request that Congress impose mandatory toy safety testing standards. But what Mr. Eckert and other major toy makers should also apologize for is the toys themselves and the way they are promoted.
When I looked at Mattel’s list of recently recalled toys, it became obvious that something more than our dependence on foreign goods or even the physical safety of children is at stake here. The problem is that the toys and the business model that creates them has so little to do with the needs of children and their parents.
On the list were 56 Polly Pocket sets (including a Lip Gloss Studio Playset), 11 Doggie Daycare toys, 4 Batman figures, 43 Sesame Street toys (not just Elmo Stacking Rings but Giggle Grabber Soccer Elmo and Grow Me Elmo Sprinkler), 10 Dora the Explorers and more than a score of assorted figures and cars. These are designed mostly for preschoolers; none encourage violence and many feature the cute and caring. But, a parent might ask, why 56 Polly Pocket sets? Wouldn’t a half-dozen meet the needs of any child? And why teach 4-year-olds the fine points of cosmetics?
Yet most of us are not shocked by this list. Indeed, a business model that sells endless additions to basic toys even when they have nothing to do with any recognized child-rearing ideal or even imaginative play seems natural.
This wasn’t always the case. In the early 1970s, child advocates like Action for Children’s Television recognized that television ads for toys had a magical power over children. They tried to ban these commercials to give parents, not toy companies, control over the desires of their offspring. In 1978, Michael Pertschuk, chairman of the Federal Trade Commission, argued that ads appealing to young children were inherently “unfair.”
The toy and candy industries, which advertised directly to children, mobilized and accused the commission and child advocates of trying to restrict commercial-free speech and of wanting a nanny state. In 1980, Congress complied by prohibiting the commission from regulating ads aimed at children.
About the same time, toy makers noticed that their earnings from selling “Star Wars” characters were more profitable than the movies themselves and fully embraced character licensing. Aided by the early ’80s deregulation of ads, Mattel, Hasbro and others created cartoons that were essentially program-length commercials. These cartoons, like “He-Man and the Masters of the Universe” or “Care Bears,” promoted toy lines in their story plots and led to an endless wave of toys based on television and movie characters.
At the same time, American toy makers outsourced production, mostly to China, and concentrated on design and marketing, transforming a seasonal industry (mostly at Christmas) into wave after wave of movie-toy promotions. As a result, in 1987, 60 percent of toys sold in the United States were based on licensed characters, compared with about 10 percent in 1980. Toy sales increased from $6.1 billion in 1982 to $12.5 billion in 1986.
This was a superb model for business success, but it hasn’t been such a good way to raise children. Since 1973, the Consumer Product Safety Commission has set standards and recalled hazardous toys, protecting the physical safety of children. But government does nothing to protect children’s psychological needs. Sure, youngsters want this stuff (after all, they see it on television every day) and they find ways of playing with these toys, sometimes imaginatively abandoning the commercial back story of the characters.
But the problem is that the fun built into the toy is mostly in receiving the latest Polly Pocket and adding it to a collection, rather than playing with it. Additive — if not addictive — desire is created and satisfied by these toy lines. They serve little positive purpose other than to teach children to be good consumers and want all the Dora the Explorer toys.
Many people might associate this selling tactic with violent action figures or Barbie and Bratz dolls, but PBS Kids’ cartoon characters and Children’s Television Workshop (now Sesame Workshop) puppets have been licensed to the toy companies since 1971. How many toddlers do you know who are obsessed with anything having to do with Elmo and Thomas the Tank Engine toys?
Is it any surprise that children are running through their childhoods so quickly? Not only do many of these licensed toys introduce young people to fashion and consumerism before they have developed critical judgment, but we as parents give them the stuff too early. And so much of it is junk.
Perhaps it’s time to rethink the decision to allow the unrestricted advertising and cartoon promotion of toy lines that has produced year-round marketing and piles of plastic toys, bought and soon discarded. After all, we ought to be just as concerned about the impact of character licensing and toy advertising on our children’s psyche as we are on protecting them from ingesting leaded paint and magnets.
Gary Cross, a professor of history at Pennsylvania State University, is the author of “Kids’ Stuff: Toys and the Changing World of American Childhood.”
September 16, 2007
Op-Ed Contributor
Toys for Saps
By GARY CROSS
University Park, Pa.
THE chief executive of Mattel, Robert Eckert, has just apologized to America’s parents for allowing hundreds of thousands of Chinese-made toys decorated with leaded paint or containing powerful magnets into the country, exposing children to danger. This is admirable, as is the recall of these toys and the toy industry’s request that Congress impose mandatory toy safety testing standards. But what Mr. Eckert and other major toy makers should also apologize for is the toys themselves and the way they are promoted.
When I looked at Mattel’s list of recently recalled toys, it became obvious that something more than our dependence on foreign goods or even the physical safety of children is at stake here. The problem is that the toys and the business model that creates them has so little to do with the needs of children and their parents.
On the list were 56 Polly Pocket sets (including a Lip Gloss Studio Playset), 11 Doggie Daycare toys, 4 Batman figures, 43 Sesame Street toys (not just Elmo Stacking Rings but Giggle Grabber Soccer Elmo and Grow Me Elmo Sprinkler), 10 Dora the Explorers and more than a score of assorted figures and cars. These are designed mostly for preschoolers; none encourage violence and many feature the cute and caring. But, a parent might ask, why 56 Polly Pocket sets? Wouldn’t a half-dozen meet the needs of any child? And why teach 4-year-olds the fine points of cosmetics?
Yet most of us are not shocked by this list. Indeed, a business model that sells endless additions to basic toys even when they have nothing to do with any recognized child-rearing ideal or even imaginative play seems natural.
This wasn’t always the case. In the early 1970s, child advocates like Action for Children’s Television recognized that television ads for toys had a magical power over children. They tried to ban these commercials to give parents, not toy companies, control over the desires of their offspring. In 1978, Michael Pertschuk, chairman of the Federal Trade Commission, argued that ads appealing to young children were inherently “unfair.”
The toy and candy industries, which advertised directly to children, mobilized and accused the commission and child advocates of trying to restrict commercial-free speech and of wanting a nanny state. In 1980, Congress complied by prohibiting the commission from regulating ads aimed at children.
About the same time, toy makers noticed that their earnings from selling “Star Wars” characters were more profitable than the movies themselves and fully embraced character licensing. Aided by the early ’80s deregulation of ads, Mattel, Hasbro and others created cartoons that were essentially program-length commercials. These cartoons, like “He-Man and the Masters of the Universe” or “Care Bears,” promoted toy lines in their story plots and led to an endless wave of toys based on television and movie characters.
At the same time, American toy makers outsourced production, mostly to China, and concentrated on design and marketing, transforming a seasonal industry (mostly at Christmas) into wave after wave of movie-toy promotions. As a result, in 1987, 60 percent of toys sold in the United States were based on licensed characters, compared with about 10 percent in 1980. Toy sales increased from $6.1 billion in 1982 to $12.5 billion in 1986.
This was a superb model for business success, but it hasn’t been such a good way to raise children. Since 1973, the Consumer Product Safety Commission has set standards and recalled hazardous toys, protecting the physical safety of children. But government does nothing to protect children’s psychological needs. Sure, youngsters want this stuff (after all, they see it on television every day) and they find ways of playing with these toys, sometimes imaginatively abandoning the commercial back story of the characters.
But the problem is that the fun built into the toy is mostly in receiving the latest Polly Pocket and adding it to a collection, rather than playing with it. Additive — if not addictive — desire is created and satisfied by these toy lines. They serve little positive purpose other than to teach children to be good consumers and want all the Dora the Explorer toys.
Many people might associate this selling tactic with violent action figures or Barbie and Bratz dolls, but PBS Kids’ cartoon characters and Children’s Television Workshop (now Sesame Workshop) puppets have been licensed to the toy companies since 1971. How many toddlers do you know who are obsessed with anything having to do with Elmo and Thomas the Tank Engine toys?
Is it any surprise that children are running through their childhoods so quickly? Not only do many of these licensed toys introduce young people to fashion and consumerism before they have developed critical judgment, but we as parents give them the stuff too early. And so much of it is junk.
Perhaps it’s time to rethink the decision to allow the unrestricted advertising and cartoon promotion of toy lines that has produced year-round marketing and piles of plastic toys, bought and soon discarded. After all, we ought to be just as concerned about the impact of character licensing and toy advertising on our children’s psyche as we are on protecting them from ingesting leaded paint and magnets.
Gary Cross, a professor of history at Pennsylvania State University, is the author of “Kids’ Stuff: Toys and the Changing World of American Childhood.”
Sunday, September 09, 2007
The New York Times
September 10, 2007
Drugs Banned, World’s Poor Suffer in Pain
By DONALD G. McNEIL Jr.
WATERLOO, Sierra Leone — Although the rainy season was coming on fast, Zainabu Sesay was in no shape to help her husband. Ditches had to be dug to protect their cassava and peanuts, and their mud hut’s palm roof was sliding off.
But Mrs. Sesay was sick. She had breast cancer in a form that Western doctors rarely see anymore — the tumor had burst through her skin, looking like a putrid head of cauliflower weeping small amounts of blood at its edges.
“It bone! It booonnnne lie de fi-yuh!” she said of the pain — it burns like fire — in Krio, the blended language spoken in this country where British colonizers resettled freed slaves.
No one had directly told her yet, but there was no hope — the cancer was also in her lymph glands and ribs.
Like millions of others in the world’s poorest countries, she is destined to die in pain. She cannot get the drug she needs — one that is cheap, effective, perfectly legal for medical uses under treaties signed by virtually every country, made in large quantities, and has been around since Hippocrates praised its source, the opium poppy. She cannot get morphine.
That is not merely because of her poverty, or that of Sierra Leone. Narcotics incite fear: doctors fear addicting patients and law enforcement officials fear drug crime. Often, the government elite who can afford medicine for themselves are indifferent to the sufferings of the poor.
The World Health Organization estimates that 4.8 million people a year with moderate to severe cancer pain receive no appropriate treatment. Nor do another 1.4 million with late-stage AIDS. For other causes of lingering pain — burns, car accidents, gunshots, diabetic nerve damage, sickle-cell disease and so on — it issues no estimates but believes that millions go untreated.
Figures gathered by the International Narcotics Control Board, a United Nations agency, make it clear: citizens of rich nations suffer less. Six countries — the United States, Canada, France, Germany, Britain and Australia — consume 79 percent of the world’s morphine, according to a 2005 estimate. The poor and middle-income countries where 80 percent of the world’s people live consumed only about 6 percent.
Some countries imported virtually none. “Even if the president gets cancer pain, he will get no analgesia,” said Willem Scholten, a World Health Organization official who studies the issue.
In 2004, consumption of morphine per person in the United States was about 17,000 times that in Sierra Leone.
At pain conferences, doctors from Africa describe patients whose pain is so bad that they have chosen other remedies: hanging themselves or throwing themselves in front of trucks.
Westerners tend to assume that most people in tropical countries die of malaria, AIDS, worm diseases and unpronounceable ills. But as vaccines, antibiotics and AIDS drugs become more common, more and more are surviving past measles, infections, birth complications and other sources of a quick death. They grow old enough to die slowly of cancer.
About half the six million cancer deaths in the world last year were in poor countries, and most diagnoses were made late, when death was inevitable. But first, there was agony. About 80 percent of all cancer victims suffer severe pain, the W.H.O. estimates, as do half of those dying of AIDS.
Morphine’s raw ingredient — opium — is not in short supply. Poppies are grown for heroin, of course, in Afghanistan and elsewhere. But vast fields for morphine and codeine are also grown in India, Turkey, France, Australia and other countries.
Nor is it expensive, even by the standards of developing nations. One hospice in Uganda, for example, mixes its own liquid morphine so cheaply that a three-week supply costs less than a loaf of bread.
Nonetheless, it is still routinely denied in many poor countries.
“It’s the intense fear of addiction, which is often misunderstood,” said David E. Joranson, director of the Pain Policy Study Group at the University of Wisconsin’s medical school, who has worked to change drugs laws around the world. “Pain relief hasn’t been given as much attention as the war on drugs has.”
Doctors in developing countries, he explained, often have beliefs about narcotics that prevailed in Western medical schools decades ago — that they are inevitably addictive, carry high risks of killing patients and must be used sparingly, even if patients suffer.
Pain experts argue that it is cruel to deny them to the dying and that patients who recover from pain can usually be weaned off. Withdrawal symptoms are inevitable, they say — as they are if a diabetic stops insulin. But the benefits outweigh the risks.
Too Poor for Medicine
In Mrs. Sesay’s case, Alfred Lewis, a nurse from Shepherd’s Hospice, is doing what he can to ease her last days.
When he first saw her, her tumor was wrapped with clay and leaves prescribed by a local healer. The smell of her rotting skin made her feel ashamed.
She had seen a doctor at one of many low-cost “Indian clinics” who pulled at the breast with forceps so hard that she screamed, misdiagnosed her tumor as an infected boil, and gave her an injection in her buttocks that abscessed, adding to her misery.
Nothing can be done about the tumor, Mr. Lewis explained quietly. “All the bleeders are open,” he said. “Her risk now is hemorrhage. Only a knife-crazy surgeon would attend to her.”
Earlier diagnosis would probably not have changed her fate. Sierra Leone has no CAT scanners, and only one private hospital offers chemotherapy drug treatment. The Sesays are sharecroppers; they have no money.
So Mr. Lewis was making a daily 10-mile trip from Freetown, the capital, to change her dressing, sprinkle on antibiotics, and talk to her. He asked a neighbor to plait her hair for her, so she would look pretty. Mrs. Sesay said she could not be bothered.
“It’s necessary for to cope,” he said. “For to strive for be happy.”
“I ‘fraid for my life,” she said.
“Are you ‘fraid for die?”
“No, I not ‘fraid. I ready.”
“So what is your relationship to God? You good with God?”
“I pray me one.”
He asked her, half-jokingly, if she still had sex with her husband.
No, she said, since the illness, he stayed in his room and she stayed in hers. She, too, was joking. In their hut, there is only the one room.
Life has become hard, she added, and her husband is getting too old for farm labor. She, too, is getting old, she said — she is somewhere in her 40s.
“We are really being punish.”
For her pain, Mr. Lewis gave her generic Tylenol and tramadol, a relative of codeine that is only 10 percent as potent as morphine. It was all he could offer. “I would consider putting her on morphine now, if we had morphine,” Mr. Lewis said.
In New York, she would have already started on it, or an equivalent like oxycodone or fentanyl.
Even if his hospice could get it, Mr. Lewis could not give it to her.
Under Sierra Leone law, morphine may be handled only by a pharmacist or doctor, explained Gabriel Madiye, the hospice’s founder. But in all Sierra Leone there are only about 100 doctors — one for every 54,000 people, compared with one for every 350 in the United States.
In only a few places — in Uganda, for example — does the law allow trained nurses to prescribe morphine.
And pharmacists will not stock it.
“It’s opiod phobia,” Mr. Madiye said. “We are coming out of a war where a lot of human rights violations were caused by drug abuse.”
During the war, the rebel assault on the capital was called Operation No Living Thing. Child soldiers were hardened with mysterious drugs with names like gunpowder and brown-brown, along with glue and alcohol.
Esther Walker, a British nurse who sometimes works with Mr. Lewis, said she once gave a lecture on palliative care at the national medical school.
There were 28 students, and she asked them, “Who has seen someone die peacefully in Sierra Leone?”
“Not one had,” she said.
The Burden on the Young
In the poorest countries like this one, even babies suffer.
Momoh Sesay, 2, (no relation to Zainabu) is a pretty lucky little guy — for someone who tumbled into a cooking pot of boiling water.
He lost much of the skin on his thighs, and his belly is speckled with burns as if he had been sloshed with pink paint.
But he was fortunate enough to live close to Ola During Children’s Hospital, the leading pediatric institution.
No doctor was in. There was not even any electricity. At night, nurses thread IV lines into babies’ tiny limbs by candlelight. “And our eyes are not magnets,” one of them, Josephine Maajenneh Sillah, complained.
But they knew Momoh would die of shock and pumped in intravenous fluids and antibiotics.
If he had been born in New York, Momoh would have had skin grafts. Here, that is unthinkable.
Momoh was given saline washes, and his dead skin was scrubbed off with debridement, a painful procedure. In New York, he would have had morphine.
So probably would Abdulaziz Sankoh, 7, in another bed, who has sickle cell disease. He moans at night when twisted blood cells clump together and jam the arteries in his spindly legs, slowly killing his bone marrow.
As would Musa Shariff, an 8-month-old boy whose scalp is so swollen by meningitis that his eyelids cannot close. Dr. Muctar Jalloh, the hospital director, said he would not prescribe morphine to babies or toddlers if he had it. Only in the case of third-degree burns, like Momoh’s, did he say: “I would consider it — maybe.”
That flies in the face of Western medicine, which allows careful use even in premature infants.
The strongest painkiller that Momoh, Abdulaziz and Musa can take, if their parents can afford $1.65 per vial, is tramadol. It is impossible to know what morphine would cost if it were here, but it is sold in India at 1.7 cents a pill by the same company that makes tramadol.
The nurses know the prices because they sell the drugs that are available. They have not been paid for three years, they say, so they support themselves in part by filling the prescriptions that the doctors write. Kind as they are — they do extend credit, and are sometimes moved to charity by the children — it is a business.
That is the other reason Dr. Jalloh said he would not order morphine. “I wouldn’t want to leave my staff in charge of morphine,” he said. “The potential for abuse is so high.”
Worries About Abuse
If morphine were to be imported to Sierra Leone, it would be overseen by two agencies: the National Pharmacy Board and the National Drugs Control Agency.
Kande Bangura, the rangy, sharp-eyed former police commander who runs the drug control agency, said the country had a serious drug-abuse problem, especially among former child soldiers.
It also is a smuggling route. He spread out pictures of an autopsy on a British citizen with Nigerian roots who had dropped dead in line at Freetown’s airport. His intestines were found to be packed with condoms full of cocaine, one of which had burst.
Mr. Bangura said he had no objections to morphine, however, “as long as it’s for medical use and is strictly controlled by the country’s chief pharmacist.”
Wiltshire C. N. Johnson, the chief of the enforcement arm of the National Pharmacy Board, explained why painkillers were not imported.
Scarce funds must go to the top five causes of death, he said: diarrhea, pneumonia, tuberculosis, malaria and sexually transmitted diseases. “I’m not saying that palliative care doesn’t top the list, too,” he said. “But it’s officially a very small percentage of the requirement.”
He also had fears like those of Dr. Jalloh. “There’s no way we’re going to put morphine in the hands of a pharmacy technician,” he said. “In the wrong hands, drugs, like guns, are a greater evil than a cure.”
Mr. Madiye, who predicted exactly those answers before the interviews started, vented his frustration later.
He founded Shepherd’s Hospice in 1995, saw it destroyed in the civil war and rebuilt it. But he cannot get the one drug that would let him give people like Zainabu Sesay the dignified deaths that in the West would be their birthright.
“How can they say there is no demand when they don’t allow it?” he asked. “How can they be so sure that it will get out of control when they haven’t even tried it?”
September 10, 2007
Drugs Banned, World’s Poor Suffer in Pain
By DONALD G. McNEIL Jr.
WATERLOO, Sierra Leone — Although the rainy season was coming on fast, Zainabu Sesay was in no shape to help her husband. Ditches had to be dug to protect their cassava and peanuts, and their mud hut’s palm roof was sliding off.
But Mrs. Sesay was sick. She had breast cancer in a form that Western doctors rarely see anymore — the tumor had burst through her skin, looking like a putrid head of cauliflower weeping small amounts of blood at its edges.
“It bone! It booonnnne lie de fi-yuh!” she said of the pain — it burns like fire — in Krio, the blended language spoken in this country where British colonizers resettled freed slaves.
No one had directly told her yet, but there was no hope — the cancer was also in her lymph glands and ribs.
Like millions of others in the world’s poorest countries, she is destined to die in pain. She cannot get the drug she needs — one that is cheap, effective, perfectly legal for medical uses under treaties signed by virtually every country, made in large quantities, and has been around since Hippocrates praised its source, the opium poppy. She cannot get morphine.
That is not merely because of her poverty, or that of Sierra Leone. Narcotics incite fear: doctors fear addicting patients and law enforcement officials fear drug crime. Often, the government elite who can afford medicine for themselves are indifferent to the sufferings of the poor.
The World Health Organization estimates that 4.8 million people a year with moderate to severe cancer pain receive no appropriate treatment. Nor do another 1.4 million with late-stage AIDS. For other causes of lingering pain — burns, car accidents, gunshots, diabetic nerve damage, sickle-cell disease and so on — it issues no estimates but believes that millions go untreated.
Figures gathered by the International Narcotics Control Board, a United Nations agency, make it clear: citizens of rich nations suffer less. Six countries — the United States, Canada, France, Germany, Britain and Australia — consume 79 percent of the world’s morphine, according to a 2005 estimate. The poor and middle-income countries where 80 percent of the world’s people live consumed only about 6 percent.
Some countries imported virtually none. “Even if the president gets cancer pain, he will get no analgesia,” said Willem Scholten, a World Health Organization official who studies the issue.
In 2004, consumption of morphine per person in the United States was about 17,000 times that in Sierra Leone.
At pain conferences, doctors from Africa describe patients whose pain is so bad that they have chosen other remedies: hanging themselves or throwing themselves in front of trucks.
Westerners tend to assume that most people in tropical countries die of malaria, AIDS, worm diseases and unpronounceable ills. But as vaccines, antibiotics and AIDS drugs become more common, more and more are surviving past measles, infections, birth complications and other sources of a quick death. They grow old enough to die slowly of cancer.
About half the six million cancer deaths in the world last year were in poor countries, and most diagnoses were made late, when death was inevitable. But first, there was agony. About 80 percent of all cancer victims suffer severe pain, the W.H.O. estimates, as do half of those dying of AIDS.
Morphine’s raw ingredient — opium — is not in short supply. Poppies are grown for heroin, of course, in Afghanistan and elsewhere. But vast fields for morphine and codeine are also grown in India, Turkey, France, Australia and other countries.
Nor is it expensive, even by the standards of developing nations. One hospice in Uganda, for example, mixes its own liquid morphine so cheaply that a three-week supply costs less than a loaf of bread.
Nonetheless, it is still routinely denied in many poor countries.
“It’s the intense fear of addiction, which is often misunderstood,” said David E. Joranson, director of the Pain Policy Study Group at the University of Wisconsin’s medical school, who has worked to change drugs laws around the world. “Pain relief hasn’t been given as much attention as the war on drugs has.”
Doctors in developing countries, he explained, often have beliefs about narcotics that prevailed in Western medical schools decades ago — that they are inevitably addictive, carry high risks of killing patients and must be used sparingly, even if patients suffer.
Pain experts argue that it is cruel to deny them to the dying and that patients who recover from pain can usually be weaned off. Withdrawal symptoms are inevitable, they say — as they are if a diabetic stops insulin. But the benefits outweigh the risks.
Too Poor for Medicine
In Mrs. Sesay’s case, Alfred Lewis, a nurse from Shepherd’s Hospice, is doing what he can to ease her last days.
When he first saw her, her tumor was wrapped with clay and leaves prescribed by a local healer. The smell of her rotting skin made her feel ashamed.
She had seen a doctor at one of many low-cost “Indian clinics” who pulled at the breast with forceps so hard that she screamed, misdiagnosed her tumor as an infected boil, and gave her an injection in her buttocks that abscessed, adding to her misery.
Nothing can be done about the tumor, Mr. Lewis explained quietly. “All the bleeders are open,” he said. “Her risk now is hemorrhage. Only a knife-crazy surgeon would attend to her.”
Earlier diagnosis would probably not have changed her fate. Sierra Leone has no CAT scanners, and only one private hospital offers chemotherapy drug treatment. The Sesays are sharecroppers; they have no money.
So Mr. Lewis was making a daily 10-mile trip from Freetown, the capital, to change her dressing, sprinkle on antibiotics, and talk to her. He asked a neighbor to plait her hair for her, so she would look pretty. Mrs. Sesay said she could not be bothered.
“It’s necessary for to cope,” he said. “For to strive for be happy.”
“I ‘fraid for my life,” she said.
“Are you ‘fraid for die?”
“No, I not ‘fraid. I ready.”
“So what is your relationship to God? You good with God?”
“I pray me one.”
He asked her, half-jokingly, if she still had sex with her husband.
No, she said, since the illness, he stayed in his room and she stayed in hers. She, too, was joking. In their hut, there is only the one room.
Life has become hard, she added, and her husband is getting too old for farm labor. She, too, is getting old, she said — she is somewhere in her 40s.
“We are really being punish.”
For her pain, Mr. Lewis gave her generic Tylenol and tramadol, a relative of codeine that is only 10 percent as potent as morphine. It was all he could offer. “I would consider putting her on morphine now, if we had morphine,” Mr. Lewis said.
In New York, she would have already started on it, or an equivalent like oxycodone or fentanyl.
Even if his hospice could get it, Mr. Lewis could not give it to her.
Under Sierra Leone law, morphine may be handled only by a pharmacist or doctor, explained Gabriel Madiye, the hospice’s founder. But in all Sierra Leone there are only about 100 doctors — one for every 54,000 people, compared with one for every 350 in the United States.
In only a few places — in Uganda, for example — does the law allow trained nurses to prescribe morphine.
And pharmacists will not stock it.
“It’s opiod phobia,” Mr. Madiye said. “We are coming out of a war where a lot of human rights violations were caused by drug abuse.”
During the war, the rebel assault on the capital was called Operation No Living Thing. Child soldiers were hardened with mysterious drugs with names like gunpowder and brown-brown, along with glue and alcohol.
Esther Walker, a British nurse who sometimes works with Mr. Lewis, said she once gave a lecture on palliative care at the national medical school.
There were 28 students, and she asked them, “Who has seen someone die peacefully in Sierra Leone?”
“Not one had,” she said.
The Burden on the Young
In the poorest countries like this one, even babies suffer.
Momoh Sesay, 2, (no relation to Zainabu) is a pretty lucky little guy — for someone who tumbled into a cooking pot of boiling water.
He lost much of the skin on his thighs, and his belly is speckled with burns as if he had been sloshed with pink paint.
But he was fortunate enough to live close to Ola During Children’s Hospital, the leading pediatric institution.
No doctor was in. There was not even any electricity. At night, nurses thread IV lines into babies’ tiny limbs by candlelight. “And our eyes are not magnets,” one of them, Josephine Maajenneh Sillah, complained.
But they knew Momoh would die of shock and pumped in intravenous fluids and antibiotics.
If he had been born in New York, Momoh would have had skin grafts. Here, that is unthinkable.
Momoh was given saline washes, and his dead skin was scrubbed off with debridement, a painful procedure. In New York, he would have had morphine.
So probably would Abdulaziz Sankoh, 7, in another bed, who has sickle cell disease. He moans at night when twisted blood cells clump together and jam the arteries in his spindly legs, slowly killing his bone marrow.
As would Musa Shariff, an 8-month-old boy whose scalp is so swollen by meningitis that his eyelids cannot close. Dr. Muctar Jalloh, the hospital director, said he would not prescribe morphine to babies or toddlers if he had it. Only in the case of third-degree burns, like Momoh’s, did he say: “I would consider it — maybe.”
That flies in the face of Western medicine, which allows careful use even in premature infants.
The strongest painkiller that Momoh, Abdulaziz and Musa can take, if their parents can afford $1.65 per vial, is tramadol. It is impossible to know what morphine would cost if it were here, but it is sold in India at 1.7 cents a pill by the same company that makes tramadol.
The nurses know the prices because they sell the drugs that are available. They have not been paid for three years, they say, so they support themselves in part by filling the prescriptions that the doctors write. Kind as they are — they do extend credit, and are sometimes moved to charity by the children — it is a business.
That is the other reason Dr. Jalloh said he would not order morphine. “I wouldn’t want to leave my staff in charge of morphine,” he said. “The potential for abuse is so high.”
Worries About Abuse
If morphine were to be imported to Sierra Leone, it would be overseen by two agencies: the National Pharmacy Board and the National Drugs Control Agency.
Kande Bangura, the rangy, sharp-eyed former police commander who runs the drug control agency, said the country had a serious drug-abuse problem, especially among former child soldiers.
It also is a smuggling route. He spread out pictures of an autopsy on a British citizen with Nigerian roots who had dropped dead in line at Freetown’s airport. His intestines were found to be packed with condoms full of cocaine, one of which had burst.
Mr. Bangura said he had no objections to morphine, however, “as long as it’s for medical use and is strictly controlled by the country’s chief pharmacist.”
Wiltshire C. N. Johnson, the chief of the enforcement arm of the National Pharmacy Board, explained why painkillers were not imported.
Scarce funds must go to the top five causes of death, he said: diarrhea, pneumonia, tuberculosis, malaria and sexually transmitted diseases. “I’m not saying that palliative care doesn’t top the list, too,” he said. “But it’s officially a very small percentage of the requirement.”
He also had fears like those of Dr. Jalloh. “There’s no way we’re going to put morphine in the hands of a pharmacy technician,” he said. “In the wrong hands, drugs, like guns, are a greater evil than a cure.”
Mr. Madiye, who predicted exactly those answers before the interviews started, vented his frustration later.
He founded Shepherd’s Hospice in 1995, saw it destroyed in the civil war and rebuilt it. But he cannot get the one drug that would let him give people like Zainabu Sesay the dignified deaths that in the West would be their birthright.
“How can they say there is no demand when they don’t allow it?” he asked. “How can they be so sure that it will get out of control when they haven’t even tried it?”
Wednesday, September 05, 2007
