For more than 100 years, medical literature has contained reports of a debilitating illness that causes prolonged fatigue, memory loss, headaches, cognitive problems and issues with digestion and sleep. Teddy Roosevelt, John Muir and Thomas Eakins all suffered from what was then known as neurasthenia.

At that time, the recommended treatment for women was bed rest; men were advised to head to the Wild West. But neither treatment could be counted on to cure the disease.

Toward the end of the 20th century, doctors came up with the term chronic fatigue syndrome (or, in Europe, myalgic encephalomyelitis) to describe the set of symptoms that used to be called neurasthenia. But we still did not fully understand the illness, nor had we isolated its cause.

Patients have suffered because of this failure to fully understand the disease. Sometimes, doctors attributed the symptoms to anxiety, depression or hypochondria. Employers have been less than sympathetic.

Today, most health professionals have finally acknowledged that chronic fatigue syndrome is a real and serious illness. But its name, which focuses on just one of the disorder’s many symptoms, has served to trivialize the condition, making it seem more psychological than physical and reducing interest in the disease among mainstream medical and scientific researchers.

This low interest among researchers is unfortunate because most of the biggest unsolved problems with chronic fatigue syndrome are scientific ones. We need to learn what causes the illness and we need to use that information to develop tests to diagnose, prevent and treat it.

The current consensus is that chronic fatigue syndrome is probably caused by a disturbance to the immune system. In ways that are not entirely clear, this disturbance upsets the immune system for a prolonged period of time and leads the body to become hyper-responsive and produce a large outpouring of toxic substances, which then cause the fatigue, muscle aches, headaches and mental confusion associated with the disease.

Scientists have speculated that the chain of events that leads to this prolonged immune disorder begins when someone is exposed to a triggering agent — a toxic chemical, for instance, or a bacterial or viral infection. But identifying such an agent has proved difficult.

One complication has been that by the time someone develops symptoms and seeks treatment, the underlying infection is no longer detectable, so there is no longer a way to identify the causative agent from blood tests.

To complicate things even more, the over-responsive immune systems of people with chronic fatigue syndrome can activate co-infections, including Epstein-Barr virus, CMV and HHV-6, which make it even more difficult to identify the initial trigger.

Some doctors are beginning to believe that there may not be one single cause of this syndrome but a number of causes that all produce the same disturbance in the immune system. But what those agents are and how they cause the disturbance are challenging questions.

In the last few decades a number of viruses and bacteria have been fingered as possible culprits for causing chronic fatigue syndrome, but none ultimately stood the test of scientific scrutiny. The most dramatic example came two years ago when a group of researchers reported finding a mouse-related virus called XMRV, a pathogen in the same family as HIV, which causes AIDS. They believed they had identified this virus in the blood of a several patients with chronic fatigue syndrome, raising the hopes of patients everywhere.

Unfortunately, before this claim had been fully validated, many patients embraced XMRV as the long-sought cause of this illness and began considering potential treatments. Because of the similarities between the mouse virus and HIV, some of them even started taking AIDS drugs.

Then, we found out the truth.

In more than 10 follow-up studies, research in our UC San Francisco laboratories and elsewhere failed to find any evidence of XMRV in the blood of the chronic fatigue patients tested. Moreover, experiments indicated that this virus does not survive well in human blood, making it an unlikely source for a human infection. Other studies have suggested that the XMRV detected in the original studies may have come from contaminated lab materials.

So where does this leave the millions of people in the United States who suffer from chronic fatigue syndrome? Frustrated.

The medical community, and the agencies and foundations that fund medical research, have never given this illness the attention it deserves. That needs to change.

Some have suggested that a name change might help. Chronic fatigue immune dysfunction syndrome would be a more accurate name that would call attention to the fact that the disease is tied to a disturbed immune system.

Next, we need to retrench, to reconsider the direction of research on this disease. We should embrace the fact that we still do not understand what causes it and that until we do, we will always be restricted in our ability to develop new ways of diagnosing, treating and preventing it. This will continue to be frustrating to patients and their families, but embracing science that is later disproved hasn’t served sufferers well.

Until we determine the causes and work out the best treatments for this debilitating condition, people with chronic fatigue syndrome will continue to suffer. In the meantime, we must increase support for basic research and for finding the best, evidence-based approaches for treating the disease.

Nothing is more rapidly globalized than nuclear fear.

The partial meltdown of reactors in Fukushima, Japan, has created overwhelming fear in people living nearby, considerable fear in people living in the rest of Japan, and a certain amount of fear in people throughout Asia and even in Europe and the United States.

Nor can this fear be simply dismissed as hysteria. It can be exaggerated — especially in relation to other continents — but the fact is that, depending on what happens to the reactors, how the wind blows, and what kind of radiation plume develops, the danger could be grave. Moreover, there is still much ignorance about the kind of harm done to human beings by various levels of radiation.

Fukushima is not Hiroshima; it is nuclear weapons that most endanger mankind. But as with nuclear weapons, the radiation released by power plants is a form of what in writing about Hiroshima I called “invisible contamination” — a poison that one cannot see, smell or feel, and whose effects are so lasting that, even if they do not show up in one year — or one generation — they may well do so in the next. As one survivor put it to me: “You may look healthy from the outside but all of a sudden something goes wrong and you are sick and you die.”

When I interviewed survivors in Hiroshima decades ago, they described their terror at witnessing and experiencing grotesque radiation symptoms: acute effects of severe diarrhea, bleeding from various bodily orifices, dreaded “purple spots” from bleeding into the skin, extreme weakness and frequently death; and delayed effects including increased incidence of leukemia during early post-bomb years, and later of cancer of the thyroid, stomach, lung, ovary and uterine cervix. Since it is known that radiation can have genetic effects over the generations, there was much fear in Hiroshima about giving birth to abnormal children.

None of this may happen in connection with Fukushima, and it is quite possible that reactors there will be sufficiently treated and cooled to avoid a large-scale nuclear disaster. But we are talking about the same technology, so we should not be surprised that radiation released from reactors creates nuclear fear similar to that associated with the weapons.

I found this also to be true at Three Mile Island, where less radiation was released than at Fukushima, but people nonetheless expressed the full panoply of fear associated with the invisible contamination of radiation. Such fear has pervaded the nuclear accident at Chernobyl, and has by no means entirely disappeared to this day. The same fear of invisible contamination occurred in Americans exposed to nuclear radiation in various other places: to plutonium waste at Hanford, Washington, in connection with the production of the Nagasaki bomb; to nuclear testing over decades at Rocky Flats, Colorado; and to Ground Zero at test sites in Nevada, from which G.I.’s were marched shortly after nuclear explosions.

One may ask how it is possible that Japan, after its experience with the atomic bombings, could allow itself to draw so heavily on the same nuclear technology for the manufacture of about a third of its energy. There was resistance, much of it from Hiroshima and Nagasaki survivors.

But there was also a pattern of denial, cover-up and cozy bureaucratic collusion between industry and government, the last especially notorious in Japan but by no means limited to that country. Even then, pro-nuclear power forces could prevail only by managing to instill in the minds of Japanese people a dichotomy between the physics of nuclear power and that of nuclear weapons, an illusory distinction made not only in Japan but throughout the world.

There is also the hope (and here the sameness of the technology is recognized) that something peaceful and life-enhancing can be derived from the awesome, world-destroying nuclear deity; that we humans who commissioned and built the weapons can somehow find redemption in that same ultimate technology. And there are the “risk-assessment” studies that find nuclear power quite safe in statistical terms, failing as these studies do to account for extreme events of nature as well as human error and technical malfunction.

Some have been objecting to the “doomsday language” used in connection with Fukushima’s radiation dangers. And it is true that exaggerations at all levels should be discouraged, exacerbating as they do fears on the part of everyone. But that doomsday language has its source in the doomsday nature of the stuff that is feared, and in the realization that we have created a technology with which we can annihilate ourselves as a species. Here too the association between bomb and reactor cannot be willed out of existence.

We do better to overcome our denial and dissociation and to instead acknowledge that radiation effects are one and the same no matter what their source, that the combination of nature and human fallibility makes no technology completely safe, and that the technology most dangerous to us can hardly be relied upon to provide something “clean” or pure, or to otherwise redeem us.

Le peuple japonais vit l’un des pires accidents industriels de l’histoire du capitalisme. A l’occasion du 20e anniversaire de Tchernobyl, Sveltana Alexievitch, auteur biélorusse d’un livre de témoignages des victimes de Tchernobyl, avait eu cette pensée prémonitoire : “Tchernobyl : notre passé ou notre avenir ?” (Le Monde, 25 avril 2006). Hélas, en ce 25e anniversaire de Tchernobyl, le cauchemar de Fukushima renoue, au Japon, avec cette expérience terrible de l’accident nucléaire.

Tant l’exploitant japonais Tepco et les autorités japonaises que leurs homologues français n’ont admis la gravité de ce qui se passait à Fukushima qu’à reculons, au compte-gouttes, cherchant à protéger le plus longtemps possible l’industrie nucléaire elle-même des conséquences économiques et symboliques de ce désastre, plutôt que ses victimes. Les uns et les autres ont sans cesse parlé d’une catastrophe à venir, alors qu’elle est là depuis le premier panache de fumée radioactive. Les dirigeants d’Areva l’ont compris dès le vendredi 11 mars, jour du tremblement de terre, eux qui ont immédiatement fait évacuer leurs salariés allemands intervenant dans la maintenance du site de la centrale de Fukushima.

Cet accident dramatique s’inscrit en continuité d’une autre catastrophe, insidieuse et niée, celle des conséquences sanitaires – tenues délibérément invisibles – de la contamination et de l’irradiation de faible intensité, liées au développement de la filière nucléaire, au Japon comme ailleurs. Mais revenons tout d’abord sur ce qui se passe à Fukushima.

Fukushima : la contamination radioactive et ses victimes

Engagés dans une lutte acharnée contre le pire – l’explosion nucléaire, aux abords de Tokyo, ville de 35 millions d’habitants -, des travailleurs subissent depuis une semaine de très fortes expositions à la radioactivité au sein des installations détériorées. Mardi 15 mars, après l’explosion du bâtiment qui abrite le réacteur n° 2, explosion ayant entraîné une perte de confinement, les autorités japonaises ont publié des niveaux d’exposition externe excessivement élevés, de 30 à 400 milliSieverts (mSv) par heure, autour des différents réacteurs.

Selon le communiqué de la Criirad du 16 mars, avec des valeurs aussi élevées (1 million de fois et plus le bruit de fond naturel), des effets directs (dits “déterministes”) sur l’organisme humain se produisent rapidement (en quelques heures, quelques jours, quelques semaines). Il s’agit d’une destruction massive des cellules, en particulier celles de la moelle osseuse, de la muqueuse intestinale, ainsi que les cellules basales de la peau.

Cette destruction cellulaire peut altérer le fonctionnement de certains organes, voire engager le pronostic vital. Plus le nombre de cellules détruites est important, plus les effets sont graves. Les travailleurs exposés à ces très fortes doses de rayonnements ont-ils été “désignés volontaires” ? Qui sont-ils ? Aucun témoignage direct n’a été recueilli auprès d’eux. Comme les “liquidateurs” de Tchernobyl, ils sont sacrifiés pour tenter d’empêcher l’apocalypse.

Depuis samedi matin 12 mars, et la première explosion sur le réacteur n° 1, l’échappement de vapeurs radioactives dans l’atmosphère est continu. Les populations vivant sous le vent de ces vapeurs radiotoxiques subissent une exposition à la radioactivité, sous forme de particules présentes dans l’air contaminé. A faible et très faible dose, les effets de l’exposition à la radioactivité sont différés dans le temps. Il s’agit, entre autres, des cancers et des atteintes à la reproduction.

La radioactivité entraîne des mutations cellulaires, à l’origine de la prolifération de cellules cancéreuses. Les cancers d’enfants peuvent être associés non seulement à une exposition aux rayonnements ionisants de l’enfant lui-même, mais aussi à une exposition in utero lors de la grossesse de sa mère ou à une mutation cellulaire de l’ADN du père du fait de sa propre exposition aux rayonnements ionisants. Des altérations génétiques provoquées par la radioactivité portent atteinte à la fonction reproductive, conduisant à la stérilité ou à des malformations graves chez les nouveau-nés.

Enfin, des effets de la contamination radioactive chronique à faible dose, mal étudiés, ont aussi été décelés, notamment chez les enfants biélorusses, à la suite de l’accident de Tchernobyl, provoquant notamment des pathologies cardiaques précoces. Les conséquences des expositions à faible dose se manifesteront, de façon aléatoire, dans dix ans, vingt ans, trente ans, voire plus.

L’absence de recensement rigoureux de ces atteintes, au fur et à mesure de leur apparition, comme dans le cas des essais nucléaires ou des catastrophes précédentes (en particulier Tchernobyl) empêchera de faire le terrible bilan de cette catastrophe. Quel est donc le retour d’expérience dont parlent les autorités gouvernementales françaises ?

En France, irradiation et contamination à bas bruit

La France n’a pas connu d’accident majeur, mais une contamination radioactive insidieuse s’est installée en continu à partir de différentes sources, à commencer par les déchets miniers de sites désormais fermés. Chaque année, l’Autorité de sûreté nucléaire recense sur le parc nucléaire plusieurs centaines d’”incidents”, dont certains s’accompagnent de rejets radioactifs dans l’environnement.

Des autorisations de rejets radioactifs sont régulièrement octroyées aux différents sites nucléaires, entraînant une pollution radioactive de l’air et des rivières. La gestion des déchets nucléaires et le démantèlement des réacteurs en fin de vie supposent une pollution radioactive chronique, tandis qu’un arrêté ministériel du 5 mai 2009 prévoit la dérogation possible du code de la santé publique pour l’ajout de substances radioactives dans les biens de consommation (www.criirad.org). Il s’agit d’une augmentation lente et pernicieuse du niveau de radioactivité dite “naturelle”.

Une longue enquête auprès des travailleurs intervenant en sous-traitance de la maintenance des installations nucléaires en France m’a permis d’approcher l’envers de l’industrie nucléaire. Les 58 réacteurs nucléaires français supposent la réalisation annuelle d’arrêt de certains réacteurs pour maintenance. Entre 25 000 et 35 000 travailleurs de la maintenance (robinetiers, décontamineurs, décalorifugeurs, mécaniciens, électriciens, agents de contrôle) interviennent en zones dites “contrôlées” (c’est-à-dire radioactives) pour effectuer les vérifications, réparations, modifications nécessaires au bon fonctionnement des réacteurs et des circuits de refroidissement.

Plus une centrale vieillit, plus la contamination radioactive est intense et plus l’intervention est “coûteuse en dose”. C’est ainsi que les exploitants français du nucléaire ont été amenés à sous-traiter ces tâches dangereuses et à mettre en place un système de gestion de l’emploi par la dose.

Sur une intervention à fort débit de dose, plusieurs ouvriers vont se succéder très rapidement afin de rester dans la limite de dose autorisée. Le récit de ces activités permet de lever le voile sur cet envers incontournable, mais invisible, de l’industrie nucléaire. C’est ce que montre l’histoire de Pierre, atteint à 52 ans d’un cancer professionnel reconnu radio induit par l’assurance-maladie.

Directement affecté aux travaux sous rayonnement (DATR)

Pierre est DATR. Cela signifie qu’il a reçu une formation de quelques jours en radioprotection et que le médecin du travail a signé pour lui un certificat médical de “non-inaptitude à l’exposition aux rayonnements ionisants”. Salarié d’une entreprise sous-traitante, il intervient en zone irradiée des centrales, par exemple pour la pose de protections aux “points chauds” (débit de dose : 50 à 60 mSv/heure).

Pour permettre la réalisation d’opérations de maintenance par d’autres travailleurs (robinetier, tuyauteur), il faut ramener le débit de dose en dessous de 2 mSv/heure. Pour cela, Pierre doit entourer la tuyauterie radioactive d’un matelas de plomb en le maintenant avec une sangle. C’est une opération pour laquelle les intervenants se relaient à plusieurs toutes les quinze minutes.

Une autre activité habituelle de Pierre est la décontamination des parois de la piscine dans laquelle le combustible a été entreposé lors des arrêts de tranche. Le travail se fait au chiffon, à genoux. L’ouvrier est protégé de la contamination radioactive par une tenue vinyle – dite “Mururoa” – et un appareil de respiration assisté. Mais cet équipement ne le protège pas de l’irradiation externe.

Se déplaçant de centrale en centrale, Pierre a accompli ce travail pendant vingt-huit ans avant de tomber malade. La reconstitution de son exposition aux rayonnements ionisants montre une dose cumulée tout au long de sa carrière de 316 mSv. La dose carrière moyenne sur trente ans d’un agent EDF est de 19 mSv, soit 15 fois moins. Or, une enquête épidémiologique internationale chez les travailleurs statutaires du nucléaire de 15 pays montre une surmortalité par cancer dans cette population exposée, en moyenne sur la durée de la vie professionnelle, à 19 mSv.

Les travailleurs sous-traitants reçoivent plus de 80 % de la dose collective annuelle subie sur les sites. Parmi ces travailleurs, certains sont aujourd’hui atteints de cancer, mais rien n’est fait pour relier précisément leur cancer à leur parcours professionnel dans l’industrie nucléaire.

Ils auraient dû ou devraient bénéficier d’un suivi médical gratuit permettant d’enregistrer au fil du temps, dans cette population fortement exposée, la survenue des cancers et d’étudier l’incidence du cancer en référence aux caractéristiques de leur exposition. L’enregistrement systématique de leur dosimétrie l’aurait permis. Le choix des autorités a été de ne pas s’engager dans cette voie. Ces travailleurs demeurent invisibles et leurs cancers se “diluent” dans l’ensemble des cas de cancer.

Un fléau comparable à l’amiante

Tricastin, Paluel ou Fessenheim, Tchernobyl et Fukushima, tous ces sites nucléaires participent d’une même catastrophe sanitaire d’une ampleur comparable à celle de l’amiante, qu’il s’agisse de la contamination radioactive à bas bruit dans la routine des parcs nucléaires, ou d’une pollution de grande ampleur provoquée par les accidents tels que ceux de Tchernobyl et de Fukushima.

Partout dans le monde, à longueur d’année, pour assurer la maintenance des installations nucléaires, des travailleurs, le plus souvent précaires, subissent des conditions de travail et de vie incompatibles avec la dignité humaine. Les maintenir dans l’invisibilité est le moyen choisi par le lobby nucléaire pour sauvegarder l’image, aujourd’hui brisée, d’une industrie sans risques.

La catastrophe de Fukushima révèle au monde cet autre scandale de santé publique. Puisse cet article contribuer à la reconnaissance de l’engagement des travailleurs de Fukushima qui, aujourd’hui, sacrifient leur vie pour tenter d’éviter l’apocalypse.

Banned books and milk powder: What do they have in common?

This: They are among the most prized commodities on the must-buy list for many of the millions of Chinese tourists who come to Hong Kong every year.

In this former British colony, books considered too politically sensitive for mainland China are widely available in bookshops. And since news emerged two years ago that many young children in China had died or fallen seriously ill after drinking local formula adulterated with the toxic chemical melamine, imported milk powder has become a priority purchase for our visitors.

When a Chinese writer whose books are banned in China visited Hong Kong recently, I asked if he would have time to meet up for a chat.

“I would love to, but I’m afraid I have something really important to get done first,” he replied.

I thought he was probably busy with his new book, which daringly criticizes the country’s top leadership. But he surprised me.

“I have to take a crate of baby milk powder across the border for a friend,” he said. “I also have to buy more for my son before I leave. You know what milk is like in China,” he said, rolling his eyes.

Food safety was one key issue that prompted me to leave Beijing two years ago. When I became pregnant, everything that residents complain about in Beijing — air pollution, dangerous roads, and most importantly, food safety — suddenly became real issues.

Although that was before the tainted-milk scandal broke, there had been plenty of food scares floating around: The fake baby formula that killed 12 babies in 2004, the carcinogenic food-coloring that found its way into many food products in 2005, not to mention fake eggs, fake vaccines and flour tainted with powdered lime.

Just months after we returned to Hong Kong, news about the melamine-laced milk emerged — more than 300,000 infants were made seriously ill and at least six died from kidney stones resulting from drinking formula adulterated with the industrial chemical.

So it is unsurprising that many Chinese tourists flock to Hong Kong to stock up on foreign-produced milk powder. Here, imported goods are more readily available and less heavily taxed. In a busy, neon-lit shopping area, there is even a book shop popular with mainland Chinese tourists that specializes in books banned in China — and Japanese milk powder.

The proprietor told me that sales of milk powder surged after the melamine scandal in 2008. Nowadays, 90 percent of his customers are from mainland China and he sells up to 1,800 units of milk powder per month — bringing in double the profits he makes from books.

The Chinese media has also chronicled stories about people scrambling for foreign baby formula through a variety of channels, be it begging families living abroad to send it or paying couriers to sneak it in from Hong Kong.

My cousin, a working mother from southern China, used to queue up with hundreds of people to cross over to Macau to buy milk for her baby.

“Nobody trusts locally produced milk,” she fumed. “In fact, you never know what is safe to eat and what’s not.”

So popular is the demand for foreign-made milk powder that the Chinese tax authorities imposed a new rule in September that drastically cuts the duty-free allowance for milk powder brought into the country.

The lives of millions of Chinese babies are still at risk. This year, melamine-laced milk resurfaced in the market apparently recycled from contaminated powder that was not destroyed in the 2008 scandal. Recently, there have been accusations that a Chinese-brand milk-powder causes premature puberty in baby girls — although the manufacturer denied it.

Parents of children affected by the last scandal are outraged. They say this is happening because corrupt officials who condone malpractice have gone unpunished, while their own cries for help have been silenced. A father who campaigned on behalf of other families was recently jailed for two-and-a-half years. Another father, whose one-year-old died of urinary system failure due to tainted milk, was given “re-education through labor” detention this year for daring to complain on the Internet.

So it is perhaps not so amusing that even dissident authors, who cannot take their own books home, should make it a priority to take something they can take back to China: milk powder. But millions of parents who cannot afford to travel outside mainland China are less lucky.

One mother of a three-year-old girl who got kidney stones from drinking toxic milk told me that poorer families like them simply do not have a choice.

“People round here just can’t afford imported milk, let alone going to Hong Kong,” she said. “We feel hopeless but what can we do?”

An army of health activists and world leaders will gather at the United Nations this week to review the eight Millennium Development Goals agreed to at the start of the century and to recalibrate and recommit to more effectively achieve them by 2015. The overarching and noble goal is reducing global poverty. But the most compelling and achievable objectives — huge reductions in maternal and child mortality worldwide — will be severely undermined if the Obama administration either directly or covertly integrates abortion into the final outcome document.

If the summit is sidetracked by abortion activists, the robust resolve required at national levels to deploy the funds needed to achieve the internationally agreed targets will be compromised. The risk is real. Secretary of State Hillary Clinton has said publicly that she believes access to abortion is part of maternal and reproductive health, thinking that runs contrary to the understanding of the more than 125 U.N. member states that prohibit or otherwise restrict abortion in their sovereign laws and constitutions. Moreover, speaking before the House International Relations Committee in 2005, Mark Malloch Brown, chief of staff for then-Secretary General Kofi Annan, said concerning reproductive health, “we do not interpret it as including abortion.” Clinton also calls pro-abortion nongovernmental organizations “partners.”

At the Group of Eight meetings in Canada this year, Prime Minister Stephen Harper rebuffed Clinton’s attempt to integrate abortion with initiatives to reduce maternal mortality. He stated his opposition to funding abortions by saying: “We want to make sure our funds are used to save the lives of women and children and are used on the many things that are available to us, and, frankly, do not divide the Canadian population.”

Millennium Development Goal No. 4 is reducing child mortality rates two-thirds from 1990 levels. It is clear that myriad cost-effective interventions need to be expanded to save children’s lives. These include treatment and prevention of disease, as well as greater access to adequate food and nutrition, clean water, childhood vaccinations, oral rehydration packets, antibiotics, and drugs to inhibit mother-to-child HIV transmission.

Similarly, unborn children desperately need care to optimize their health before and after birth. Healthy children start in the womb.

Abortion is, by definition, infant mortality, and it undermines the achievement of the fourth Millennium Development Goal. There is nothing benign or compassionate about procedures that dismember, poison, induce premature labor or starve a child to death. Indeed, the misleading term “safe abortion” misses the point that no abortion — legal or illegal — is safe for the child and that all are fraught with negative health consequences, including emotional and psychological damage, for the mother.

Talk of “unwanted children” reduces children to mere objects, without inherent human dignity and whose worth depends on their perceived utility or how much they’re wanted. One merely has to look at the scourge of human trafficking and the exploitation of children for forced labor or child soldiering to see where such disregard for the value of life leads.

The long-neglected health of mothers is prioritized by Millennium Development Goal No. 5, which rallies the world to cut maternal mortality rates 75 percent from 1990 levels.

We have known for more than 60 years what actually saves women’s lives: skilled attendance at birth, treatment to stop hemorrhages, access to safe blood, emergency obstetric care, antibiotics, repair of fistulas, adequate nutrition, and pre- and post-natal care. The goal of the upcoming summit should be a world free of abortion, not free abortion to the world.

A recent landmark study funded by the Bill and Melinda Gates Foundation and published in the British journal the Lancet in April is a great encouragement to governments that have been seriously addressing maternal mortality in their countries. The study, confirmed by similar numbers in a World Health Organization report released just this month, shows progress in the fight against maternal mortality; the number of maternal deaths per year as of 2008 has been reduced to 342,900 — or 281,500 in the absence of HIV deaths — some 40 percent lower than in 1980. And contrary to prevailing myths, the study underscored that many nations that have laws prohibiting abortion also have some of the lowest maternal mortality rates in the world — Ireland, Chile and Poland among them.

Implementation of the Millennium Development Goals will cost tens of billions of dollars. Credible polls from CNN and Gallup show that huge majorities of Americans don’t want their tax dollars used to pay for abortions.

Including abortion in the U.N. Outcome Document or in its implementation will undermine the Millennium Development Goals. Actions and programs to achieve the latter must embrace all of the world’s citizens, especially the weakest and most vulnerable. We must affirm, respect and tangibly assist the precious lives of women and all children, including the unborn.

As 140 heads of state and government gather Monday at the United Nations for the Millennium Development Goals summit, they and the public will ask what has come out of this decade-long effort.

The answer will surprise them: A great deal has been achieved, with some of the most exciting breakthroughs occurring in Africa.

I recall how the Millennium Development Goals were initially greeted with cynicism — as unachievable, pie-in-the-sky, a photo-op rather than a development framework. Cynicism has been replaced by hope, born of experience, commitment and breakthroughs.

Back in 2000, the situation in Africa was widely regarded as hopeless. Roughly half of Africa’s population was living on less than one dollar a day. AIDS, malaria and TB were out of control. Wars were pervasive; Liberia, Sierra Leone, Sudan, Uganda, Somalia, and the biggest of all, Congo, were all entangled in conflicts. The African economies had stagnated or declined for a generation.

When my colleagues and I suggested that AIDS, malaria and other epidemic diseases could be controlled and that Africa’s economic growth could be spurred if the world helped the continent to achieve the Millennium Goals, we were often greeted with derision. Africa, I was told, was simply too violent, too corrupt, too divided to improve.

A decade later, the picture has changed dramatically. AIDS incidence has declined, from an estimated 2.3 million new cases in 2001 to 1.9 million in 2008; longevity has risen tremendously, with millions of Africans now on antiretroviral treatment. Malaria is dropping decisively because of programs to distribute bed nets and provide medicines. Measles deaths fell by 90 percent between 2000 and 2008, before a frustrating uptick this past year when donors mistakenly cut back their financing for immunizations. Primary school net enrollments have risen from 58 percent in 2000 to 74 percent in 2007. Most of Africa’s major wars have subsided.

Africa’s economy has also picked up. During 1990-2000, Africa’s per capita G.D.P. declined by 0.3 percent per year. Between 2000 and 2010, per capita growth was around 3.1 percent per year. And Africa has shown resilience in the current crisis, with this year’s per capita economic growth at around 2.5 percent.

Extreme poverty is declining, though not yet fast enough to meet the MDG targets. The share of the African population in extreme poverty has also declined from around 58 percent in 1999 to probably under 50 percent in 2010.

The Millennium Development Goals themselves deserve a lot of credit by providing a powerful organizing framework and a bold but realistic time horizon.

Dozens of African governments have now adopted national planning strategies based on the Millennium Goals. Nations around the world now have specific, time-bound, outcome-oriented plans that are showing real progress because they are tapping into the synergies of poverty reduction, increased agricultural output, disease control, increased school enrollments and improved infrastructure as targeted by the Millennium Development Goals. The donor countries helped to promote major advances in public health when they created the Global Fund to Fight AIDS, TB and Malaria, and the Global Alliance for Vaccines and Immunizations.

China’s economic rise has also pulled up the demand for Africa’s mineral and hydrocarbon resources. China obliged as well by becoming a major funder of Africa’s roads and power networks — critical areas where the United States and Europe have mostly stopped financing investment projects.

Asia and the Middle East more recently have become major markets for Africa’s tropical agricultural output as well. African leaders, such as President Bingu wa Mutharika of Malawi, also broke old donor-led shibboleths by establishing new government programs to get fertilizer and high-yield seeds to impoverished peasant farmers who could not afford these inputs. Farm yields soared once nitrogen got back into the depleted soils.

The Millennium Development Goals have always recognized the need for a global partnership to end poverty, and U.N. Secretary General Ban Ki-moon and U.N. agencies have been persistent in their support of this ambitious agenda. Ironically, though, the main obstacles to achieving the goals by 2015 in Africa are international in origin, many due to high-income countries.

The first challenge is the donor shortfall in honoring specific financial commitments to Africa. Africa was told in 2005 by its donor partners to expect about $60 billion in financing from all of the world’s governments in 2010, but actual aid is only around $45 billion.

The second is human-induced climate change, another visitation upon Africa from the outside world. The region that has contributed by far the least to human-induced climate change is the one bearing the highest price in terms of drought and crop failures.

The third threat is large-scale corruption, often fueled by major American, European and Asian companies. Of course, it is Africa’s responsibility to resist temptations, but global companies (sometimes with the support or tacit knowledge of governments) must also stop spreading the big dollars around.

The fourth threat is rampant population growth. The Roman Catholic Church, politically powerful throughout the continent, continues its opposition to birth control and family planning.

The fifth threat is trade. Europe and the United States preach free trade, but then close their markets to African agricultural products.

The sixth risk is that of neglect. President Obama has spent only one day in sub-Saharan Africa, and has hardly said a word about the Millennium Goals to the American people. Ironically, it is the precisely the goals themselves, rather than hundreds of billions of dollars of annual military spending, that can offer the U.S. and other countries a path to security in places like Afghanistan, Yemen and the Horn of Africa.

The world leaders will agree on the right principles at the summit: targeted investments for agriculture, education, health, energy and microfinance; gender equality; the complementary roles of development aid, trade and private financing. The real question is whether the rich countries will deliver what they’ve promised in the five remaining years, after having fallen far short in the first 10.

When the donor nations have not just talked but have actually pooled their funds to support the national plans of poor countries, the speed of advance has been breathtaking. The Global Fund to Fight AIDS, TB and Malaria is the right model. If donors will match that successful effort with similar pooled support in areas such as smallholder agriculture, primary education, primary health, family planning and infrastructure, Africa’s leaders can do the rest.

On their 10th birthday, the Millennium Development Goals offer the world a realistic path to ending extreme poverty.

Ten years ago, heads of state from across the world promised “to spare no effort to free their fellow men, women and children from the abject and dehumanizing conditions of extreme poverty, to which more than a billion of them are currently subjected.” The historic Millennium Declaration was duly adopted and the Millennium Development Goals (MDGs) were established, with the aim of reversing the grinding poverty, hunger and disease affecting billions of people.

Ten years is a long time, and many millions will be looking to the United Nations General Assembly’s summit meeting next week to assess progress on the MDGs for a beacon of hope, a chink of light. For millions who continue to eke out a living on less than $1 a day, our words alone will not be fodder enough for the hungry and destitute, unless they are backed by action that leads to significantly more progress.

We will hear much in the coming days about maternal health and child mortality, about gender equality and combating disease. These are critically important issues and it is absolutely right that we focus on safe motherhood, redouble our efforts to fight H.I.V./AIDS and malaria, and improve the lives of women and children in all developing countries. What we will almost certainly not hear much about, however, is the most off-track and possibly least fashionable Millennium Development Goal intervention — sanitation.

Sanitation is often referred to as an “orphan” MDG, not included in the initial list of eight Millennium Development Goals until some two years after the others were established. No one likes to talk about disposal of human waste. But the lack of adequate toilets is one of the greatest untold development challenges facing the international community.

There are 2.6 billion people who will go through today, just as they do every day, without a proper toilet. According to a recent report in The Lancet, the biggest killer of African children under five is diarrhea, which kills more children globally than AIDS, measles and malaria combined. The vast majority of these deaths could be prevented by investing in safe toilet facilities, clean drinking water supplies, and raising awareness of the need to improve hygiene practices — for example, washing hands with soap. These simple and cost-effective interventions can also significantly reduce other leading causes of child deaths, such as pneumonia and under-nutrition.

Such illnesses have a critical impact on the health sector and subsequently the economy. At any one time, half of all hospital beds in developing countries are filled with people suffering from water and sanitation-related diseases, and some 443 million school days are lost each year due to sickness. We know, for example, that 11 percent more girls attend school when sanitation is available.

In Liberia, we have seen important gains in reducing child mortality and an increase in budgetary government funding to the water and sanitation sector, from $200,000 in 2006 to $524,000 last year. With just 14 percent of Liberians having somewhere to call a toilet of their own, huge challenges remain, especially if we are to reach the most vulnerable and marginalized sections of society, and improve the population’s well-being.

If our heads of state meeting next week are serious about achieving the Millennium Development Goals — not only to halve the proportions of people without access to sanitation and water by 2015, but also to get more children into school and to reduce child mortality by two thirds — we must commit ourselves to ending water and sanitation poverty.

April of this year witnessed the first glimmer of hope. At the first high-level meeting of the Sanitation and Water for All partnership, Liberia, together with 17 other African and Asian countries, made strong commitments to increase access to basic sanitation and safe drinking water at the national level. These countries also reiterated their commitment, under the eThekwini Declaration, to allocate 0.5 percent of their G.D.P. to sanitation.

In Liberia, we recognize that we will face challenges in meeting these targets at the national level. But we are totally committed to face and overcome them by working effectively in partnership with civil society, the private sector and other financial and development partners, to ensure that no child dies needlessly from sanitation and water-related illness.

We cannot wait another 10 years. Let us act now to ensure that citizens everywhere can live healthy and dignified lives, full of the promise and potential that is their right.

Isabel is four years old. Her belly and ankles are swollen and she walks as if it hurts a little bit. Her family, who live in eastern Guatemala, have not had the means to feed her properly, so she is being treated for kwashiorkor – acute malnutrition.

Even though it is classified by the World Bank as a middle income country, the level of inequality in Guatemala is such that almost half its children under five suffer from chronic malnutrition. This is the fifth highest rate of chronic malnutrition in the world, higher even than that in Haiti, which is by far the poorest country in the Americas.

Isabel will stay in the clinic supported by Christian Aid until she is well again. In some ways, she is lucky. At this time of year when the previous year’s harvest has run out, children do die of hunger in this part of Guatemala.

Isabel will recover from kwashiorkor but she will never recover from the irreversible effects of chronic malnutrition, which severely stunts physical and mental development. There’s no excuse for this anywhere, and especially not in a country with as much wealth as Guatemala. Along with the dubious distinction of having the fifth highest level of chronic malnutrition, it is also the world’s fifth largest exporter of coffee and sugar.

This state of affairs is no accident. It is a direct result of the extremely regressive tax regime in Guatemala and many other Latin American countries. The poorest pay a far higher proportion of their income on the equivalent of VAT and other indirect taxes, whilst the business elite enjoy a very generous regime of tax incentives. As a result, one in 20 Guatemalan children does not reach the age of five due to infectious and diarrheal diseases that are easily preventable and treatable. Two-thirds of the country’s children do not complete primary school on time and illiteracy levels are closer to the average for sub-Saharan Africa than to that for Latin America.

Guatemala stands out as much for its indicators of wealth as for those of poverty. The country with the highest number of private aeroplanes and helicopters per head in Central America is also the country with the highest rate of women dying from complications in pregnancy because they lack affordable transportation to a health centre.

In an effort to address these extreme inequalities, a Christian Aid-supported thinktank, the Central American Institute for Fiscal Studies (Icefi in Spanish), hosted an international symposium in Guatemala City last week. It was attended by Simon Pak, an internationally recognised tax expert, with a view to strengthening the Tax Justice Network in Latin America and tackling some of the more regressive policies in the region. Because Guatemala has one of the lowest tax burdens in Latin America, as well as one of the most generous regimes of tax breaks, Icefi chose to focus on the country as a case history for regressive tax policies in the region.

The report focuses on three human rights – those to food, health and education – and on three serious threats to these rights: child malnutrition, maternal mortality and low primary school completion. These issues were selected because they have been declared national priorities by successive governments in Guatemala. They also represent three key fronts in the struggle against poverty, to which all states have committed through the framework of the UN millennium development goals. If they are to have any hope of achieving the goals, and reducing the number of damaged children like Isabel, then governments need money. And the only reliable, sustainable source of that money is tax.

The global economic crisis has claimed many victims – unemployed workers, flooded homeowners and bankrupt pensioners – but nowhere have the repercussions been as devastating as in the developing world.

The setback to the fragile gains of recent years, particularly in Africa, threatens to return millions of people to the extreme poverty from which they had just managed to escape. In addition to the prospect of enormous human suffering, severe economic, political, and social pressures now threaten to overwhelm and destabilise developing countries, triggering conflict on an unprecedented scale.

What makes the downward spiral particularly disheartening is that the economic crisis has hit at a time of the first glimmerings of progress, notably in healthcare. Since 2000, the rate of people dying from Aids has declined, child-killing diseases like malaria and measles are being tackled more effectively, universal primary education is inching forward, and the targets for safe drinking water are in sight.

Now, though, the global economic crisis is sapping developed countries’ shaky efforts to fulfil their commitments for official development assistance (ODA) in order to achieve the United Nations’ millennium development goals (MDGs). A UN report warns that annual investment from these donor countries is falling $35bn short of the $150bn goal. Unless something changes, there is little chance that the MDG targets can be sustained in the long run.

Indeed, the consequences of the fall-off in ODA are already dramatic; the number of people going hungry and in extreme poverty is now far greater than before, and the same is true of the unemployed, those who work in vulnerable jobs, or earn less than $1.25 (81p) a day. Progress in health and literacy is being undermined. World Bank data links the economic downturn to an increase in mortality among children under the age of five.

Moreover, 536,000 women a year die in childbirth, and maternal health is also the one goal towards which progress has stagnated since the targets were established 10 years ago. Every minute that passes means one less mother, and it is shameful that 99% of these deaths occur in developing countries.

So should we despair of achieving the MDGs, not just by the original deadline of 2015 but even by the end of the century? Viewed through the traditional ODA prism, with its one-year budgets, public-finance constraints and competing national priorities, there seems little cause for optimism. But there is a way to replace the traditional paradigm with an internationally accepted model that has a proven record of success, particularly in healthcare.

Innovative financing mechanisms offer the means to tap incrementally into global financial flows without disrupting economic activity. Among the best-known examples is Unitaid, a UN-sponsored international drug-purchase facility funded largely through a small fee added to airline tickets, which has raised $1.5bn since 2007. This reliable funding source has spearheaded the fight on the three health-related MDGs: treating and fighting life-threatening diseases like HIV/Aids, malaria, and tuberculosis; reducing childhood mortality; and improving maternal health.

Providing funding in 93 countries, Unitaid today finances drugs for three-quarters of the children around the world who receive antiretrovirals. Widespread coverage has been achieved through Unitaid’s influence on the price of life-saving drugs: it guarantees a market through long-term commitments to purchase high volumes of medicines and diagnostics – a commitment made possible by the sustainable and predictable funding of the “air tax”. As a result, the price of antiretrovirals has been cut by more than 50%.

Similarly, Unitaid is attacking child mortality through Unicef’s extensive programme to eradicate mother-to-child HIV transmission. By the end of 2010, 4 million African women will be screened, and tri-therapies treatment provided to 500,000 pregnant women worldwide.

Unitaid is now building on this success by teaming up with the Millennium Foundation to give individuals a chance to help fight major diseases through micro-contributions. An innovative fundraising mechanism called Voluntary Solidarity Contribution will allow air travellers and others to make a voluntary micro-donation to Unitaid simply by ticking a box when buying say, a plane ticket, and adding $2 to the total cost.

The “air tax” currently applies to only 7-10% of all airline tickets sold, yet the $400m it brings in yearly accounts for three-quarters of Unitaid’s financing. With more than a billion people now travelling by air every year, and with a total of 2.2bn flights sold, extending the “air tax” approach to a voluntary contributions model would vastly multiply the programme’s benefits.

Such new financing mechanisms, in addition to national ODA investments, are an important means of supporting the beleaguered MDGs. In September, Ban Ki-moon, the UN secretary general, convenes a summit in New York to renew the drive toward reaching the MDGs, the world leaders in attendance should endorse their use to address MDG priorities in areas other than health.

When the MDGs were adopted in 2000, the sense of urgency was powered by the moral conviction that extreme poverty had become an unacceptable anachronism in our globally connected world. But more is needed, and September’s summit in New York will be an important opportunity for countries to voice their full-throated support for innovative financing mechanisms, and thus give the MDGs a fighting chance.

The right of every human being to safe drinking water and basic sanitation should be recognized and realized.

The United Nations estimates that nearly 900 million people live without clean water and 2.6 billion without proper sanitation. Water, the basic ingredient of life, is among the world’s most prolific killers. At least 4,000 children die every day from water-related diseases. In fact, more lives have been lost after World War II due to contaminated water than from all forms of violence and war.

This humanitarian catastrophe has been allowed to fester for generations. We must stop it.

Acknowledging that access to safe water and sanitation is a human right is crucial to the ongoing struggle to save these lives; it is an idea that has come of age. It was first proposed a decade ago by civil society organizations, like Green Cross International, which I helped establish in 1992. Today, it is a mainstream demand that many governments and business leaders support. That is a great achievement.

This month, for the first time, the U.N. General Assembly is preparing to vote on a historic resolution declaring the human right to “safe and clean drinking water and sanitation.” It is a pivotal opportunity.

So far, 190 states have acknowledged — directly or indirectly — the human right to safe water and sanitation. In 2007, leaders from the Asia-Pacific region recognized safe drinking water and basic sanitation as human rights and fundamental aspects of security. In March, the European Union affirmed that all states must adhere to their human rights commitments in regard to safe drinking water.

Not all nations are on board, however. The United States and Canada are among the very few that have not formally embraced the right to safe water. Their continued reluctance to officially recognize the right to water should be questioned, not least by their own citizens. President Barack Obama’s national security strategy calls for furthering human rights and sustainable development around the world; that goal should be translated into support for access to water as a human right.

A few other states, like Turkey and Egypt, have also hesitated to formally acknowledge the right to water, mainly because of boundary-related water issues.

However, an absolute global consensus is not essential. The reluctance of a handful of countries cannot derail this vitally important trend.

Recognizing water as a human right is a critical step, but it is not an instant “silver bullet” solution. This right must be enshrined in national laws, and upholding it must be a top priority.

Failures to provide water and sanitation are failures of governance. Recognizing that water is a human right is not merely a conceptual point; it is about getting the job done and actually making clean water widely available. We must clarify the obligation of governments to finance and carry out projects that bring these services to those who need them most.

Developing countries that have incorporated the right to water in their legislation, like Senegal and South Africa, have been more effective in providing safe water than many of their neighbors.

Recent U.N. statistics show that the world is on track to meet, or even exceed, the Millennium Development Goal to halve the number of people without safe drinking water by 2015. This should be applauded. But the goal for sanitation will be missed by 1 billion people. At current rates, some parts of Africa are at least a century away from providing safe water and sanitation to all. A “water apartheid” has descended across the world — dividing rich from poor, included from excluded. Efforts to redress this disparity are failing.

Expanding access to water and sanitation will open many other development bottlenecks. Water and sanitation are vital to everything from education to health to population control. As population growth and climate change increase the pressure for adequate water and food, water will increasingly become a security issue. As global temperatures rise, “water refugees” will increase. Water touches everything, and strong collaboration among all sectors of society — governments, activists, farmers and the business and science communities — is needed to increase its availability.

Making access to water and sanitation a daily reality is good business, and good for the world economy. According to the U.N. Environment Program, a $20 million investment in low-cost water technologies could help 100 million farming families escape extreme poverty. Dedicating $15 billion a year to the water and sanitation millennium goals could bring $38 billion a year in global economic benefits. That’s a pretty good rate of return in today’s financial climate. It is within our grasp for the first time.

There is tremendous political will and popular momentum behind the movement to formally declare safe water and sanitation as human rights. We must seize this moment and translate our enthusiasm into solid, binding legislation and action at the national and international levels — starting with the expected U.N. vote this month.

I was pleased a few weeks ago to hear President Nicolas Sarkozy call for the 2012 World Water Forum — to be held in the French city of Marseille — to be the venue for the international recognition of the universal right to safe water and sanitation. This cause needs more “champions” — respected public figures and opinion leaders who act as its ambassadors around the world.

The actions and voices of millions of citizens have brought the global movement for the right to water this far. I hope that more people will join us to help bring us closer to the ultimate goal — a world where everyone’s right to safe water and sanitation is not just recognized but is also fulfilled.

Pretend it didn’t happen. That’s apparently the strategy of the Chinese government, the World Health Organisation, and the International Olympic Committee toward China’s melamine milk contamination scandal during the Beijing Olympics.

An official ban on reporting of “all food safety issues” during the games stifled domestic media coverage of revelations that at least 20 dairy firms were spiking milk products with the chemical melamine. That cover-up contributed to the deaths of six children and illness among 300,000 others.

But there’s not a whisper of melamine – or of the reporting ban – in a May 2010 book jointly issued by the Chinese government, the WHO and IOC, The Health Legacy of the 2008 Beijing Olympic Games: Successes and Recommendations.

That publication instead declares that “no major outbreak of food-borne disease occurred during the Beijing Olympics”. The book describes, without irony, the Chinese government’s attention to food safety during the Beijing Olympics as “an instructive example of how mass events can be organised to promote health in a value-added way”.

The book’s introduction features tributes from the IOC president, Jacques Rogge, who praises the Beijing Olympics for providing a “lasting legacy to the benefit of the population in and around Beijing”. The WHO director-general, Margaret Chan, commends the Beijing Games for spurring “innovative measures to protect the health of visitors and the local population”.

The WHO’s and IOC’s parroting of the Chinese government’s rosy assessment of the Beijing Olympics’ health legacy doesn’t just defy the historical record. It adds insult to the injury of China’s child melamine victims by whitewashing the role of official censorship in their misery. China’s state-controlled media was not allowed to publish the melamine contamination story until September 2008. This fact goes unmentioned in the book.

Nor is there a discussion of ongoing persecution of some public health advocates. On 30 March 2010, Zhao Lianhai was hauled before a Beijing court in a one-day closed trial on charges of “provoking disorder” for blowing the whistle on the government’s failure to assist the thousands who became ill. Zhao helped to establish a grassroots advocacy group, Home for Kidney Stones Babies, which rallied parents of sick children to demand official compensation and an official day of remembrance. For his efforts, Zhao faces a possible prison term of up to five years.

The Chinese government has a long history of denying or covering up issues it broadly defines as “sensitive” – even public health emergencies. The government stifled public disclosure of its severe acute respiratory syndrome (Sars) outbreak to ensure a crisis-free meeting of the National People’s Congress in early 2003.

That decision helped fuel an epidemic, which spread to 25 other countries and killed 774 people before it was contained in July 2003. Two years later, the government blocked all domestic media reports of the massive spill of the toxic chemical benzene in the Songhua river in Heilongjiang province until wild rumours about the disaster prompted disclosure of what had actually happened.

If the WHO is genuinely committed to “the attainment by all people of the highest possible level of health” – its stated objective – it should examine the good, the bad, and the ugly in China, not put its imprimatur on half-truths and cover-ups as to the real health legacy of the Beijing Olympics. The WHO reflected some discomfort when Human Rights Watch inquired about its co-authorship. An email from the WHO’s regional office of the western Pacific defends the book as a “scientific study”, but adds that its contents “do not necessarily reflect WHO’s views, nor does WHO necessarily endorse them”.

The IOC’s complicity is no less shameful, but less surprising given its well-documented tolerance of the Chinese government’s unrelenting campaign to squelch legal peaceful protests, limit media freedom and restrict the internet access of journalists ahead of and during the Beijing Olympics.

The WHO and the IOC owe China’s citizens and the international community the truth and not some selective and rosy portrayal dressed up as “science”. The WHO should undertake independent reporting on the Beijing Olympics’ public health legacy in its monthly medical bulletin. The IOC should integrate ethical principles based on the values enshrined in the Olympic charter to establish human rights-compatible standards to guide the Olympic movement and the selection of future Olympic host cities. And both should demand that the Chinese government immediately release Zhao, stop harassing those seeking redress and allocate necessary funds for their compensation and medical treatment.

That would be an Olympic legacy worth writing about.

La creciente incidencia en el entorno laboral de la psicopatología conocida como burn-out (“quemado por el trabajo”) recomienda orientar su difusión, incidiendo en los aspectos de prevención. Mas allá del tratamiento individual, analizando el origen de un síndrome individual, pero que implica a dos componentes; al trabajador y a la organización. En consecuencia podremos establecer criterios compartidos de intervención para prevenir esta patología desde la doble vertiente de responsabilidad.

De entre las dos decenas de definiciones de burn-out existentes, la de Gil Monte – “todo trabajador que se enciende con su trabajo, puede llegar a acabar quemándose en él”-nos permite ubicar el origen de este síndrome en la decepción que siente el trabajador al no ver logradas sus expectativas, ni compensados sus esfuerzos laborales… En cambio debe de enfrentarse a una realidad laboral muy diferente a la imaginada, lo que le desimplica progresivamente de la tarea, provocándole un intenso agotamiento emocional, en el que se mezcla la impotencia para alcanzar sus objetivos y la falta de recursos para lograrlo. Se genera así un desajuste laboral que se alarga en el tiempo controlándose de forma tardía y con mayor coste de remisión.

Un psiquiatra norteamericano, Freudenberg, buscando respuestas sobre el estrés crónico, define en el año 1974 el burn-out como una vivencia de agotamiento emocional y pérdida de interés por la actividad laboral. En 1976 Malasch se refiere al burn-out como una sobrecarga emocional en un proceso gradual de pérdida de responsabilidad profesional y desinterés por la tarea.

El burn-outes una forma de acoso psicosocial, que no se debe confundir con el mobbing.En el burn-out,el sentimiento de acoso lo constituye la propia tarea que desborda y paraliza al trabajador, quien se autopercibe sin recursos ni capacidad suficiente para reaccionar. En el mobbing el trabajador es acosado específicamente por terceros. Tampoco hay que confundir burn-out con boreout,en la medida en que una cosa es estrés en el trabajo y otra aburrimiento en el trabajo. El boreout se caracterizaría por una respuesta más controlada y adaptativa que conduciría inicialmente a contrarrestar el aburrimiento, con unas posiciones de fingimiento, engaño o disimulo. Esta desmotivación prolongada podría llegar a derivar en síntomas psicosomáticos menos controlables.

Lo que estaría ocurriendo en los episodios de burn-out se referiría a unas exigencias laborales que para el afectado no se corresponderían con el acuerdo laboral pactado entre trabajador y empresario. Los trabajadores con síndrome de burn-out se caracterizarían por una tendencia inicial a entregarse plenamente a su trabajo incluso en clave de cierto comportamiento adictivo (workaholic)que ante la progresiva decepción se suprimiría para enquistarse, dejando paso a un sentimiento de impotencia, frustración y parálisis.

Estaríamos por tanto ante un importante desnivel entre contratante y contratado, al producirse una evolución irregular entre las demandas del puesto de trabajo y las expectativas ante el mismo. Por lo tanto el burn-out además de un abordaje individual requeriría de una intervención conjunta (puesta en común de los desajustes y voluntad mutua de su revisión) en un proceso de mediación y equilibrio tutelado por un experto.

La decepción que llevaría al burn-out se evidenciaría más en periodos en los que se inicia un nuevo proyecto profesional, momento de expectativas idealizadas y promesas que luego no se materializarían. Se detectaría mayor incidencia del burnout en la asunción de turnos horarios irregulares, en los sectores de salud o de servicios, en los procesos bruscos de cambio organizativo, siendo la mujer nuevamente el colectivo mas vulnerable.

Culturas tan diferentes como la de Europa y Japón nos muestran unos parecidos efectos devastadores del que finalmente constituye un estrés agudo. En el caso de Francia, sociedad muy jerarquizada, con los recientes suicidios (24) en una misma empresa, Télécom, y en el caso de Japón, territorio marcado por el confucionismo, con la muerte súbita por karoshi (derrame cerebral o ataque al corazón) de numerosos trabajadores, en muchos casos en su mismo puesto de trabajo (media de 3.000 muertes anuales).

Vemos finalmente como el estrés laboral extremo preside dos escenarios de trabajo que, aunque diferentes, desembocan igualmente en la muerte de los afectados. Se pone en evidencia que, a pesar de las diferencias, la coincidencia en la progresiva y absoluta intolerancia ante un trabajo que resulta tan angustiante como agotador llega hasta el extremo de morir por él. Al parecer nadie podría intervenir con efectividad para prevenir y evitar esta pérdida de vidas, ni siquiera en una sociedad aparentemente tan avanzada y preocupada por los trabajadores como la nuestra.

Amid the news about U.S. failures in Afghanistan stands a clear success: a vast expansion of primary health-care services, including a major increase in the number of female health workers to provide prenatal care, attend births and treat female patients. By supporting the capacity of the Afghanistan Ministry of Public Health to develop and implement these services, the United States has contributed to a dramatic reduction in deaths of Afghan infants and young children. Yet the approach that fueled this success is in jeopardy of being subordinated to the objective of employing health development resources to support military operations. Such a shift has no proven linkage to enhancing stability in the short term and undermines policies that can contribute to the emergence of a legitimate state.

Afghan life expectancy is only 47 years for men and 45 years for women. More women die in childbirth in Afghanistan than in any country but Sierra Leone. After the U.S.-led intervention in 2001, the U.S. Agency for International Development, the World Bank and the European Union collaborated with the Afghan Ministry of Public Health to extend basic health services to help reduce premature, preventable deaths, especially among women and children. This initiative has been supplemented by special programs focusing on reducing death in childbirth, training health workers and tuberculosis control.

Despite uncertain security conditions, severe shortages of health workers and almost no health infrastructure, progress is clear. As has been noted in journal articles and reports from the Afghan health ministry, donors and academic evaluators, the number of health facilities has doubled and the number of trained midwives quadrupled. The share of health facilities with at least one female health worker has climbed to 83 percent. The number of children dying in infancy or before age 5 has declined nearly 25 percent, which translates into nearly 100,000 fewer infants and children dying this year, compared with 2002.

These initiatives have strengthened the foundations of a state that can serve its people. Rather than providing or contracting for services directly, USAID, the World Bank and the European Commission have strengthened the capacity of the Ministry of Public Health to develop and implement health policies, oversee programs, manage resources, engage communities and control the delivery of services. In contrast to the corruption obvious elsewhere, the health ministry has shown a level of transparency and accountability that allows U.S. funds to flow directly to the government for the provision of basic health services.

Saving lives through effective prevention and primary care services remains daunting in such a poor and chaotic country. Much remains to be done to extend health services nationwide, especially in regions where fighting inhibits access. But foreign assistance in this field has helped save thousands of lives and has built sustainable government capacity.

Unfortunately, such work for Afghanistan’s future is at risk. In an effort to win over populations in Taliban-controlled areas, the Obama administration is considering reducing overall funding for USAID health programs and concentrating development resources to support military operations. This means moving funds to certain geographic areas and emphasizing immediate results. Yet there is no evidence that expensive “quick impact” health projects that are not integrated into a larger strategy, or that do not actively engage locals, either contribute to security or wean populations from the enemy.

Quick-impact projects, such as clinic construction or the provision of new medical equipment, are rarely sustainable and seldom based on the community engagement needed for long-term effects. These simplistic and immediate interventions have been known to backfire. One military health analyst has criticized “drive-by” health interventions as “Band-Aid” operations that raise — and then crush — local expectations and ultimately lead to greater dissatisfaction and distrust. Moreover, as resources are diverted from the Afghan-led effort to build a system of effective and responsive primary care services, the emergence of a legitimate state will be compromised.

If the Obama administration is serious about supporting the emergence of a legitimate Afghan state and meeting the needs of people who have suffered for decades, it should not confuse health policy with military strategy. The United States should maintain its commitment to proven approaches in Afghan health care and support the Ministry of Public Health’s plans for expanding primary care and hospital services. Washington can continue to fund critical health services in areas of conflict. Afghan health officials, working with U.S. assistance, can develop and expand health services in volatile areas as safety increases. This approach would not divert U.S. health-development activities from the long-term goals of promoting good health and effective governance for Afghans.

As leaders of the world’s largest economies gather today in Pittsburgh for the Group of 20 meeting, people in the world’s poorest countries will likely look on with a mix of hope and trepidation, wondering whether their needs will figure in the deliberations at all. The G-20 nations could help both the poor and the global economy by fully financing lagging efforts to fight poverty and disease worldwide, and the best way to do this would be to impose a very small tax on the prosperous foreign exchange industry.

The eight United Nations Millennium Development Goals — which include eradicating extreme poverty and hunger, establishing universal primary education, reducing child mortality, improving maternal health and combating AIDS, malaria and other diseases — are meant to be reached by 2015. Morally and practically, the world must try harder to keep these promises. President Obama has made it clear that the United States has, in his words, “a responsibility to protect the health of our people, while saving lives, reducing suffering and supporting the health and dignity of people everywhere.”

Disease takes an enormous toll on economic growth: it sidelines or kills productive workers and causes tremendous suffering. Take, for instance, tuberculosis, an illness that with the right treatment can usually be cured. In 2007, it killed nearly 1.8 million people, more than 600 times the number who have died from H1N1 swine flu. The World Bank estimates that tuberculosis has caused the gross domestic product in some countries to fall as much as 7 percent.

Or consider maternal health. About 530,000 women worldwide die each year from pregnancy-related causes, most of them preventable, and millions more suffer injuries or develop lifelong disabilities. A serious effort to reduce those numbers would bring real economic gains. Improvements in the health of Asian women and children accounted for a significant share of that continent’s economic growth from 1965 to 1990.

Unfortunately, though, there is an enormous shortfall in the level of outside aid needed to reach the goals the world has set. Donor countries, including the wealthiest of the G-20, are providing only 0.3 percent of their combined income in development aid. Although the donor countries have made commitments to provide more money, they are not giving it fast enough to tackle runaway health problems, including the emergence of drug-resistant pathogens that threaten people across the globe.

The one untapped source that could easily provide the amount of money needed is the foreign currency market, which handles almost $800 trillion in trades annually, all of which is untaxed. A tiny levy of 0.005 percent on transactions involving the world’s most traded currencies — the dollar, the euro, the pound and the yen — would raise more than $33 billion annually for development, while not hurting the market or affecting the average international traveler.

The tax could be collected automatically by the computer system that handles foreign exchange transactions — so it would be easy to put into place, and impossible to evade. And because not all currencies would be taxed, only the countries whose currencies would be affected would need to consent. France already supports the idea, and Chancellor Angela Merkel of Germany has signaled her willingness to consider it.

We have already seen what innovative taxation can do to save lives, with sufficient political will. Since 2005, France and 10 other countries have collected a small tax on airline tickets (in France, it amounts to only $1 to $5 per ticket). And this has, without hurting the airline industry, raised about $700 million — enough to finance three-quarters of the AIDS treatment now being received by the world’s H.I.V.-positive children. Unitaid, the international organization that I lead and that manages the money from the airline tax, has also been able to negotiate 50 percent to 60 percent reductions in the price of pediatric anti-retroviral drugs in low-income countries.

How should the proceeds of a foreign exchange transaction tax be managed? One model is the Global Fund to Fight AIDS, Tuberculosis and Malaria, which holds medical programs in more than 100 countries to high performance standards, and can withhold financing when money is not used properly.

The banking industry has so far managed to keep currency trading untaxed, but this industry, which has so recently been dependent on government aid, has a duty to give back. President Obama has reminded Wall Street leaders about what he called their “obligation to the goal of wider recovery, a more stable system and a more broadly shared prosperity.” The same principle applies internationally. President Obama and other G-20 leaders should harness the mighty foreign exchange market in the service of better health for all.

There are two reliable ways of telling if you have won an argument. The first is if your disputants switch from discussion of the facts to accusations about motives; the second, more obviously, is if they descend to mere abuse.

Alan Dangour, a nutritionist at the London School of Hygiene and Tropical Medicine, should therefore feel he has had an encouragingly uncomfortable week. He is the author of a peer-reviewed meta-study in the American Journal of Clinical Nutrition that concluded, from 50 years of scientific evidence, that so-called “organic” food was no healthier than conventionally farmed products. By the end of last week Dangour felt as if he had been covered with the brown stuff the organic lobby holds most sacred. He revealed that he had received “hate mail” and was “taken aback” by the “abusive” language used.

Ben Goldacre, an NHS doctor and author of the acclaimed book Bad Science, has had a similar week. In his newspaper column he had taken apart the Soil Association’s criticisms of Dangour’s paper – which was funded by Britain’s Food Standards Agency – notably its claim that the health benefits of organic food relating to the absence of pesticides “could not be measured by the evidence identified in the FSA paper”.

As Goldacre pointed out to the Soil Association: “Either you are proposing that there are health benefits which cannot ever be measured. In this case you have faith, which is not a matter of evidence. Or you are proposing that there are health benefits which could be measured, but have not been yet. In which case, again, you have faith rather than evidence.” Cue an avalanche of organic ordure on the “comments” section at the foot of the online edition of Goldacre’s column.

When I called him, he remarked: “In my experience the [comments of the] organic food, antivaccine and homeopathy movements are unusually hateful and generally revolve around bizarre allegations that you covertly represent some financial or corporate interest. I do not; but I do think it reveals something about their own motives that they can only conceive of a person holding a position as a result of financial self-interest.”

His linking of the organic movement with homeopathy is telling. They are cults masquerading as science, rather like the creationists of America’s Bible Belt – but at least the latter have the self-awareness to acknowledge their opinions are based on faith. The organic movement, philosophically, is based on an inchoate faith in nature, seeing any human interference with nature as in some way bad and destructive of the “roots” of creation.

As Luc Ferry, the French philosopher, wrote in The New Ecological Order: “The hatred of the artifice connected with our civilisation… is also a hatred of humans as such. For man is the antinatural being par excellence… This is how he escapes natural cycles, how he attains the realm of culture, and the sphere of morality, which presupposes living in accordance with laws and not just with nature.” Guided by Ferry’s insight that this philosophy is based on “hatred” of humanity – and I accept this is dangerously close to an attack on motives – we should hardly be surprised by the nature of the e-mails directed at Dangour and Goldacre.

Nor, indeed, should anyone have been in the least surprised by Dangour’s results. The more rational among the organic movement long ago stopped claiming as scientific fact that their products are better for humans. The Canadian Organic Growers, reacting less hysterically than the Soil Association, responded to Dangour’s survey by saying that it “didn’t make health claims based on the nutrition of organic food”. This is the scientifically responsible attitude; but it is also a deadly blow to the marketing of organic foods, which depends on yummy mummies continuing to believe that if Cecilia and Frederick are fed only organic foods, then the little darlings will grow up healthier and stronger. It is in this sense that the organic business – ordinary food at extraordinary prices – is nothing more than a tax on gullibility.

Such gullibility can have dangerous effects on your health, as well as your bank balance. A few years ago my wife decided we should have an entirely organic vegetable garden. To this end she refused all man-made fertilisers and ordered a truckload of pigeon droppings. What could be more natural? Neither was there anything unnatural in the germs I inhaled through the spores of our organic manure, thereby contracting psittacosis. This developed into “atypical” pneumonia, which was of course resistant to all standard antibiotics. Had a hospital doctor not guessed the cause and put me on a drip with the appropriate drugs – ooh, chemicals! – I could have become a fatal casualty of the organic movement. Obviously my wife might have ordered cow manure rather than pigeon poo; then I could have been felled by E coli instead.

Think about it from the other end: if chemicals and pesticides in foods are as dangerous for humans as the Soil Association claims, we should expect conventional farmers, who handle the stuff in industrial quantities, to be dropping dead before the rest of us with all sorts of chemical-induced cancers.

The most exhaustive analysis of this matter was published in 2004, a peer-reviewed paper by Professor Anthony Trewavas of Edinburgh University, entitled “A critical assessment of organic farming-and-food assertions with particular respect to the UK and the potential environmental benefits of no-till agriculture”. (Trewavas is an advocate of no-till farming, which avoids damage to the soil caused by ploughing; “organic” farmers must plough to destroy all the weeds which would otherwise have been killed by pesticides.) His paper revealed that “of 12 separate investigations on farmers involving in total about 300,000 people, 11 found that farmers had overall cancer rates very substantially lower than the general public”.

Trewavas concludes that “the reasons why farming is so healthy are not known, but these data indicate not only a null result for the hypothesis relating pesticide exposure to cancer, but a consistent result for the alternative, that pesticide exposure may protect against cancer”. I realise that publicising Professor Trewavas’s paper might itself cause medical problems, as Soil Association executives choke with rage, but I think this a risk offset by the benefits to the public as a whole.

The provocative professor also points out that in the period since 1950 – as pesticides and industrial farming took an increasing role in food production – “stomach cancer rates have declined by 60% in western countries”. This is generally ascribed to the fact that fruit and vegetable consumption has doubled in that period – but why did this change in diet occur? Because modern agriculture, aided by air freight, has been able to get such products to consumers at ever-cheaper prices all year round.

This just demonstrates the common-sense point that diet, rather than whether food is produced “organically” or not, is the key to healthy eating. It is that which lies behind the Ratner moment of the chief executive of Whole Foods, who confessed last week that he had been selling “a bunch of junk”. What the organic chain store boss was trying to say, I think, is that a high-fat diet is as bad for you when the food has an “organic” sticker on it as when it doesn’t.

The general public, however, had already begun to call the organic bluff, perhaps one reason Whole Foods’ sales have suffered over three consecutive quarters in the United States and Prince Charles’s Duchy Originals has seen its profits slump. That noise – half-fart, half-howl – you heard last week was the organic balloon bursting.

As the global recession puts government aid budgets under pressure, and with the UN revealing a funding shortfall of nearly $5bn last week, calls are being made to expand the role of private philanthropy. There have even been suggestions that the wealthy should be given tax breaks to incentivise more private giving.

A new buzzword is “philanthrocapitalism“, a view that the talents and methods of successful capitalists should be applied to the “business” of social welfare and poverty alleviation because governments, traditional charities and NGOs are comparatively ineffective and inefficient. This is part of the “New Philanthropy”, the ascendancy of private foundations within public policy and international development, dominated by the Bill and Melinda Gates Foundation.

In 2007, the foundation spent $1.22bn (£718m) on its global health programme and $234m on its 700-plus staff and operations, a little less than the annual budget of the World Health Organisation. What Microsoft did in the software market, the foundation appears to be replicating in global health. Its reach covers an astounding spectrum of global health actors, and it has an active role in shaping their policies, plans and actions.

Between 1998 and 2007, 20 recipients accounted for about two thirds of the foundation’s total spend. They included the WHO and Unicef, public-private partnerships such as the Global Fund to Fight Aids, universities, key NGOs and even the World Bank. It sits on the governing structures of many global health institutions, and has the ear of government and business leaders worldwide.

The WHO, having been weakened as an independent multilateral agency over the past two decades, now has a private foundation as one of its biggest funders, which uses its financial leverage to guide the WHO in certain directions.

The influence of the Gates Foundation also has knock-on effects. NGOs and universities that are not recipients of its money or not aligned to its vision can become marginalised. Health issues it deems unimportant are sidelined. This is relevant, because the way the health problems of the poor are defined and prioritised is crucial in framing an effective response. But, unlike other big global health institutions, the foundation is unaccountable. It has no formal governing body. Though it has an advisory board and consults widely, some in the health community feel it only listens to what it wants to hear.

Given its widespread influence, the argument that private foundations built on private wealth need not be publicly accountable is mistaken. After all, most private foundations are publicly subsidised through tax breaks. Independent evaluation of private foundations is important because philanthropy can have unintended consequences. The health systems of poor countries are fragile, and it is not uncommon for misdirected aid to damage them further.

Accountability is also important because of potential conflicts of interest. After three decades of neoliberal orthodoxy coupled with the “public-private partnership” paradigm, which encourages corporate involvement in policy-making and promotes corporate social responsibility as an alternative to effective public regulation, the New Philanthropy offers the danger of extending the undue influence of private actors over public policy and institutions.

There is nothing inherently wrong with this sort of philanthropy, and there are many examples of it catalysing development and promoting social justice. In a global economy that increases the disparity between rich and poor, philanthropy and generosity need to be encouraged. But not at the expense of social justice, or as a substitute for a more effective public redistribution of wealth.

Threats to good governance and the accountable and democratic functioning of public institutions also need to be better recognised – and rigorously assessed. Historically, health has been built on the base of effective and accountable public bodies, coupled with technology and community empowerment. If the Gates Foundation’s strapline – “all lives have equal value” – is to be meaningful, it must strive harder for a fairer distribution of power and agency, and recognise its responsibility towards enabling democracy and good governance.

¿Cuánto vale ese halcón que tiene debajo del mostrador? Alan Bennett, el gran escritor inglés, oyó la pregunta cuando hacía cola en una freiduría del norte de Inglaterra. Desde su puesto en la larguísima cola no podía ver el mostrador, y tuvo que echar a volar su imaginación para deducir cómo podía estar aquella noble bestia atrapada en un sitio tan insólito. ¿Qué extraña circunstancia habría llevado a un halcón a parar debajo del mostrador de una tienda inglesa de pescado empanado y patatas fritas? ¿Se habría muerto el halcón y, echando de menos el inmenso cielo había acabado allí debajo? ¿Lo había disecado el encargado para levantar el interés de los visitantes, situándolo en el mostrador de su tienda? Y, en cualquier caso, ¿cómo podía haber ocurrido aquello?

La inteligencia de Alan Bennett, por fecunda que fuese, quedó inmovilizada ante el enigma que le suponía la presencia del animal en el mostrador, y dedicó los pocos minutos que le quedaban esperando en la cola a pensar en lo difícil que es entender el mundo de hoy, tan lleno de maravillas cambiantes que se multiplican con una rapidez apabullante, sin seguir ningún patrón lógico ni obedecer a ninguna disciplina racional. Cuando llegó al mostrador, Bennett se dió cuenta de que El Halcón no era más que una marca de cerveza.

Desde que oyó la anécdota, mi mujer siempre califica como «un halcón debajo del mostrador» a cualquier aspecto del mundo que nos rodea y que consideramos incomprensible.

Y son muchos. No puedo explicarme, por ejemplo, la popularidad de McDonald’s o CocaCola; tampoco la necesidad de tanta burocracia como la que aguantan los españoles o la estupidez de los lectores de Dan Brown. Pero tal vez el aspecto más desconcertante del mundo actual, por ser el más universal, es la excesiva y mórbida preocupación por la salud.

Escribo estas líneas en plena crisis -según dicen los propagadores profesionales de noticias alarmantes- de la supuesta pandemia de la influenza porcina -o gripe A/H1N1, como debemos llamarla para no molestar a los criadores de cerdos-. Resulta que ni es una crisis, ni una pandemia, ni creo que se trate siquiera de una enfermedad grave.

Acabo de escuchar a unas señoras estadounidenses, mientras se tomaban un vinito en la sala VIP del aeropuerto londinense de Heathrow, asegurar que, para tomar precauciones, ni siquiera van a hablar con un mexicano antes de que la enfermedad desaparezca. En el Reino Unido, donde cuando concluyo este texto hay aproximadamente media docena de enfermos, ninguno de ellos gravemente afectado, el Gobierno va a distribuir un panfleto en todos los hogares del país para informar a los ciudadanos sobre las medidas que hay que tomar en caso de caer enfermo. Entre los consejos que propone el Ejecutivo británico está el de formar grupos de vecinos para que si uno de ellos se encuentra en cuarentena, los demás le ayuden a hacer la compra u otros servicios amigables. Por otra parte, en Estados Unidos escuché en la radio a un experto aconsejando a los oyentes que no saliesen del país sin consultar a un médico -y es que en EEUU hay más casos de afectados que en cualquier otro país, incluido México-.

Los más enloquecidos se están poniendo mascarillas, mientras piden cita a los médicos con llamadas ansiosas sobre una gripe que, probablemente, ni les va a afectar, y que en caso de afectarles no les hará mucho daño. A mí supongo que me pondrán en cuarentena ya que cada vez que estornudo -lo que hago a menudo en esta época del año por la concentración de polen- suena al gruñido de un cerdo acatarrado.

Está claro que en el mundo desarrollado pretendemos ser demasiado sanos. Dejar de pensar en nuestras enfermedades nos liberaría para gozar más de la vida. Aceptar con dignidad un poco más de mala salud nos haría más felices, y nos ahorraría mucho dinero. Hoy en día, es absurdo todo lo que se gasta en buscar la salud perfecta. En marzo de este año en España se gastó algo menos de 1.100 millones de euros en medicamentos adquiridos con receta farmaceútica -un aumento de más del 9% respecto al mismo mes del año anterior-. Cabe preguntarse si la población española está sufriendo tanto que no es capaz de aguantar enfermedades a las que nuestros antepasados ni le hubieran hecho caso y por las que, por supuesto, no habrían gastado tanto dinero en medicamentos.

En el Reino Unido, el presupuesto para la salud pública en 2009 asciende al 9% del Producto Nacional Bruto y a más del 16% del presupuesto total. En Estados Unidos, el aumento en gastos relacionados con asuntos de salud está en torno al 6% anual, mientras que la economía se está estancando. La situación es claramente insostenible, y es consecuencia de unos valores cuanto menos extraños, ya que sería más lógico y más útil para la humanidad reducir el presupuesto de la salud pública en los países desarrollados -donde prolongamos nuestras vidas inútilmente y mimamos a nuestros hipocondríacos,- para repartir ese dinero a comunidades en zonas menos privilegiadas del mundo donde sí siguen padeciendo pestes horribles y niveles de mortalidad infantil escalofriantes.

Por supuesto, no invertimos tanto en nuestra salud para estar más sanos: ya estamos sobrada y escandalosamente sanos, y la preocupación por la salud es en sí misma una enfermedad que fomentamos e impulsamos despilfarrando tanto dinero. Nuestros motivos no son sanitarios, ni saludables, sino políticos, sociales, económicos, y psicológicos.

Los políticos buscan votos sobornando a los electores con píldoras y pastillitas. Las instituciones intentan edificar una morada social cuidando y nutriendo una cultura de vocación social. Las industrias farmacéuticas y de ingeniería médica siembran ansiedad por la salud para ganar dinero. La gente quiere medicinas y camas de hospital como muestras del cariño que le falta en sus relaciones con sus parejas e hijos.

En el fondo, la preocupación por la salud responde a nuestra necesidad básica de compartir valores con nuestros conciudadanos. Antes compartíamos patriotismo, religión, ideologías o valores morales. Hoy no nos queda nada de eso. En nuestras sociedades plurales, la sanidad es el único bien que atrae el respeto de casi todos. La salud es nuestra moralidad. Los hospitales y clínicas son nuestros templos. Los médicos son nuestros sacerdotes, y el presupuesto sanitario es la ofrenda que sacrificamos al gran ídolo e ideal de un cuerpo perfectamente sano.

Pensar en la salud de los demás es una virtud, hacerlo en la propia es un vicio. Por supuesto, es imprescindible, si queremos mantener una sociedad eficaz y una economía vigorosa, que dispongamos de una población trabajadora sana y bien nutrida. Para mantener una sociedad que valga la pena tenemos que dedicar un porcentaje suficiente de los impuestos de los ricos a la mejora de la salud de los gravemente enfermos, los niños, los pobres y los menos privilegiados. Pero para conseguir estos fines, no nos hace falta seguir mejorando tratamientos que ya son muy buenos, preocupándonos por alarmas provocadas por enfermedades de desconocido alcance, desarrollando nuevas tecnologías médicas excesivamente complejas y costosas, y gastando más tiempo en consultas y más dinero en los presupuestos sanitarios. Al contrario, tendríamos más dinero para cuidar a los más necesitados si los que estamos relativamente sanos dejáramos de acaparar tantos recursos.

Nos hace falta una revolución en los valores y en las expectativas. Busquemos valores más dignos sobre los que sostener una sociedad plural más allá de ese culto a la salud: la paz, por ejemplo, el respeto, el placer de conocer y experimentar culturas diversas. Dejemos de esperar que nuestra salud sea perfecta. Abracemos a las peripecias de la salud como oportunidades de sufrir callándose y de resistir al egoísmo. Ajustémonos a una vida incierta y peligrosa que pudiera ser corta pero que saldrá por cierto más interesante que una vida entregada al deseo de prolongarse. Enfrentémonos a la muerte como proceso natural, sin temores. Insistamos en no recurrir al médico ni al hospital sino por motivos auténticamente graves. Soportemos los achaques, aguantemos los dolores, las tensiones, las fatigas y los malos humores como episodios normales de una vida sana.

Intentemos seguir llegando a nuestros lugares de trabajo a pesar de los catarros y gripes y otras enfermedades cotidianas. Boicoteemos a las medicinas de marca y los tratamientos excesivamente sofisticados y caros. Renunciemos a la seguridad y la comodidad. Sustituyamos el aprecio a una vida entera, denodada y difícil. Si dejamos de pensar en la salud, seremos más sanos o, por lo menos, no nos daremos cuenta de que no lo somos, que al fin y al cabo es la misma cosa.

Por supuesto, otra gran peste vendrá a exterminarnos o a acabar con la vida de muchos millones de personas. El mundo de los microbios es tan mutable y tan volátil, y la evolución de los virus se desarrolla con tanta rapidez que es inevitable que algún día de estos aparecezca una nueva cepa para desafiar con éxito a todas nuestras medidas de resistencia. Pero la influenza porcina no la es. Hay que tratarla con desdén. Si seguimos reaccionando exageradamente a enfermedades desdeñables, lo más probable es que cuando nos toque la próxima Peste Negra, estemos tan hartos de esas alarmas que acabaremos rindiéndonos al desastre como los oyentes de Casandra o del niño que gritó «¡lobo!».

China’s food supply appears to be awash in the industrial chemical melamine. Dangerous levels have been detected not only in milk and eggs, but also in chicken feed and wheat gluten, meaning that melamine is almost impossible to avoid in processed foods. Melamine in baby formula has killed at least four infants in China and sickened tens of thousands more.

In response, the United States has blasted lax Chinese regulations, while the Food and Drug Administration, in a rare move, announced last week that Chinese food products containing milk would be detained at the border until they were proved safe.

For all the outrage about Chinese melamine, what American consumers and government agencies have studiously failed to scrutinize is how much melamine has pervaded our own food system. In casting stones, we’ve forgotten that our own house has more than its share of exposed glass.

To be sure, in China some food manufacturers deliberately added melamine to products to increase profits. Makers of baby formula, for example, watered down their product, lowering the amount of protein and nutrients, then added melamine, which is cheap and fools tests measuring protein levels.

But melamine is also integral to the material life of any industrialized society. It’s a common ingredient in cleaning products, waterproof plywood, plastic compounds, cement, ink and fire-retardant paint. Chemical plants throughout the United States produce millions of pounds of melamine a year.

Given the pervasiveness of melamine, it’s always possible that trace elements will end up in food. The F.D.A. thus sets the legal limit for melamine in food at 2.5 parts per million. This amount is indeed minuscule, a couple of sand grains in an expanse of desert that pose no real threat to public health. Moreover, the 2.5 p.p.m. figure is calculated for a person weighing 132 pounds — a cautious benchmark given that the average adult weighs 150 to 180 pounds.

But these figures obscure more than they reveal. First, while adults eat about one-fortieth of their weight every day, toddlers consume closer to one-tenth. Although scientists haven’t measured the differential impact of melamine on infants versus adults, it’s likely that this intensified ratio would at least double (if not quadruple) the impact of legal levels of melamine on toddlers.

This doubled exposure might not land a child in the hospital, but it could certainly contribute to the long-term kidney and liver problems that we know are caused by chronic exposure to melamine.

On a more concrete note, melamine not only has widespread industrial applications, but is also used to buttress the foundation of American agriculture.

Fertilizer companies commonly add melamine to their products because it helps control the rate at which nitrogen seeps into soil, thereby allowing the farmer to get more nutrient bang for the fertilizer buck. But the government doesn’t regulate how much melamine is applied to the soil. This melamine accumulates as salt crystals in the ground, tainting the soil through which American food sucks up American nutrients.

A related area of agricultural concern is animal feed. Chinese eggs seized last month in Hong Kong, for instance, contained elevated levels of melamine because of the melamine-laden wheat gluten used in the feed for the chickens that produced the eggs.

To think American consumers are immune to this unscrupulous behavior is to ignore the Byzantine reality of the global gluten trade. Tracking the flow of wheat gluten around the world, much less evaluating its quality, is like trying to contain a drop of dye in a churning whirlpool.

More ominous, the United States imports most of its wheat gluten. Last year, for instance, the F.D.A. reported that millions of Americans had eaten chicken fattened on feed with melamine-tainted gluten imported from China. Around the same time, Tyson Foods slaughtered and processed hogs that had eaten melamine-contaminated feed. The government decided not to recall the meat.

Only a week earlier, however, the F.D.A. had announced that thousands of cats and dogs had died from melamine-laden pet food. This high-profile pet scandal did not prove to be a spur to reform so much as a red herring. Our attention was diverted to Fido and away from the animals we happen to kill and eat rather than spoil.

Frightening as this all sounds, the concerned consumer is not completely helpless. We can seek out organic foods, which are grown with fertilizer without melamine — unless that fertilizer was composted with manure from animals fed melamine-laden feed (always possible, as the Tyson example suggests).

We could further protect ourselves by choosing meat from grass-fed or truly free-range animals, assuming the grass was not fertilized with a conventional product (something that’s also very hard to know).

But as all the caveats above indicate, these precautions will only go so far. Melamine, after all, points to the much larger relationship between industrial waste and American food production. Regulations might be lax when it comes to animal feed and fertilizer in China, but take a closer look at similar regulations in the United States and it becomes clear that they’re vague enough to allow industries to “recycle” much of their waste into fertilizer and other products that form the basis of our domestic food supply.

As a result, toxic chemicals routinely enter our agricultural system through the back channels of this under-explored but insidious relationship.

So, sure, let’s keep the heat on China. And, yes, let’s take with a big dose of skepticism the Chinese government’s assurances that they’re improving the food supply.

At the same time, though, instead of delivering righteous condemnation, the United States should seize upon the melamine scandal as an opportunity to pass federal fertilizer standards backed by consistent testing for this compound, which could very well be hidden in plain sight.

Numerous media reports followed a federal task force’s announcement this month that there is insufficient medical evidence to assess the risks and benefits of prostate cancer screening in men younger than 75 and that doctors should stop testing men over age 75 [" U.S. Panel Questions Prostate Screening; 'Dramatic' Risks for Older Men Cited," front page, Aug. 5].

It’s important to note that consideration was not given to the overwhelming body of emerging evidence that screening with PSA tests and digital rectal exams saves lives. Rates of death from prostate cancer and rates of diagnosis at advanced stages have decreased markedly since testing became widespread.

As a physician and a researcher specializing in prostate cancer, I worry that this recommendation will result in delays in potentially lifesaving treatment and possibly the unnecessary loss of life.

The U.S. Preventive Services Task Force did not even recommend screening for men at higher risk because of race or family history. The task force reasoned that screening might harm more men than it helps and that in men over 75 there was moderate certainty that the harm outweighs the benefits.

Physicians and patients who are concerned about preventing prostate cancer deaths choose to screen with prostate-specific antigen (PSA) tests because an inconclusive but increasingly compelling body of evidence shows that the screening reduces suffering and death from prostate cancer — the second-leading cause of cancer death among men in the United States.

Numerous studies have shown that PSA-based tests, such as those that detect increases in PSA over time and the percentage of PSA floating free in the blood, help to decrease unnecessary biopsies and also identify men with the most aggressive tumors so that they can receive timely treatment.

Eliminating screening also eliminates the possibility for early diagnosis and curative treatment in healthy men. Until we can prevent prostate cancer or cure patients at advanced stages of the disease, the only practical strategy for reducing death rates is early diagnosis and effective treatment. Because this tumor arises silently and often passes into an incurable stage before symptoms occur, the only way to detect it early is through screening.

Both the American Urological Association and the American Cancer Society recommend offering screening beginning at age 50 in men with a life expectancy of 10 years. High-risk men, such as African Americans and those with a strong family history of prostate cancer, are urged to consider screening at an earlier age. The National Comprehensive Cancer Network’s guidelines recommend that screening begin at age 40. These guidelines include emerging evidence to help guide physicians and patients in their diagnostic and treatment decisions. These organizations, unlike the U.S. Preventive Services Task Force, have urologists on their panels who see firsthand the ravages of prostate cancer.

Consider that in the United States alone, the rate of advanced cancer at the time of diagnosis has fallen 75 percent since the PSA screening era began, and age-adjusted prostate cancer death rates have declined 35 percent. Statistical studies suggest that 45 to 70 percent of this decrease is due to PSA screening.

Evidence from U.S. cancer registries shows less advanced cancer and lower prostate cancer death rates in regions where PSA testing is more prevalent.

On a global scale, prostate cancer death rates have decreased in countries where PSA screening and active treatment are typically practiced and have remained stable or increased in countries where screening and active treatment are not practiced.

PSA tests are a powerful marker for the risk of developing prostate cancer and dying from it. Reports of over-diagnosis and over-treatment are exaggerated. More often, prostate cancer is diagnosed too late rather than “too early.”

If screening detected only harmless cancers, treating them could not produce the striking decline in prostate cancer death rates that has occurred. We should combat the risk of over-diagnosis through continued research for improving the accuracy of screening and high-quality treatment.

This misguided recommendation, and the resulting media coverage, could give reluctant men an excuse to postpone or forgo screening. The consequence might be that many men die of prostate cancer unnecessarily. Men should follow the recommendations of the American Urological Association, the American Cancer Society and the National Comprehensive Cancer Network, all of which recommend screening for early detection and treatment of prostate cancer.

Here’s a concept you’ve probably never heard of: “viral sovereignty.” This extremely dangerous idea comes to us courtesy of Indonesia’s minister of health, Siti Fadilah Supari, who asserts that deadly viruses are the sovereign property of individual nations — even though they cross borders and could pose a pandemic threat to all the peoples of the world. So far “viral sovereignty” has been noted almost exclusively by health experts. Political leaders around the world should take note — and take very strong action.

The vast majority of repeated avian flu outbreaks the past four years, in both humans and poultry, have occurred in Indonesia. At least 53 types of H5N1 bird flu viruses have appeared in chickens and people there, the World Health Organization has reported.

Yet, since 2005, Indonesia has shared with the WHO samples from only two of the more than 135 people known to have been infected with H5N1 (110 of whom have died). Worse, Indonesia is no longer providing the WHO with timely notification of bird flu outbreaks or human cases. Since 2007, its government has openly defied International Health Regulations and a host of other WHO agreements to which Indonesia is a signatory.

Moreover, the Indonesian government is threatening to close down U.S. Naval Medical Research Unit Two (NAMRU-2), a public health laboratory staffed by Indonesians and U.S. military scientists. NAMRU-2 is one of the world’s best disease surveillance facilities, and it provides health officials worldwide with vital, transparent information. The Indonesian government has accused NAMRU-2 scientists of everything from profiteering off its “sovereign” viruses to manufacturing the H5N1 bird flu in an alleged biological warfare scheme. There is no evidence to support these outlandish claims.

A year ago, Supari’s assertions about “viral sovereignty” seemed to be odd yet individual views. Disturbingly, however, the notion has morphed into a global movement, fueled by self-destructive, anti-Western sentiments. In May, Indian Health Minister A. Ramadoss endorsed the concept in a dispute with Bangladesh. The Non-Aligned Movement — a 112-nation organization that is a survivor of the Cold War era — has agreed to consider formally endorsing the concept of “viral sovereignty” at its November meeting.

Indonesia argues that a nation’s right to control all information on locally discovered viruses should be protected through the same mechanisms that the U.N. Food and Agriculture Organization uses to guarantee poor countries’ rights of ownership and patents on the seeds of its indigenous plants. Under the FAO seed accord, a nation can register plants, share their seeds and derive profits from products made from the botanicals. This useful policy reduces exploitative practices that sometimes enable multinational corporations and wealthy governments to obtain outrageous profits from indigenous agriculture.

It is dangerous folly, however, to extend this policy to viruses. If the concept of “viral sovereignty” had been applied to AIDS 25 years ago, we would not have central repositories of thousands of varieties of HIV today; these allow scientists to test drugs and vaccines against all the different strains of the AIDS virus. It is even more ludicrous to extend the sovereignty notion to viruses that, like flu, can be carried across international borders by migratory birds.

In this age of globalization, failure to make viral samples open-source risks allowing the emergence of a new strain of influenza that could go unnoticed until it is capable of exacting the sort of toll taken by the pandemic that killed tens of millions in 1918. As the world learned with the emergence of severe acute respiratory syndrome (SARS) — which first appeared in China in 2002 but was not reported by Chinese officials until it spread to four other nations — globally shared health risk demands absolute global transparency.

There is strong evidence from a variety of sources that forms of the bird flu virus circulating in Indonesia are more virulent than those elsewhere and in a few cases may have spread directly from one person to another. The WHO has tried for two years to accommodate Indonesia, without success. Under pressure from scientists worldwide, Indonesia agreed in June to share genetic data on some of its viral samples but not the actual microbes. Without access to the viruses, it is impossible to verify the accuracy of such genetic information or to make vaccines against the deadly microbes.

Outrageously, Supari has charged that the WHO would give any viruses — not just H5N1 — to drug companies, which in turn would make products designed to sicken poor people, in order “to prolong their profitable business by selling new vaccines” (a charge oddly reminiscent of the plot of John le Carré’s novel “The Constant Gardener”). The WHO has elicited pledges from the world’s major drug companies not to exploit international repositories of genetic data for commercial benefit, but this has not satisfied Indonesia.

Indonesia’s claim that NAMRU-2 is a biological weapons facility must be confronted head-on. The U.S. ambassador in Indonesia, Cameron Hume, is actively trying to prevent a catastrophe. So far, there has been insufficient support from senior Washington officials. They must get involved. And China, in particular, must use its substantial influence with Jakarta on this issue — in its own self-interest.

The failure to share potentially pandemic viral strains with world health agencies is morally reprehensible. Allowing Indonesia and other countries to turn this issue into another rich-poor, Islamic-Western dispute would be tragic — and could lead to a devastating health crisis anywhere, at any time.

El cocinero Santi Santamaria ha desatado un debate sobre lo que es y debería ser nuestra cocina, y el papel que pueden tener en ella los aditivos alimentarios. Los resultados gastronómicos del trabajo de los cocineros son una cuestión de gustos, y las diferentes visiones sobre si la cocina debe ser tradicional o creativa e innovadora, no tienen que ser excluyentes por fuerza, del mismo modo que la pintura puede ser figurativa o abstracta por un lado, y buena o mala por el otro, y todas las combinaciones son posibles.
Ahora bien, respecto al papel de la tecnología en la elaboración de los alimentos y en su seguridad, hay que tener en cuenta datos científicos y no percepciones emocionales. Estos datos no siempre son verdades absolutas, pero solo con ellos podemos valorar objetivamente los hechos. Los tratamientos tecnológicos introducen en los alimentos cambios controlados para hacerlos más seguros y estables, o más nutritivos y sabrosos. Es cierto que algunos procesos –calentar, por ejemplo– pueden disminuir el contenido de algún nutriente, pero eso pasa más en la cocina que en la industria, porque la industria puede controlarlo mejor. Hacer chup-chup sin control al cocer un plato un buen rato es demoledor para la vitamina C, por ejemplo, algo que podemos compensar comiendo fruta o verdura fresca.
Las industrias alimentarias son empresas que buscan, entre otras cosas, el beneficio económico, como los restaurantes, pero no son laboratorios misteriosos en los que se hacen alimentos sintéticos, sino grandes cocinas que hacen el trabajo que no podemos o no queremos hacer, y la interrelación cocina-industria no es una perversión del tratamiento de los alimentos, si las cosas se hacen bien.
Los aditivos alimentarios son un recurso tecnológico más, y se puede hacer un buen uso o un mal uso de ellos, pero, con datos científicos en la mano, no tiene sentido hacer una valoración negativa de ellos en bloque, ni en la industria ni en la cocina. Son productos añadidos para mejorar la estabilidad o los caracteres sensoriales de los alimentos (color, sabor, aroma, textura). Su uso tiene que ser siempre restringido y controlado, y solo se permite si el efecto buscado no se puede lograr por técnicas físicas (calentar, congelar, deshidratar, agitar…). Un ejemplo puede ser esclarecedor. Como la mayonesa hecha en casa, con tiempo y buena mano, no hay nada. Pero si no podemos hacerla, la industria nos proporciona una mayonesa de calidad, estable y que no se corta, gracias a la tecnología y los aditivos. La cocina puede usarla si quiere disponer de mayonesas diferentes de las que comemos en casa.

TAMPOCO es correcto asociar aditivo con riesgo, ya que los productos autorizados como aditivos han sido rigurosamente evaluados, y las dosis que se autorizan son muy inferiores a las que se ha demostrado que no tienen efectos negativos. Muchos productos naturales, como la cafeína, no superarían hoy el examen que han superado muchos aditivos, y que quede claro que, si no abusa de ellos, el café y el té son bebidas muy adecuadas.
Es evidente que la seguridad absoluta no existe, en ningún producto ni actividad humana, pero hay que tener muy presente que los efectos de las sustancias, beneficiosos o tóxicos, dependen de la dosis. Aquí también hay que precisar que hay aditivos de origen natural y otros sintéticos, pero que considerar que lo que es natural o biológico es bueno, y lo que es sintético o químico es malo es una visión emocional, no racional ni científica de los hechos. El organismo distingue lo que le resulta útil o nocivo independientemente de su origen. Como decía Francisco Grande Covián, “nada más natural que el microbio causante del cólera y nada más químico que el cloro, pero gracias a que cloramos las aguas no nos morimos de cólera”.
Por otra parte, tratar los alimentos en la cocina, incluso con los métodos más tradicionales, puede generar sustancias tóxicas. Cuando hacemos a la brasa o al horno un alimento, sin ningún aditivo, y va cogiendo el color y el aroma del tostado, se forman compuestos que, considerados de forma aislada, son cancerígenos. Tampoco superarían la evaluación de seguridad de los aditivos. Eso no quiere decir que comer de vez en cuando carne a la brasa sea cancerígeno, sino que abusar de alimentos tostados es un factor que incrementa el riesgo de cánceres, que, por otra parte, tienen causas complejas. ¿También lo tienen que indicar, esto, los restaurantes? ¿Y por qué no el contenido de sal o colesterol, importante para muchas personas?

CONSEGUIR ciertos tipos de platos de características innovadoras o singulares solo es posible con aditivos, que se han de utilizar con cuidado y conocimiento de causa. Si su uso se generaliza habrá que controlarlo, y el cliente ya elegirá. No se obliga a nadie a ingerirlos, y, obviamente, las posibilidades de la cocina sin aditivos son inmensas. Existe el derecho a la información, como en las etiquetas de los alimentos. Pero si seguimos desconfiando de los productos de la industria alimentaria, y ahora también de los de la cocina, tal vez, con el tiempo, cuando vayamos a un restaurante tendremos que pedir el prospecto, no la carta.

It is unusual for politicians to face up to the obvious, but the Scottish Executive seems for once to have done so: it has recognised what has long stared it in the face, namely that dishing out methadone to drug addicts is not the answer to their problems or to the problems that they cause society. A different approach is needed.

Perhaps in 100 years historians will wonder why so many of the governing elite, from senior doctors to Cabinet ministers, persisted for so long in the belief that doling out methadone was the answer. The explanation, I think, will be that they wilfully misunderstood the nature of the problem.

Many years ago I used to dole out methadone like the best (or the worst) of them. This was before I thought at all deeply about the question of drug addiction and accepted uncritically all that I had been taught about it by doctors senior to me. I began to change my opinion when I worked in prison where it was the clinical policy to give addicts methadone. I noticed that, far from creating an atmosphere of contentment and satisfaction, it created one of perpetual tension and irritation. Shortly after having been prescribed a dose, the prisoner would return and say, in an intimidating fashion: “It’s not holding me, doc, it’s just not holding me,” and sometimes announce that, unless he was prescribed more, he would end up attacking other prisoners, and then it would be the doctor’s fault.

In Scotland the great majority of addicts prescribed methadone by their doctors never stop taking it, and most of them take other drugs as well. A particularly dangerous combination of drugs is methadone and benzodiazepines (drugs such as Valium), and yet drug clinics and other doctors persist in prescribing this often fatal combination – largely, I suspect, because they are too frightened of their patients to refuse them anything.

The number of people admitted to hospital having taken a dangerous overdose of methadone (556 in 2006-07) is greater, proportionately, than the number of people admitted to hospital having taken a dangerous overdose of heroin (1,530 cases). In Dublin recently, more people have died of methadone poisoning than of heroin overdose. The supposed cure causes as many problems as the supposed disease. If addicts prescribed methadone are given the opportunity to divert it on to the black market, they will: which suggests that they do not really need it in the first place.

In France, addicts are often prescribed a different drug, buprenorphine, which soon became the street drug of preference in Finland, to which it was illegally re-exported by the addicts. More recently, a huge epidemic of buprenorphine addiction has occurred in Georgia (the ex-Soviet republic), numbering scores of thousands of addicts, who take buprenorphine diverted from France. If the addicts really needed the drugs, they would take them rather than divert them on to a black market.

In the prison in which I used to work, a buprenorphine tablet that had been prescribed for an addict to alleviate the symptoms of withdrawal from heroin on arrival in the prison, and which an addict had put in his mouth and spat out for sale to another prisoner, was known as a “furry” because of its rough surface. Again, this suggests that addicts did not really need what they were prescribed, and that the whole basis of prescription was flawed.

The fundamental error that the Scottish Executive has now admitted is in having regarded addiction to heroin as a technical medical problem, to be solved by technical medical means. But that old approach amounts to a surrender to blackmail: give me what I want or I will continue to behave badly and to hold you responsible for the ill-effects of my own behaviour.

Suppose we gave money to burglars to induce them to stop burgling. No doubt most of them would stop for a length of time depending upon how much we gave them. But this does not mean that money is the treatment of the dreadful disease of burglary, or because we prevented certain individuals from continuing to burgle it means that we had reduced the disease of burglary in society as a whole. Rather, we would have encouraged its spread.

This is precisely the logic that has been applied to drug addiction. Just how precisely is evident from the Government’s recent declared policy that clinics should now give drug addicts money or other rewards for not taking drugs (as least as proved by drug-free urine samples, something experienced drug addicts have long learnt to provide). This is the first time in the history of medicine, so far as I know, that bribery has been considered a medical treatment.

Contrary to what everyone supposes, withdrawal from heroin is not a serious medical condition – unlike, say, withdrawal from alcohol when it results in delirium tremens (the DTs). The suffering is grossly exaggerated and, in so far as it is genuine, is largely produced by anticipatory anxiety that is itself the consequence of years of mythologising the fearsomeness of withdrawal.

Addiction to heroin is a medical problem only to a minor extent, which is why predominantly medical means will never solve the problem. Most of Britain’s 300,000 addicts are drawn from broken families, have a poor education, are without much hope for (or for that matter fear of) the future and have no cultural life, intellectual interests or religious belief. Delusory euphoria – the paradise at three pence a bottle that De Quincey described in his Confessions of an English Opium Eater – is the best that they think that they can hope for in life. This is not a medical problem. Where addiction is concerned, it is time to throw physic to the dogs.

Cuando el brutal encarecimiento de los alimentos provoca protestas en medio mundo y se habla ya de crisis alimentaria universal, puede parecer muy frívola una polémica entre cocineros de ringorrango que no dan de comer por menos de 100 o 150 euros. Y puede causar asombro la repercusión mediática y popular de este debate, cuando el 99% de la población no ha catado ni catará nunca un plato elaborado por Santi Santamaría o por Ferran Adrià… Pero, en más de un sentido, esta pelea entronca con aquella crisis y está sirviendo -en medio del estruendo y de las descalificaciones- para colocar sobre el tapete algunas cuestiones que van a pesar en el futuro sobre la forma de alimentarnos y la calidad de lo que comemos.

Naturalmente, el morbo del asunto nace de la decisión de Santamaría de buscar la confrontación en el terreno de la salubridad de la alta cocina moderna, al cuestionar en su libro La cocina al desnudo (Ed. Temas de Hoy) los efectos sobre la salud de aditivos que emplean Adrià y otros muchos modernistas. Y ha ardido Troya. Luego, el propio tres estrellas catalán matizaba su discurso en una agitada conferencia de prensa, pero lo matizaba… de aquella manera: «Yo no digo a nadie que no use esos productos, digo que informe. Yo no digo que son tóxicos, digo que tienen consecuencias indeseables». Y remachaba que lo preocupante son las altas dosis de algunos aditivos.

La realidad, en pocas palabras, es que Santamaría se ha equivocado de objetivo, dejándose llevar por la pasión con la que desde hace años combate el tecnicismo culinario. Carecen de peligro los espesantes y gelificantes que permiten hacer esas cosas tan curiosas (esferificaciones, gelatinas calientes…) y que concitan sus iras, o sazonadores como el glutamato monosódico. Más interesante es su propuesta de que los menús indiquen todos los ingredientes (como en Alemania, donde deben citarse los aditivos, o en Italia, donde debe avisarse de todo lo que sea congelado) si la llevamos al terreno de la cocina barata, muy industrializada, a base de conservas diversas, que se ofrece en comedores escolares o empresariales y demás refectorios públicos. Pero, claro, ahí no habría morbo ni titulares…

En el terreno de la alta cocina, donde se emplean en dosis homeopáticas aditivos de calidad, los verdaderos expertos lo tienen claro. (Y, por cierto, El Periódico descubría ayer aditivos de ésos que Santamaría denuncia… ¡hasta en recetas publicadas por Santamaría!).

Fuchsia Dunlop, escritora y cocinera británica, es sin duda la persona que mejor conoce en Occidente la cocina china; ha sido la única graduada extranjera en toda la historia del Instituto de Alta Cocina de Sichuan. El año pasado explicaba en The New York Times cómo había vencido sus prejuicios negativos sobre el glutamato monosódico, descubierto hace exactamente un siglo por el científico japonés Kikunae Ikeda:

«Fabricado industrialmente, el glutamato es una forma químicamente limpia de uno de los compuestos umami [el quinto sabor de la cocina oriental] que deleitan nuestras papilas gustativas cuando se encuentran de manera natural en el queso, el jamón o las algas, igual que la sal es una forma limpia de la salinidad del agua marina y el azúcar blanco lo es del dulzor de la caña de azúcar. ¿Va a ser peor para nosotros que la sal o el azúcar refinados?».

Por su parte, el doctor Raimundo García del Moral, de la Facultad de Medicina de la Universidad de Granada y pionero de algunas de las técnicas culinarias de vanguardia que Santamaría reprueba, acaba de escribir (en el blog de internet www.lomejordelagastronomia.com) sobre los polímeros hidrocarbonados:

«A excepción de la metilcelulosa (que es un producto completamente atóxico procedente de la transformación química de la celulosa), los hidrocoloides empleados en la cocina de vanguardia (agar agar, alginatos, carragenanos, etcétera) se obtienen a partir de algas naturales, que curiosamente son utilizadas con profusión en la carta del restaurante Can Fabes [de Santamaría] y constituyen la base de la cocina japonesa, una de las más tradicionales y sanas del mundo. La diferencia principal entre los hidrocoloides de las algas y el almidón de los cereales, estructuralmente bastante similares, es que los primeros son acalóricos e insípidos, mientras que el segundo tiene gran poder energético -es decir, engorda- y cierto sabor dulce puesto que la enzima amilasa de la saliva lo transforma en glucosa. Por este último motivo, los hidropolímeros coloidales son una sólida alternativa para la dieta en la diabetes y la obesidad, que son las dos plagas más amenazadoras para la civilización del siglo XXI».

Según García del Moral, «la supuesta acción laxante de la metilcelulosa argüida para oponerse a su empleo en cocina, donde se usa a dosis tan bajas como 250 mg por plato, no es sino un efecto fibra equivalente al producido por la celulosa y que en condiciones normales es muy positivo para la mejora del tránsito intestinal».

Casi no hace falta añadir que las exquisitas setas silvestres están casi totalmente compuestas por celulosa, por lo que un festín otoñal o primaveral a base de hongos puede acarrear serios problemas digestivos. O que, consumidos en cantidades excesivas, el azúcar, la mantequilla o la carne de buey tienen efectos muy perniciosos. O que los largos menús de degustación de algunos restaurantes modernos que practican una cocina con raíces entroncada en el terruño, como la que defiende Santamaría, resultan ser una ruta del colesterol (la expresión es de García del Moral).

Más interesante para quien esté interesado por la gastronomía o sencillamente por la alimentación sería ver a dónde nos llevan las tendencias culinarias ahora en pugna. No nos engañemos: como la Fórmula Uno prefigura lo que luego se extiende a toda la industria del automóvil, la alta cocina lleva dos siglos marcando los cambios en la cocina burguesa y, a la larga, en todo lo que se come. Además, no olvidemos que la actual crisis alimentaria, como recalca Amartya Sen, Nobel de Economía, no nace de alguna hambruna bíblica, sino del encarecimiento provocado por un aumento de la demanda: es decir, se va viviendo mejor en el mundo, y se va consumiendo más. Se ha comido para poder vivir. Hoy, cada vez más, se puede vivir con la aspiración de comer mejor.

Existen, es cierto, dos escuelas en la cocina pública creativa. Una de ellas, más proclive a recordar sabores tradicionales a una clientela muchas veces nostálgica y a entroncarse en los productos de cada territorio, aunque desde la depuración técnica y la precisión de las cocciones que nos legó la Nueva Cocina francesa desde hace cuatro decenios. Es la de Santamaría, entre otros: nada que ver, por cierto, con el tradicionalismo puro en el que algunos despistados le colocan estos días. La otra está inspirada a la vez por algo muy oriental como es la obsesión con la textura de los alimentos (tan importante para los chinos y los japoneses como el sabor… o más) y por los estudios del físico-químico francés Hervé This. Explora sin cesar las formas de crear («deconstruir», según sus críticos; «construir», según This) platos y productos nuevos y sorprendentes, más por la textura y la apariencia que por los aromas o sabores. Ahí están Adrià, Andoni Luis Aduriz, Quique Dacosta, el francés Pierre Gagnaire, el británico Heston Blumenthal y muchos más.

Lo que sucede es que resulta artificioso establecer una frontera radical, nítida, entre las dos tendencias. La mayoría de los cocineros de terruño recurre a innovaciones técnicas, incluidos ciertos aditivos; la mayoría de los deconstructivistas, moleculares (expresión de This) o tecnoemocionales (feo palabro, promovido por un periodista, que parece extraído de un spot de Seat) hacen guiños a platos tradicionales y a productos de su entorno. Muy pocos, como Adrià, se han lanzado a la creación pura, sin echar el menor vistazo atrás a tradiciones o nostalgias. De ahí, a veces, saltos al vacío y resultados caricaturescos, que sí son criticables.

Este cronista siempre se ha sentido más cercano a la cocina que evoluciona que a la que rompe con todo. Pero ninguna es rechazable, ni es aceptable el poner puertas al campo como parece pretender ese gran cocinero pero equivocado ensayista que es Santamaría. No podemos ignorar tampoco el atractivo que hoy ejercen también -¡y no digamos entre los jóvenes!- cocinas exóticas como la japonesa o la tailandesa, sin mayor relación con nuestra memoria gustativa que la de Adrià. La innovación y la fusión han movido el progreso culinario. Y, si se generalizan la carestía o incluso la desaparición de tantos productos nobles que hoy observamos a diario, podemos estar seguros de que las técnicas moleculares se extenderán rápidamente para hacer más paladeables los pescados de piscifactoría, los pollos industriales y demás componentes, ¡ay!, de nuestra dieta del mañana.

Habrá que hacer una resonancia para conocer el alcance de la lesión”, o bien “su rodilla será operada mediante una artroscopia”, son frases que hemos leído a menudo en las secciones deportivas de los periódicos, referidas a las lesiones de nuestros ídolos deportivos. Pero ¿a qué embarazada no se le practica al menos una ecografía?, o ¿en qué entorno familiar no hay algún miembro portador de una prótesis de rodilla, una lente intraocular, un marcapasos o un implante dental? Todos estos métodos de diagnóstico y estos implantes quirúrgicos han revolucionado la práctica de la medicina y de la cirugía a lo largo de estos últimos cuarenta años. Aún es posible acordarse de cuando el diagnóstico de nuestro médico de cabecera sólo se podía basar en la auscultación mediante estetoscopio, toser y decir treinta y tres, un cuidadoso análisis de la sintomatología, y en ciertos casos la visita incluía “pasar por la pantalla”, lo cual significaba observar los pulmones del paciente mediante un vetusto aparato de rayos X. Este profundo cambio se ha producido gracias al desarrollo de lo que hoy denominamos la bioingeniería, consistente en la integración interdisciplinar entre la medicina y la cirugía con las ciencias básicas (física, química, biología y matemáticas) y las ingenierías.

A pesar de que los sistemas de salud de las sociedades más avanzadas disponen ya de sofisticados recursos de lo que denominamos tecnologías médicas, las posibilidades de evolución son enormes, puesto que debemos esperar espectaculares progresos a corto y a medio plazo. Los más recientes avances en biología celular y molecular combinados con la aparición de las nanotecnologías permiten pensar y soñar en nuevos métodos de diagnóstico más personalizados, más precisos y más precoces, así como en nuevas terapias también mucho más personalizadas y a su vez regeneradoras del organismo.

La farmacia y la biotecnología no sólo vienen desarrollando nuevos principios activos que están en la base de nuevos medicamentos innovadores más eficientes y más eficaces, sino que dentro del campo de la nanomedicina, el desarrollo de nuevas tecnologías de liberación controlada de fármacos permitirá transportar y liberar con precisión el medicamento allí donde es requerido, sin afectar a otros tejidos u órganos. Así, nanopartículas inteligentes podrán acceder específicamente a las células enfermas y no a las demás.

Diagnosticar precozmente una enfermedad es un primer paso para poder vencerla, y las nanotecnologías desempeñarán aquí un papel protagonista. Técnicas de biofotónica permitirán detectar ópticamente proteínas relacionadas con ciertas enfermedades. Por su parte, micro o nanosensores con anticuerpos específicos podrán detectar de forma irrefutable la presencia de moléculas marcadoras en el estado más incipiente de la enfermedad. Sistemas de lab-on chip permitirán detectar, de forma inmediata, la presencia de bacterias patógenas utilizando cantidades muy pequeñas de fluidos corporales.

A los conceptos de sustitución o reparación de tejidos u órganos dañados se ha añadido recientemente el de su regeneración, lo que se conoce como medicina regenerativa. En general, la sustitución o reparación de tejidos se ha llevado a cabo mediante la implantación de dispositivos quirúrgicos. Su integración en el tejido circundante y su estabilidad a largo plazo podrán abordarse con garantías con la aplicación de las nanotecnologías, que permitirán controlar y modificar física y químicamente las superficies, ya sea de implantes ortopédicos, o bien de stents cardiovasculares. De forma alternativa, el concepto de regeneración se ha ido abriendo paso a medida que se ha ido entendiendo el potencial de las células madre. Inicialmente, la ingeniería de tejidos proponía cultivar células del paciente sobre matrices tridimensionales de materiales biodegradables, de manera que al implantar el conjunto material-células se evitara el rechazo y se regenerara el tejido dañado. Al comprenderse que prácticamente todos los tejidos contienen sus propias células madre, la estrategia ha empezado a cambiar y actualmente se busca poder estimularlas allí donde se encuentren. Para ello es necesario disponer de materiales biodegradables que contengan moléculas señalizadoras que permitan activar a las células madre existentes.

El médico del 2050 dispondrá de una variedad tan extensa de tecnologías para el diagnóstico y la terapia, que la práctica clínica cambiará de forma casi inimaginable, tanto desde su vertiente como desde la del paciente. Será la bioingeniería la responsable de este cambio, y por ello la bioingeniería es hoy posiblemente uno de los campos de investigación más estimulantes, pues su naturaleza realmente interdisciplinar propone retos que parecen casi de ficción mientras que la propuesta es la de resolverlos por la vía de la ciencia.

The idea that cholesterol plays a key role in heart disease is so tightly woven into modern medical thinking that it is no longer considered open to question. This is the message that emerged all too clearly from the recent news that the drug Vytorin had fared no better in clinical trials than the statin therapy it was meant to supplant.

Vytorin is a combination of cholesterol-lowering drugs, one called Zetia and the other a statin called Zocor. Because the two drugs lower LDL cholesterol by different mechanisms, the makers of Vytorin (Merck and Schering-Plough) assumed that their double-barreled therapy would lower it more than either drug alone, which it did, and so do a better job of slowing the accumulation of fatty plaques in the arteries — which it did not.

Heart disease specialists who were asked to comment on this turn of events insisted that the result implied nothing about their assumption that LDL cholesterol is dangerous, only about whether it is always medically effective to lower it.

But this interpretation is based on a longstanding conceptual error embedded in the very language we use to discuss heart disease. It confuses the cholesterol carried in the bloodstream with the particles, known as lipoproteins, that shuttle that cholesterol around. There is little doubt that certain of these lipoproteins pose dangers, but whether cholesterol itself is a critical factor is a question that the Vytorin trial has most definitely raised. It’s a question that needs to be acknowledged and addressed if we’re going to make any more headway in preventing heart disease.

To understand the distinction between cholesterol and lipoproteins it helps to know something of the history of cholesterol research.

In the 1950s, two hypotheses competed for attention among heart disease researchers. It had been known for decades that cholesterol was a component of atherosclerotic plaques, and people who have a genetic disorder that causes extremely high cholesterol levels typically have clogged arteries and heart attacks. As new technology enabled them to look more closely at lipoproteins, however, researchers began to suspect that these carrier molecules might play a greater role in cardiovascular disease than the cholesterol inside them. The cholesterol hypothesis dominated, however, because analyzing lipoproteins was still expensive and difficult, while cholesterol tests were easily ordered up by any doctor.

In the late 1960s, biochemists created a simple technique for measuring, more specifically, the cholesterol inside the different kinds of lipoproteins — high-density, low-density and very low-density. The National Institutes of Health financed a handful of studies to determine whether these “cholesterol fractions” could predict the risk of cardiovascular disease. In 1977, the researchers reported their results: total cholesterol turned out to be surprisingly useless as a predictor. Researchers involved with the Framingham Heart Study found that in men and women 50 and older, “total cholesterol per se is not a risk factor for coronary heart disease at all.”

The cholesterol in low-density lipoproteins was deemed a “marginal risk factor” for heart disease. Cholesterol in high-density lipoproteins was easily the best determinant of risk, but with the correlation reversed: the higher the amount, the lower the risk of heart disease.

These findings led directly to the notion that low-density lipoproteins carry “bad” cholesterol and high-density lipoproteins carry “good” cholesterol. And then the precise terminology was jettisoned in favor of the common shorthand. The lipoproteins LDL and HDL became “good cholesterol” and “bad cholesterol,” and the lipoprotein transport vehicle was now conflated with its cholesterol cargo. Lost in translation was the evidence that the causal agent in heart disease might be abnormalities in the lipoproteins themselves.

The truth is, we’ve always had reason to question the idea that cholesterol is an agent of disease. Indeed, what the Framingham researchers meant in 1977 when they described LDL cholesterol as a “marginal risk factor” is that a large proportion of people who suffer heart attacks have relatively low LDL cholesterol.

So how did we come to believe strongly that LDL cholesterol is so bad for us? It was partly due to the observation that eating saturated fat raises LDL cholesterol, and we’ve assumed that saturated fat is bad for us. This logic is circular, though: saturated fat is bad because it raises LDL cholesterol, and LDL cholesterol is bad because it is the thing that saturated fat raises. In clinical trials, researchers have been unable to generate compelling evidence that saturated fat in the diet causes heart disease.

The other important piece of evidence for the cholesterol hypothesis is that statin drugs like Zocor and Lipitor lower LDL cholesterol and also prevent heart attacks. The higher the potency of statins, the greater the cholesterol lowering and the fewer the heart attacks. This is perceived as implying cause and effect: statins reduce LDL cholesterol and prevent heart disease, so reducing LDL cholesterol prevents heart disease. This belief is held with such conviction that the Food and Drug Administration now approves drugs to prevent heart disease, as it did with Zetia, solely on the evidence that they lower LDL cholesterol.

But the logic is specious because most drugs have multiple actions. It’s like insisting that aspirin prevents heart disease by getting rid of headaches.

One obvious way to test the LDL cholesterol hypothesis is to find therapies that lower it by different means and see if they, too, prevent heart attacks. This is essentially what the Vytorin trial did and why its results argue against the hypothesis.

Other such tests have likewise failed to confirm it. A recent trial of torcetrapib, a drug that both raises HDL and lowers LDL cholesterol, was halted midstream because the drug seemed to cause heart attacks and strokes rather than prevent them. Estrogen replacement therapy also lowers LDL cholesterol, but it too has failed to prevent heart disease in clinical trials. The same goes for eating less saturated fat.

So it is reasonable, after the Vytorin trial, to question the role of LDL cholesterol in heart disease. Not whether statins help prevent heart disease, but whether they work exclusively, or at all, by this mechanism.

There are numerous other ways in which statins might be effective. They reduce inflammation, which is now considered a risk factor for heart disease. They act to keep artery walls healthy. And statins act on lipoproteins as much as on the cholesterol inside them. They decrease the total number of low-density and very low-density lipoproteins in the blood, including the smallest and densest form of LDL, which is now widely believed to be particularly noxious.

Because medical authorities have always approached the cholesterol hypothesis as a public health issue, rather than as a scientific one, we’re repeatedly reminded that it shouldn’t be questioned. Heart attacks kill hundreds of thousands of Americans every year, statin therapy can save lives, and skepticism might be perceived as a reason to delay action. So let’s just trust our assumptions, get people to change their diets and put high-risk people on statins and other cholesterol-lowering drugs.

Science, however, suggests a different approach: test the hypothesis rigorously and see if it survives. If the evidence continues to challenge the role of cholesterol, then rethink it, without preconceptions, and consider what these other pathways in cardiovascular disease are implying about cause and prevention. A different hypothesis may turn out to fit the facts better, and one day help prevent considerably more deaths.

A lo largo del siglo pasado se produjo en Occidente un abandono casi total de la lactancia materna. En los años setenta, pocas madres daban el pecho más de un mes, y casi ninguna llegaba a los seis meses.

A ello contribuyeron numerosos factores:

- Normas absurdas sin base científica ( “diez minutos cada cuatro horas…”).

- Prácticas hospitalarias que dificultaban el inicio de la lactancia: separación entre madre e hijo, salas cuna, suero glucosado, horarios rígidos…

- La industria láctea, con una contundente publicidad dirigida tanto a las madres como a los profesionales.

- La moda. Durante siglos, en la mayor parte de Europa, las mujeres ricas contrataban nodrizas. El biberón permitía a la clase media y baja imitar a la clase alta y no dar el pecho.

- El trabajo. Las mujeres siempre habían trabajado, claro; pero en el siglo XX ya no les permitían llevar a sus hijos con ellas y hacer una pausa para darles el pecho, como habían hecho toda la vida las campesinas o las hilanderas.

- El machismo. ¿Cómo va a poder una simple mujer alimentar correctamente a un bebé? ¡Con lo difícil que es eso! Seguro que los científicos lo hacen mejor…

Se estableció un círculo vicioso. La lactancia perdió todo prestigio social; era algo rural y atrasado. Había tan pocas madres lactantes que las embarazadas no tenían ocasión de observar y aprender. Médicos y enfermeras carecían de conocimientos y experiencia para ayudar a las madres: ¿para qué tratar unas grietas o una mastitis si es más fácil dar un biberón? Una nueva generación de abuelas no había dado el pecho y no podía aconsejar a sus hijas. Las madres que aún intentaban dar el pecho perdieron la esperanza: creían (porque lo veían a su alrededor) que lo normal es fracasar, que la mayoría de las mujeres no tienen leche.

Como siempre ocurre, cuando parecía que las cosas ya no podían ir peor, comenzaron a ir mejor. La recuperación comenzó en los países escandinavos, y unas décadas más tarde llegó al sur de Europa. En los últimos 10 o 15 años se ha producido en España un notable aumento de la duración de la lactancia materna, que resulta, como en el resto de los países industrializados, de dos impulsos separados pero complejamente interrelacionados: los profesionales sanitarios y las mismas madres.

Mientras biólogos y químicos encontraban nuevos componentes en la leche materna (enzimas, hormonas, factores de crecimiento, factores inmunológicos…), médicos y epidemiólogos demostraban que la lactancia artificial se asocia con múltiples problemas de salud, tanto en el niño como en la madre, tanto en los países pobres como en los ricos. Unicef calculaba que, en la década de los noventa, un millón y medio de niños morían cada año en el mundo por falta de lactancia materna. Numerosos datos experimentales y un mejor conocimiento de la fisiología de la lactancia indicaban que los horarios rígidos y la separación en el hospital eran graves obstáculos para dar el pecho. Cada vez más comadronas, enfermeras y médicos tomaban conciencia de la necesidad de formarse para ayudar a las madres. En 1991, la OMS y Unicef lanzaron la Iniciativa Hospitales Amigos de los Niños (IHAN), para conseguir que los hospitales faciliten la lactancia: puesta al pecho inmediatamente después del parto, alojamiento conjunto de madre e hijo las 24 horas, lactancia a demanda, no dar sueros glucosados ni chupetes…

Al tiempo que médicos y autoridades promocionaban la lactancia como una estrategia de salud, como método para evitar enfermedades (y ahorrar gastos sanitarios), las madres la recomendaban como una experiencia personal fundamental, como una parte de su vida a la que no querían renunciar. Había pasado la época de fe ciega en la ciencia y el progreso; lo natural volvía a tener prestigio, se veía como limpio y puro frente a lo artificial, contaminado, peligroso… Una nueva generación de madres no estaba dispuesta a “ponerse en manos del médico” pasivamente; querían opinar, decidir, convertirse en protagonistas de su propia maternidad.

Los primeros grupos de madres lactantes aparecieron en EE. UU. hace cincuenta años; aquí el movimiento fue tardío, pero explosivo, y en las últimas décadas han aparecido decenas de grupos de apoyo mutuo por toda la geografía española. Durante mucho tiempo, el trabajo de la madre no fue en España un obstáculo importante para la lactancia… porque casi todas las lactancias finalizaban antes de la vuelta al trabajo. Pero cada vez son más las madres que llegan dando el pecho al fatídico límite de dieciséis semanas, y se preguntan por qué el permiso de maternidad es tan corto en España frente a otros países europeos. Una campaña para solicitar el permiso maternal de seis meses recogió recientemente más de 300.000 firmas. Nuestros gobernantes siguen haciendo oídos sordos.

Cuando proliferan las pruebas de que la producción industrial de carne es perjudicial para el medio ambiente, de que el planeta no puede soportarla de manera equitativa, de que es un derroche de recursos, de que acelera el calentamiento global y de que propaga todo tipo de enfermedades graves, podríamos caer en la tentación de instar a todo el mundo a que se haga vegetariano. Y la idea presenta bastantes ventajas.

Las investigaciones demuestran que los ovolactovegetarianos y los vegetarianos estrictos (los que no ingieren huevos ni leche) generan menos emisiones de carbono que los carnívoros. En Estados Unidos, donde alrededor del 2,5% de la población no come carne, existe una gran diferencia entre el nivel de emisiones anuales de CO2 de los vegetarianos y el de la población media. Según un estudio reciente, la dieta habitual estadounidense aporta casi 1,5 toneladas más de CO2 que la vegetariana, y dejar de comer carne y hacerse vegetariano podría reducir hasta en un 6% las emisiones productoras de efecto invernadero que genera EE UU.

Los vegetarianos también pueden alardear con suficiencia de su salud. Diversos estudios han demostrado que tienen menos posibilidades que el ciudadano medio de morir de un derrame y de enfermedades cardiacas. A este respecto, uno de los estudios que utilizó una muestra más numerosa fue el realizado en el Reino Unido, que comparó a 33.883 carnívoros con 31.546 vegetarianos. Según esa investigación, era más probable que los primeros fumaran y que tuvieran sobrepeso. Sin embargo, y esto debería darnos que pensar, según otras investigaciones, en otras enfermedades los vegetarianos y los carnívoros igualmente preocupados por su salud presentan indicadores bastante similares.

El factor que debería disparar las alarmas es el de los “igualmente preocupados por su salud”, porque apunta que el vegetarianismo no se distribuye de manera aleatoria por la sociedad, que ser vegetariano tiene que ver con otros tipos de comportamientos saludables. Y los datos avalan esta afirmación.

En Estados Unidos, según datos demoscópicos recientes, existe una relación entre el tipo de empleo y la dieta. Los trabajadores manuales suelen comer más carne, en concreto ternera, que los del sector servicios o los profesionales. Además, el comer menos carne tiene que ver con un mejor nivel de estudios, aunque no, sorprendentemente, con mayores índices de renta, lo cual indica la presencia de un factor cultural.

Esto nos conduce a un interesante giro en nuestra forma de abordar el tema de la carne y su ausencia. Sin duda, es cierto que hacerse vegetariano, en ausencia de otros factores, puede mejorar la propia esperanza de vida. Sin embargo, precisamente porque hay otros elementos que varían, el mandamiento de ser vegetariano no es algo que todos podamos seguir con igual facilidad. Entre gran parte de la población del norte globalizado y las pautas de alimentación sostenibles se alza todo un abanico de obstáculos sociales.

Estudios realizados en California, por ejemplo, ya nos han indicado la relación directa existente entre el tiempo que se emplea en ir a trabajar y el nivel de obesidad. Sabemos que los pobres tienen menos posibilidades de vivir cerca de su lugar de trabajo que los ricos. También sabemos que el 14% de las comidas rápidas que se consumen en Estados Unidos -ricas en carne animal- se come en los coches. Esto no surge de una especial afición nacional por la utilización de los vehículos como restaurantes, sino del hecho de que la única posibilidad que tienen muchos pobres de Estados Unidos de hacer una de sus comidas es cuando se desplazan de un empleo a otro.

Además, es mucho más difícil ser vegetariano cuando no se tiene acceso a frutas y verduras frescas. En Estados Unidos, si vives en un barrio pobre, puedes verte afectado por las “líneas rojas del supermercado”, es decir, por un fenómeno cuyo nombre procede de su similitud con las prácticas bancarias, en las que se trazan líneas rojas en los mapas locales para señalar las zonas en las que el banco no va a conceder créditos. Las líneas rojas de los supermercados son iguales, pero con la comida. Cada vez es más frecuente en la geografía estadounidense que los barrios de pocos ingresos tengan muchísimas menos posibilidades de contar con mercados de productos frescos, y que sean mucho más proclives a tener restaurantes de comida rápida y autoservicios de horarios muy prolongados. El proceso de concentración de los supermercados implica que en Boston, desde 1970, han cerrado más de la mitad de las 50 grandes cadenas de esos establecimientos, mientras que en el condado de Los Ángeles el descenso ha sido de casi el 50%, al tiempo que los mercados se circunscriben a los barrios acomodados.

En consecuencia, no elegimos con libertad. Y los ciudadanos más pobres son los que encuentran obstáculos más insalvables para elegir una dieta saludable. En el sur globalizado, la población es de facto vegetariana, simplemente por razones de renta. En el norte, el vegetarianismo es una prerrogativa de la clase media.

¿Qué cambios serían precisos, por tanto, para que todos los habitantes del norte globalizado avanzáramos hacia una dieta sostenible? Para empezar, deberíamos prescindir de la idea de que hay una fórmula mágica. Ninguna medida podrá librarnos del marasmo cultural y de clase que empuja a los más pobres a tener hábitos alimentarios poco sostenibles. Para avanzar hacia una alimentación sostenible es importante deshacerse de las concepciones que reducen la dieta a una elección individual. Más bien se necesita un abanico de políticas, que van desde el fomento de los mercados de fruta y verduras frescas en las zonas más deprimidas hasta el incremento del número de viviendas públicas en emplazamientos más cercanos a los lugares de trabajo, pasando por la construcción de ciudades transitables a pie y con espacios verdes, la implantación de sueldos mínimos respetables, la reducción de las jornadas laborales, y la inversión de cantidades importantes en educación y sanidad, que sofoquen las injusticias que acompañan nuestras diferencias de acceso a los alimentos.

En suma, es imposible hablar de carne en Estados Unidos o en otros países sin hablar de clase. Y no tendremos una alimentación sostenible hasta que abordemos el asunto con seriedad.

Todo ser humano sabe con certeza que va a morir. En otoño, la caída de las hojas nos lo recuerda quizá de una forma más natural que las esquelas de los periódicos. Precisamente, la palabra apoptosis, con la que se designa la muerte programada de las células, proviene del griego y quiere decir caída de hojas. Lo que nadie sabe es cuándo ni cómo va a morir. Por las estadísticas sabemos que lo más probable es que muramos por infarto de corazón, por un tumor o por una enfermedad neurodegenerativa como la de Alzheimer o la de Parkinson, si antes no hemos muerto de accidente.
Lo que no es tan seguro, sobre todo cuando vemos las noticias de accidentes de tráfico cada fin de semana o, todavía peor, cuando hay puente, es si uno llegará a la vejez, exceptuando aquellas personas cuya edad demuestra que ya han llegado a ella. Pero, aun en esas personas, es difícil definir la vejez, pues las hay que envejecen prematuramente y otras que están en forma a pesar de la avanzada edad. Algo que es conocido como la disociación entre la edad cronológica (número de años) y la biológica (estado de salud y rendimiento).

LO QUE ES seguro es que muchos llegarán a una edad avanzada, ya que la vida media de los españoles, según los datos hechos públicos por el Instituto Nacional de Estadística, supera ya los 80 años. Concretamente, la de las mujeres es de 83,66, mientras que los hombres no pasan de 76,98. Pero lo que las estadísticas no nos pueden explicar es por qué nos hacemos viejos. Desde que Elie Metchnikoff introdujo la palabra gerontología para la ciencia que estudia los procesos de envejecimiento en todos los seres vivos, las teorías que intentan explicar la causa del envejecimiento son variadas, pero ninguna de ellas es segura. En general, se acepta que, para considerarla sostenible, una teoría del envejecimiento tendría que explicar: a) Por qué conlleva pérdidas en la función fisiológica. b) Por qué es progresivo: es decir, por qué las pérdidas funcionales son graduales. c) Por qué las pérdidas funcionales se producen en todos los miembros de una misma especie.
Después de que se atribuyera la gran longevidad de los japoneses al consumo de pescado, sobre todo de pescado crudo, se dirigió la atención a la importancia de la dieta mediterránea. Sin embargo, aunque la dieta mediterránea tiene muy buenos sabores, el hecho de que las comunidades de Levante, sobre todo Valencia, Murcia y Andalucía, tengan una longevidad más reducida que otras comunidades como Navarra, Madrid y Castilla y León, que tienen poco que ver con el Mediterráneo, pero tienen la mayor esperanza de vida, no habla a favor de la dieta mediterránea. Independientemente del nombre que se le dé a la dieta, los conocimientos actuales indican que una que contenga todos los nutrientes necesarios, pero que sea baja en calorías, prolonga la vida.
La teoría más aceptada, pero no definitiva, es la de la vejez programada genéticamente para cada persona. Aun antes de que los avances de la genética hicieran verosímil que la longevidad de una persona depende de su genoma, ya era de conocimiento común que cuando los padres habían alcanzado una edad avanzada, era de esperar que los hijos también lo consiguieran. Pero precisamente el hecho de que la vida media haya subido espectacularmente en las últimas décadas demuestra que el factor genético no es el único, pues hay que suponer que el genoma de los españoles que solo alcanzaban un promedio de vida de 50 años en 1931 o de 70 años en 1961 continúa siendo el mismo.
Sin embargo, teniendo en cuenta el nivel de la medicina que se ha alcanzado en nuestros días, que permite prevenir o tratar eficazmente las infecciones, las lesiones físicas o la mala nutrición, es seguro que todo lo que no puede tratarse ha de depender de la constitución genética del individuo. Queda por aclarar el mecanismo por el que el código genético programa el envejecimiento. En los tejidos de cultivo, se ha relacionado el envejecimiento celular con la presencia de secuencias repetidas del ADN que se encuentra en los dos extremos de los cromosomas, y se acortan cada vez que una célula se divide. Después de un número determinado de divisiones, el cromosoma se ha acortado tanto que la célula muere. Pero el envejecimiento de un organismo tan complejo como el cuerpo humano no puede equipararse al de un cultivo de células.

OTRA TEORÍA, la de los radicales libres, expone que la causa del envejecimiento de las células es el resultado de las alteraciones acumuladas durante las reacciones químicas que tienen lugar continuamente en su interior y producen radicales libres. Estos últimos son sustancias tóxicas que atacan sobre todo las membranas de las células. Un ejemplo bien conocido de radical libre es el agua oxigenada, que, por su capacidad de atacar las membranas de las bacterias, se utiliza como desinfectante. Los radicales libres van aumentando con la edad y finalmente las células no pueden funcionar y envejecen. Hay distintas sustancias que ayudan a eliminar los radicales libres, entre las que figuran los pirroles, que se encuentran en el vino tinto. Por eso se recomienda una copa de vino al día. Desgraciadamente, si la dosis se aumenta demasiado, ¡se destruye el hígado o se afecta el cerebro!
Aunque ninguna sea definitiva, de cada una de estas teorías y otras muchas que existen se pueden extraer algunas de las causas por las cuales la gente envejece y muere. Pero ninguna de ellas puede impedir el envejecimiento.

El ex presidente catalán Pasqual Maragall, al declarar públicamente que le habían diagnosticado la enfermedad de Alzheimer -lo mismo que hicieron Rock Hudson y Magic Johnson cuando informaron al mundo que se encontraban amenazados por el sida-, ha demostrado, una vez más, su talla política de ciudadano comprometido con el bienestar de los miembros de la comunidad. No hay duda de que con su declaración ya ha contribuido, en alguna medida, a la normalización -y, por tanto, al examen sereno- de una enfermedad que se ha estimado que afecta a unos 800.000 españoles y a más de tres millones de familiares, y para la que, desde un punto de vista farmacológico, si bien existen grandes esperanzas, no disponemos todavía de una terapéutica curativa eficaz.

Sus palabras, a mi juicio, suscitan motivos para la reflexión en muchos sentidos. Me limitaré a dos de ellos. En primer lugar, lo mismo que en el caso del alcoholismo, el cáncer, los embarazos indeseados, las enfermedades de transmisión sexual, la obesidad, la anorexia o la hipertensión arterial, deberíamos preguntarnos si además de confiar únicamente en los agentes farmacológicos para tratar de evitar, resolver o paliar estas problemáticas, existen medios alternativos, asequibles en la actualidad, para prevenir o demorar la aparición de los síntomas de la enfermedad de Alzheimer. En segundo lugar y centrándonos en los protagonistas -Maragall, Reagan, Rock Hudson, Magic Johnson, etcétera-, cabe cuestionarnos sobre el impacto personal que tienen para ellos sus propias declaraciones.

En lo que se refiere al primer interrogante, los datos científicos de que se dispone en este momento, aunque todavía insatisfactorios, son coincidentes y apuntan en la misma dirección: esta alternativa existe. En efecto, la investigación llevada a cabo por Fries y colaboradores en 1980, apoyada posteriormente por los resultados obtenidos por el equipo de Vita, llega a la conclusión, publicada en 1998 en The New England Journal of Medicine, de que “fumar, el índice de masa corporal y las pautas de ejercicio físico en la mitad y fase avanzada de la vida… no sólo son responsables de que las personas con mejores hábitos de salud vivan más años, sino de que en tales personas la aparición de la incapacidad se demore y se reduzca a un menor número de años al final de la vida”. En 2006, otra investigación llevada a cabo por Larson y colaboradores, y dada a conocer por Annals of Internal Medicine, sugiere que un ejercicio físico moderado (andar) efectuado regularmente, puede demorar la aparición de los síntomas de deterioro.

Con respecto al problema específico de las demencias es especialmente interesante la investigación llevada a cabo por Frantiglioni en la población sueca de Kungsholmen, aparecida en Lancet en 2000. En ella se tomaron como punto de partida 1.203 personas con una edad mínima de 75 años que no mostraban síntomas de deterioro y se analizaron sus redes sociales. A los tres años, todas las personas que permanecían con vida fueron sometidas a una segunda exploración individual, encontrándose que, durante este periodo, 176 de ellas habían recibido un diagnóstico de demencia. Entonces se comparó el grupo demenciado con el no demenciado con respecto a la frecuencia y tipo de relaciones sociales. Los resultados indican que unas interacciones pobres o limitadas incrementan en un 60% el riesgo de recibir un diagnóstico de demencia. Un comentario amplio sobre este trabajo, publicado en el mismo número de la revista, destaca dos conclusiones importantes: a) La vulnerabilidad era menor en las personas que mantenían interacciones afectivas variadas: pareja, amigos, familiares, niños, etcétera; y b) un tipo de relación, al menos como factor protector de la demencia, podía sustituirse por otro.

Tales resultados concuerdan con algunos de los datos obtenidos por Snowdon en su conocida investigación sobre las monjas y de los que tanto la prensa científica como las revistas de divulgación y este mismo periódico se han hecho eco los últimos años.

Todos estos hallazgos son coherentes con la llamada “Teoría de la reserva cerebral”, según la cual el nivel de discapacidad de un individuo no constituye únicamente el reflejo de las lesiones cerebrales subyacentes, sino que es también función de la actividad cognitiva desarrollada previamente.

Hace algunos años, durante una estancia en la Universidad Nacional Autónoma de México, tuve ocasión de asistir a una conferencia de Bach-y-Rita, un conocido neurólogo mexicano que trabajaba habitualmente en California. Una de las anécdotas con las que iluminó su conferencia llamó poderosamente mi atención. Contó que su padre era un gran excursionista y que en un momento dado de su vida sufrió una hemiplejia que dejó gran parte de su cuerpo paralizado. El conferenciante tenía un hermano psiquiatra y ambos, de común acuerdo, elaboraron un programa de rehabilitación para su padre que, al cabo de varios meses, dio fruto y, poco a poco, su progenitor pudo volver a su afición favorita: subir montañas; aparentemente el éxito había sido completo. Más tarde, su padre murió y ambos hermanos, llenos de curiosidad científica, se plantearon realizarle la autopsia para saber qué había ocurrido con su cerebro. Y lo que encontraron fue que una parte del mismo estaba inservible, muerta. La explicación del éxito de su rehabilitación se encontraba en el hecho de que en su cerebro se habían creado nuevas vías que le permitían, aunque con mayor lentitud, suplir eficazmente las dañadas por la enfermedad.

Teniendo en cuenta los datos que obran en nuestro poder, de forma ciertamente provisional y revisable, señalaría que los factores de riesgo de deterioro al envejecer son: a) vivir en un hogar unipersonal; b) haber ejercitado y ejercitar (leer, escribir, pensar, meditar, charlar, etcétera) poco el cerebro; c) tener una red escasa o pobre de contactos afectivos con otros seres humanos (pareja, amigos, familiares, niños, etcétera); d) no practicar regularmente ejercicio físico (andar); e) no disfrutar con actividades a nuestro alcance.

Evidentemente, seguir estos consejos no ofrece una garantía universal. Personas como Pasqual Maragall, Adolfo Suárez, Ronald Reagan o Iris Murdoch es obvio que durante su vida han hecho trabajar su cerebro a plena potencia y han sido sumamente activos. Existen factores genéticos insoslayables. Lo que nunca sabremos es si en caso de no llevar una vida intelectual y social de una gran riqueza el inicio de su deterioro no se hubiera presentado a una edad más temprana.

Y esto nos conduce al segundo de nuestros interrogantes. ¿Vale la pena conocer que te encuentras afectado por una enfermedad progresiva grave, si en el momento del diagnóstico la misma se considera médicamente incurable? Durante años, mi respuesta a esta pregunta fue dudosa. Pero un día, una de mis alumnas de doctorado me indicó que deseaba llevar a cabo una investigación empírica sobre el problema y que le gustaría que la dirigiera; me dijo que disponía del apoyo del jefe de servicio de una unidad de consejo genético destinado a la atención de personas susceptibles de poseer los genes facilitadores de los cánceres de mama y ovarios. Antes de aceptar solicité poder conversar directamente con un grupo de mujeres a las que ya se hubieran realizado las pruebas genéticas y las mismas hubieran resultado positivas. Dispuse de un tiempo ilimitado para escuchar las historias de siete mujeres, muchas de ellas mastectomizadas, todas poseedoras de los genes involucrados, y para interactuar con el grupo. Fue muy enriquecedor.

La reunión disipó mis dudas. Todas sin excepción estaban satisfechas de haberse hecho las pruebas genéticas y conocer los resultados. Esta información no les permitía prevenir la aparición de nuevos cánceres, pero su percepción de control sobre la situación se había incrementado. El equipo sanitario del servicio era excelente y sabían que en cualquier momento que lo precisaran recibirían con rapidez la mejor atención posible.

La manifestación pública de una problemática personal supone, además, para el interesado, cortar de raíz las posibles secuelas y efectos secundarios de la llamada conspiración del silencio, fomentada, a veces, por familiares y amigos. La información veraz sobre nuestra realidad es dura de asimilar, pero constituye una base sólida a partir de la cual podemos seguir luchando por nuestro futuro.

En una buena información de César Coca sobre la situación actual de la sanidad vasca y los retos que ha de afrontar en un futuro inmediato, publicado en este mismo periódico el pasado 3 de junio, se hacía referencia, además de a la obligada optimización de los recursos humanos y técnicos, a un profundo cambio de planteamiento, considerando, como uno de los ejes clave, la promoción de la salud y el autocuidado. Esperar que Osakidetza o cualquier otro sistema sanitario público o privado, de cualquier parte del mundo, nos garantice nuestra salud es pedir peras al olmo. Simplemente, porque no pueden hacerlo más que en una pequeña proporción.

Nuestra salud depende, fundamentalmente, de cada uno de nosotros. Por eso cada uno de nosotros debe preocuparse de su propia salud. De la salud física, para controlar los factores de riesgo que pueden abocarnos a la enfermedad, y para mantener una capacidad funcional que retrase la incapacidad; y de la salud espiritual, capaz de ayudarnos a hacer frente al estrés y a llevar con dignidad y positivismo el trabajo y la vida que nos ha tocado en suerte. Llevar un estilo de vida saludable, activo y equilibrado es un deber para con nosotros mismos, para con nuestra familia y para con la sociedad en la que vivimos.

No podemos conservar la salud de manera indefinida, pero se sabe qué es lo que hay que hacer para mantenerla en la vejez, y hacer de ésta una época que no añore demasiado las ya pasadas. Claro está, con la connivencia de la buena suerte. La inactividad física es un importante factor de riesgo de muchas enfermedades crónicas no transmisibles (cardiovasculares, diabetes, cáncer, osteoporosis, EPOC, artritis), algo que acentúa el gasto sanitario y social, sobre todo en la población de edad avanzada. Y es, más que la suma de años, la principal causante de la pérdida de funcionalidad. Los estudios indican que los gastos derivados de los cuidados médicos debidos a la inactividad física son crecientes: El 2,4% del total de los gastos sanitarios en Holanda (sin contar con los gastos derivados de las drogas), el 6% en Canadá y el 9,4% en EE UU (incluyendo aquí los gastos derivados de la obesidad). En la información de César Coca se menciona, en relación a la sanidad vasca, que «en veinte años se han duplicado las consultas externas en los hospitales y la atención en urgencias y las intervenciones quirúrgicas han crecido un 60%. En los ambulatorios y otros centros, las consultas parecían estabilizadas durante los 90, pero desde 2000 han aumentado un 13%».

La OMS y otras muchas organizaciones médicas de prestigio vinculan la actividad física regular con importantes beneficios de orden físico, mental y social. De entre todos, podemos destacar la prevención y control de las enfermedades crónicas no transmisibles, del estrés, la ansiedad y la depresión moderada. La actividad física regular ayuda a controlar el peso y a mejorar la forma física, lo que en muchas personas se traduce en un aumento de la autoestima. Además, la adhesión al ejercicio físico regular se vincula normalmente, aunque no siempre, a la adquisición de otras medidas saludables como la mejora en la alimentación y la disminución del consumo de tabaco, alcohol y de drogas sociales. En las personas mayores, ayuda a evitar las caídas, a prolongar el grado de autonomía e independencia, facilitando así las relaciones familiares y sociales.

Consecuentemente, la práctica regular de actividades físicas se relaciona también con importantes ahorros económicos. Las estimaciones realizadas en distintos países arrojan algunos datos interesantes. En Australia, el beneficio neto anual calculado en 1989 si sólo un 10% de la población inactiva se tornara activa fue de 590,2 millones de dólares. En Canadá, el Canadian Fitness and Lifestyle Research Institute calculó en 1995 que podrían ahorrarse alrededor de 24.000 millones de dólares canadienses en costes sanitarios si el 40% de los canadienses inactivos se volvieran activos (un rápido ejercicio de traslado proyectaría un ahorro en Euskadi cercano a los 1.200 millones de euros, 1,7 veces la inversión de Sanidad para los próximos 6 años). Igualmente, los Centers for Disease Control and Prevention (CDC) de EE UU estimaron en el año 2000 que si todos los adultos americanos (excluyendo a los físicamente limitados) se tornaran físicamente activos (considerando para este cálculo sólo 30 minutos de actividad moderada, 3 veces por semana) el ahorro potencial podría ser de entre 76.600 y 98.500 millones de dólares americanos.

Las personas mayores constituyen el segmento de población más necesitado de cuidados médicos. Si los adultos mayores se mantienen en buena forma, pueden permanecer durante más tiempo cuidándose a sí mismos, aplazando y disminuyendo así los altos costes de los cuidados institucionales. Según Roy J. Shephard, un pionero en la investigación médica de la actividad física, la puesta en práctica de programas de educación para la salud supondría, sólo en cuidados institucionales geriátricos, un ahorro de alrededor del 30%. Un ahorro mucho mayor que el coste del más caro programa de ejercicios, incluyendo los altamente supervisados. En EE UU se estima que por cada dólar invertido en programas preventivos de este tipo el ahorro en cuidados médicos es de 3,2 dólares. En Canadá, por cada dólar invertido para aumentar la proporción de población activa en un 25%, se estima una ganancia en productividad de entre 2 y 5 dólares. Alguien podría aducir que todo esto son estimaciones, no evidencias; pero, como comenta Shephard, los experimentos controlados, amplios, randomizados y a doble ciego no resultan factibles en este contexto. Si realizáramos este tipo de investigaciones en Euskadi, seguramente comprobaríamos cómo aquí también la actividad física es económicamente beneficiosa, y cómo la prevención nunca resulta cara.

La OMS, en su documento Health Promotion -Active Living- Evidence (1999) concluye que la actividad física regular es una intervención de salud pública altamente efectiva en relación al coste; esto es, una buena inversión en salud pública. E insta a los Estados miembros a que «elaboren, apliquen y evalúen políticas y programas que promuevan un envejecimiento activo y saludable». En muchos países, el ejercicio físico regular poblacional es considerado como uno de los mayores intereses para la atención sanitaria pública. En Estados Unidos se incluye entre los 10 indicadores prioritarios de salud -Healthy People 2010-, algo que implica una imperiosa necesidad de reevaluar continuamente los programas de actividad física poblacional. Programas que, en su mayoría, animan a dedicar no más de una hora al día, aunque sea de manera fraccionada, a la actividad física cotidiana o al ejercicio físico programado, todos o casi todos los días de la semana -recordemos aquí que el 65% de la población vasca de más de 16 años de edad se declara sedentaria (Eustat-2002)-.

Para finalizar, dos ideas clave: la primera, tomada del informe de la OMS The Health and Economic Impact of an Aging Society, es que se conocen las estrategias para controlar las causas de muerte, incapacidad y enfermedad; pero estas estrategias no se aplican convenientemente. Y la segunda, tomada del informe de los CDC Opportunities to Improve the Health and Quality of Life of Older Americans, que la actividad física es crucial para envejecer con salud; y, sin embargo, en ningún lugar hay una laguna mayor entre lo que sabemos y lo que tenemos que hacer que en el área de la actividad física, y en ningún área la rentabilidad potencial es mayor. Ánimo a todos.

If it turns out that none of his fellow passengers were actually infected with the dangerous form of tuberculosis he carries, then Andrew Speaker, the young honeymooner who recently eluded government efforts to keep him off commercial flights, may actually have done a favor to public health. His case has brought to light the neglected but growing problem of super drug-resistant tuberculosis, and the ease with which this deadly airborne disease can travel around the world.

Federal health officials have recently warned state and city TB treatment programs to expect budget cuts of as much as 25 percent over the next five years. But Mr. Speaker is not the first world traveler to carry the most drug-resistant TB, and he will surely not be the last. Instead of cutting back on TB research and treatment, we should be intensifying our efforts to fight the disease.

We urgently need tests capable of diagnosing drug resistance overnight, so that we can know which patients present the most danger to the public. We need new drugs to outwit the disease. And we need to support a worldwide effort to prevent TB bacteria from developing further drug-resistance.

Tuberculosis is an illness that was once thought to be under control. A century ago, it was responsible for one in five deaths in the United States. But then antibiotics came along, and a national effort to develop new drugs and diagnostic tools and to institute TB-control public health programs drove down the rates of tuberculosis in the United States to the point where people assumed it was eradicated.

Twenty years ago, complacency about TB control combined with the H.I.V. epidemic and a growing immigrant population to bring about a resurgence. As a result, in the early 1990s, TB programs in the United States were rebuilt to provide better patient care and case investigation and to improve adherence to treatment.

These programs have become models for TB treatment around the world. But unfortunately, in many countries, public health standards still fall short. Patients infected with tuberculosis are given inadequate courses of antibiotics, or they fail to adhere to the course of treatment they are given. In such cases, the most drug-resistant strains of the bacteria are allowed to multiply.

It’s easy to see how drug resistance in any one country grows into a global problem. One-third of the world’s population carries the TB bacillus in their bodies, and in the stream of people traveling around the world the bacteria are constantly on the move.

The World Health Organization estimates that each person with TB infects 10 to 15 other people, usually by coughing the germs into the air. And once the bacteria reach a new host, they can either progress to disease, keeping the cycle going, or be carried around for years or decades, only to cause illness later on in a chosen few. A robust immune system is needed to contain the infection, but even in healthy people, 5 percent to 10 percent of those exposed go on to develop TB.

The most extremely resistant form of the illness — the kind that Mr. Speaker has, known as XDR-TB, which is impervious to even our most powerful antibiotics — is now found all over the world. It is thought to be rare, though the exact numbers are unknown. But we know that the numbers are rising, because strains of TB that are resistant to multiple drugs — the precursors to XDR-TB — are proliferating. In 2004, almost half a million of the more than 8 million cases of tuberculosis worldwide were resistant to the most potent TB drugs. And drug resistance feeds further drug resistance.

Adding to the problem is the long time, often a period of months, that it takes to detect drug resistance. Doctors are forced to treat in the dark, not knowing whether their drugs are actually working.

What is needed are tests capable of diagnosing drug resistance within 24 hours — tests that do not require letting the bacteria grow in culture for days but rather identify gene mutations that confer drug resistance.

Such genetic tests to detect resistance to first-line TB drugs already exist, though they are in limited use, mainly in New York and California. We need to put in the effort to develop them for the second-line antibiotics, and make the investment to ensure that the quick tests are put into widespread use.

Perhaps if Mr. Speaker’s doctors had known before he left for Paris that his tuberculosis was the drug-resistant kind, they might have taken even stronger action to keep him from flying to Europe in the first place. State and federal laws give public health officials the authority they need to keep contagious patients away from the public, but in exercising that authority, it helps to know the danger that a patient poses.

In addition, we need more drugs to treat TB. No new drug class has been approved for TB since the antibiotic rifampin, 35 years ago. Without effective drugs to treat the new superbugs, patients often suffer longer periods of contagion, and that makes their treatment extremely costly (from about $90,000 to more than $700,000 per patient).

Last fall, the World Health Organization proclaimed XDR-TB to be a public health emergency and called on governments to provide $95 million in 2007 to deal with the problem. Three bills now before Congress would increase domestic and international spending for TB treatment and research.

As global travel continues to increase and the rate of drug-resistant TB rises, the number of cases of drug-resistant tuberculosis inevitably will grow. It is essential that we redouble our efforts to halt the epidemic of drug resistance and the global spread of all forms of TB.

Cuando recibí la invitación a asistir a la conferencia que impartía la consellera de Salut Marina Geli en la torre Agbar, fui consciente de que se iban a tratar allí aspectos de la salud con un enfoque poco usual y que se trataba de un tema del que se conoce bien poco.

Las especificidades de la mujer en temas de salud, sobre todo en referencia a la reproducción, han sido ampliamente abordadas, tanto desde el punto de vista estrictamente médico como en sus aspectos más sociales, pero la contrapartida en la parte masculina no ha sido equivalente.

Empezando por el final de la vida, es de todos conocido que las mujeres tienen una esperanza de vida mayor que los hombres. La esperanza de vida ha aumentado de forma global y en Catalunya se sitúa alrededor de los ochenta años, siendo de 77 en el hombre y de 84 en la mujer, con seis años de diferencia. Esto se mantiene en todos los países desarrollados, y es menor esta diferencia en los países en desarrollo.

Los condicionantes sociales y económicos son determinantes para la esperanza de vida, aunque se sabe que las mujeres tienen una cierta ventaja fisiológica respecto de los hombres al presentar mayor resistencia frente a determinadas enfermedades. Por otra parte, las actividades profesionales que los hombres desempeñan preferentemente conllevan un mayor riesgo de muerte que las que practican las mujeres, aunque estas diferencias tiendan a igualarse.

Las principales causas de muerte en la población catalana son los tumores y las enfermedades cardiovasculares. En el caso de los hombres, los tumores más frecuentes son los de pulmón, colon y próstata, y en las mujeres, el primer lugar lo ocupa el cáncer de mama, seguido del de colon y de pulmón. Las enfermedades cardiovasculares afectan más a los hombres que las mujeres. Aparecen diferencias claras en cuanto a que los hombres tienen más patologías del sistema digestivo y presentan más mortalidad por causas externas, como los accidentes de tráfico. De nuevo, estas diferencias son explicables por variables fisiológicas y también por variables de actividad, sobre todo profesional.

Analizando el caso específico de la salud mental, se observa que las mujeres padecen más trastornos mentales que los hombres en la edad adulta, mientras que el patrón es a la inversa en la etapa infantil y adolescente. Esto podría explicarse por el modo que tienen los adolescentes de exteriorizar la confusión y la posible desorientación en este periodo vital. Los chicos tienden a expresarse con más frecuencia a través de reacciones conductuales de oposición, enfrentamiento y violencia que pueden agravarse al combinarse con conductas adictivas. El patrón es distinto en el colectivo femenino en esa misma franja de edad. Hay que tener en cuenta la posibilidad de que se detecte este tipo de trastornos en menor medida entre los hombres, dada la mayor dificultad que ellos tienen para pedir ayuda, al no reconocer que necesitan apoyo, evitando expresar una posible debilidad.

Si se analizan los factores de riesgo para la salud, ya se ha comentado que los hombres tienen actividades de más riesgo para la salud que las mujeres, tanto en el plano profesional como en el de ocio. Hay una mayor incidencia de accidentes de tráfico y lo mismo ocurre con los accidentes laborales. La diferencia en cuanto a actividad física de uno u otro sexo se pone de manifiesto ya en la edad infantil, probablemente siguiendo modelos sociales y culturales distintos en los niños y las niñas.

El programa Salut i Escola (conselleries de Salut y Educació) muestra que, en la etapa infanto-juvenil, a la hora de acudir a los profesionales de la salud de que disponen en el ámbito escolar, las niñas y adolescentes participan más y se interesan principalmente por temas relacionados con la sexualidad y la afectividad, la salud alimentaria y la salud mental, mientras que los chicos participan menos y lo hacen para temas relacionados con drogas, tabaco y alcohol. Cabe preguntarse cuál es el origen de tan distintas actitudes y si es tan sólo consecuencia de la diferencia de roles en uno u otro sexo, ya en edades tempranas.

Es muy evidente que los trastornos alimentarios se dan con mayor frecuencia en niñas y adolescentes, a pesar de que está también aumentando la prevalencia de este problema en el sexo masculino. El tabaquismo es un problema que afecta a casi un 25% de la población catalana, con mayor afectación de los hombres frente a las mujeres. Se observa por primera vez una disminución importante de la prevalencia de esta adicción, tanto en hombres como en mujeres, derivada tanto de la legislación como de la percepción del riesgo que esta práctica conlleva para la salud.

También los hombres presentan un mayor consumo de bebidas alcohólicas frente a las mujeres. Lo mismo sucede con el consumo de otras drogas. De nuevo, las pautas sociales y las diferencias de rol tienen un papel relevante en este hecho y las mujeres muestran una mayor sensibilidad a la hora de valorar los riesgos que estas prácticas comportan.

Está claro que las diferencias que se observan entre uno y otro sexo en el ámbito de la salud tienen su origen tanto en las especificidades fisiológicas de hombres y mujeres como en los aspectos sociales y económicos, que condicionan su actividad profesional y de ocio. Probablemente, la incorporación de las mujeres al ámbito profesional típicamente masculino y de los hombres al ámbito social y familiar típicamente femenino hará que estas diferencias se reduzcan en buena medida.