How to save money on health care, if you're on vacation and have all day

Here's just one example of why American health care costs so much more than anybody else's.

My husband is going to have outpatient hernia surgery in a couple of weeks. His doctor told him he had to get an EKG before surgery. He suggested that he go to the local urgent care facility to have it done. Being consumer-oriented types, we decided it would be a good idea to find out how much it was going to cost.

First, David called the urgent care center. They were sorry, but the billing office was closed. Could he call back the next day.

No problem. This morning he called the billing office. They were sorry, but they didn't know how much it would cost. He would have to contact his insurance company.

So he called Blue Cross Blue Shield Illinois. The EKG, they told him, would be billed as an outpatient procedure. There would be no co-pay, and since he had already paid his deductible, he would be responsible for only 20% of the cost. Right, said my husband, but how much will the cost be? They were sorry, they said, but they didn't know. That would depend on the provider's tax ID number and the diagnosis code.

So David called the urgent care center again. They gave him the provider's tax ID number and told him there was no diagnosis code, since this was a pre-op procedure. They thought, though, that the charge would be around $250.

At this point, David had to go meet an appointment, so I took over. I called Blue Cross Blue Shield, gave the information to the agent, and waited while she tried to figure out the answer. "We can't do pricing for hospitals," she told me at one point. Hospitals, it seems, have just too labyrinthine a discount policy for even the insurance agents to figure out. But bless her, she kept trying.

She needed a procedure code, however, which is different from a diagnostic code. After eight minutes of checking her own resources, she put me on hold and called the urgent care center herself. They referred her to the hospital's billing center, so the agent put me on hold again and called the hospital. (Say what you will about Blue Cross Blue Shield, they do have excellent customer service.) The hospital provided the necessary code, so the agent went off again to check.

Alas, she finally told me, this was indeed a hospital procedure, and therefore she would not be able to tell me what the cost would be. However, she thought it would be around $250, which means that our portion would be around $50.

Let me ask you something else, I said. Suppose David goes to a doctor and the EKG is done right there in the doctor's office. Would we then pay only the copay for a doctor's visit - $20 for a generalist, $40 for a specialist? The agent checked, and told me I was absolutely right. She sounded surprised.

She thanked me for my patience, and I thanked her for her excellent service (and indeed she was very accommodating). The phone call lasted 22 minutes, and I still was not sure what this procedure would cost.

Next I called a nearby medical group and asked if they are equipped to do EKGs right there in the office. Yes we are, said the receptionist. And, I pursued, if my husband sees a doctor who then immediately does an EKG, do we then just pay the copay? Yes indeed, she said.

So my husband has an appointment for tomorrow afternoon, and it's going to cost us $20 instead of $50 (more or less - we never did find out for sure), and it took only about an hour of our time to figure this out, plus of course whatever it cost Blue Cross, the hospital, the urgent care center, and the doctor's office who helped us.

In France, by contrast, charges are posted on the doctor's office wall for all to read.

Interestingly, the per-capita cost of health care in the U.S. is nearly double its cost in France. Personally, I think socialized medicine is a great way to keep costs down and increase efficiency. But if I were a total free-market type, I'd be equally disgusted with the U.S. system. How can consumers possibly influence the market if providers make it almost impossible to know costs?

If this is the invisible hand at work, it's giving us the finger.

2010: Not necessarily the year's best books

For you who can't resist every newspaper's or blogger's "best books of 2010" list - and for you who find such lists overwhelming and discouraging - here's a very short list of ten new books I enjoyed this year. I can't claim they're the best, because I didn't read all that many of the approximately 1,000,000 books published worldwide. I didn't even read many of the nearly 300,000 published in the United States (if 2010 figures are close to those of 2009).

To be perfectly honest, I read only one book that made it onto Publishers Weekly's and the New York Times's top ten lists, and I wasn't wild about it. Interestingly, those two lists agreed about only three titles. My list, which is even more fallible than theirs, is at least different : it doesn't include a single book they liked.

The books on my list are not scholarly or even intellectual. My favorite novels (this year and every year) are books that tell stories, that let me peek into other people's minds and hearts, and that are funny or at least upbeat enough not to leave me clinically depressed. The nonfiction books on my list either interested me in topics I knew little about or deepened my understanding of topics that already interested me. They did this through excellent journalism, human interest stories, and just the right amount of authorial involvement with the topic.

Eight of these books were first published in 2010. The other two were published in the U.S. in 2009 and came out in paperback this year. I've reviewed or commented on all of them on this blog or elsewhere. To read my review, click on the pound sign. To see what Amazon has to say about a book, click on its title.

Fiction
# Cleave, Chris: Little Bee (pb)
# Connelly, Michael: The Reversal
# Freitas, Donna: This Gorgeous Game
# Lamott, Anne: Imperfect Birds
# Tyler, Anne: Noah's Compass

Nonfiction
# Carr, Nicholas: The Shallows: What the Internet is Doing to Our Brains
# French, Thomas: Zoo Story: Life in the Garden of Captives
# Kaye, Jeffrey: Moving Millions: How Coyote Capitalism Fuels Global Immigration
# Safran Foer, Jonathan: Eating Animals (pb)
# Shulevitz, Judith: The Sabbath World: Glimpses of a Different Order of Time

My favorites? Probably Little Bee and The Sabbath World. Of course, the year isn't finished yet.

Happy New Year, and happy reading!

THE SISTERS OF SINAI by Janet Soskice

When my friend Irene, who reads much more deeply than I do, said "I love this book," I thought, Uh oh. Now I'm going to feel shallow unless I read it too. So I put a hold on it at the public library (no commitment required), and I looked at Amazon's reviews, which you can find here.

Whoa... an "enthralling narrative"? "Luminous"? "Absorbing and delightful"? "Lively and lucid"? Improbable descriptors for a book about two middle-aged female linguists who discover a Syriac palimpsest in St. Catherine's Monastery, and I've been in publishing long enough not to trust book-jacket blurbs.

Still, it's no mean feat to garner favorable reviews - or, really, any reviews at all -  from the New York Times, the Christian Science Monitor, the Washington Post, Books and Culture ... well, I was beginning to be embarrassed that I hadn't heard of the book before my friend tipped me off. And now that I've read it, I pass her tip on to you.

Janet Soskice, who is Professor in Philosophical Theology at the University of Cambridge, has nevertheless written a fascinating biography of Agnes Lewis and Margaret Gibson, twin sisters from Scotland who were never as famous as they deserved to be for discovering an ancient biblical manuscript.

Their discovery, which came at a time when ancient biblical manuscripts were all the rage, was of one of the oldest New Testament manuscripts ever found. It contained most of the Gospels, almost definitively proved that the original book of Mark did not include the snake-handling, poison-drinking verses in the last chapter, and was written in Syriac - first cousin to the Aramaic spoken by Jesus and the disciples. So why have we never heard of Mrs. Lewis and Mrs. Gibson?

Mostly because they were women. Born in 1843, they educated each other, becoming proficient in a variety of languages ancient and modern. They could not earn university degrees, because universities in mid-nineteenth century did not award degrees to women. Besides, they were Scottish Presbyterians, who were not especially in favor at Oxford or Cambridge. And several university professors desperately wanted the credit for their work.

Luckily, Mrs. Lewis and Mrs. Gibson were extremely rich and incredibly motivated.

Soskice has done a fine job of presenting them and their era in all their glorious eccentricities, turning their story into a good read even for people who are not usually fascinated by archaeological findings and ancient manuscripts.

Thanks, Irene.

Fixing health care - or, when the demon you DON'T know is better than the one you do

Last week a federal judge from Virginia ruled that part of The Patient Protection and Affordable Care Act is unconstitutional, and now the legal battle is moving to Florida. Also last week a Bloomberg poll found that 55% of Americans would like to repeal the health-care law, while only 40% want to keep it as is (5% aren't sure).

Now, I'm not sure what all of those 55% were thinking. I can imagine wanting to repeal the Affordable Care Act if I were fully persuaded that a better health-care law would immediately replace it - one that was funded either by a single payer or by not-for-profit private insurance; one that would put price controls on pharmaceuticals, medical equipment, hospitals, medical salaries, and other out-of-control expenses; one that would dramatically lower the cost of medical education so that we'd have more doctors, and so that more of them could afford to go into primary care; one that would assign a lot of primary care to pharmacists, midwives, physician assistants ...

Yes, I like socialized medicine. Not every aspect of it, and not necessarily the way it is practiced in every country that has it (though I'd be quite happy with France or Switzerland pretty much across the board). But even so, I don't think I would have answered yes to repealing the health-care law, because I don't think America has yet figured out how to do health care better.

Alas, most Americans are completely unaware that health care as practiced in other developed countries costs considerably less than our patchwork system, and that the results are nearly always equivalent or better. In fact, an October 2010 study by the Commonwealth Fund shows that "even as health care spending per capita has increased in the U.S. over the last three decades, the nation has fallen behind 12 other wealthy nations in 15-year survival for men and women at ages 45 and 65." Furthermore, the study points out, these rates can't be explained by smoking (we smoke less) or obesity (we're obese, but our obesity rate has increased less).

Steven Miles, MD, Professor of Medicine and Bioethics at the University of Minnesota Medical School in Minneapolis, has put together a fascinating Power Point presentation comparing health care in 15 developed nations. To see it, go to his faculty web page, scroll down (reading his impressive credentials as you go), and click on "US and Developed Countries:  Comparing Health Care Systems - 2009." In 48 slides he not only compares systems, he also dispels myths and offers alternatives. Here are a few of his findings:

• Of the 15 countries surveyed, the U.S. spends the most per capita on health care.
• The U.S. has the highest infant mortality and the lowest female life expectancy at birth.
• The U.S. has the highest rates of preventable death.
• The U.S. has the lowest number of MDs per capita.
• Hospital stays are shortest in the U.S.
• Heart patients are likely to get more high-tech treatment in the U.S., but survival rates are the same as in countries that rely primarily on meds.
• Hip replacements are done more quickly in the U.S., but the fewest number of people get them.
• Americans should be healthier than others: we smoke and drink less than most, and we are on average younger than the others. We are more obese, however.
• The U.S. government - before the Affordable Care Act - was already spending more per capita on health care than were the governments of most of the other developed nations. U.S. individuals were spending way more.
• A major reason that Americans spend more, with poorer results, is that (unlike people in other countries) we do not make adequate use of  primary care. A minority of us have a primary care provider that we see regularly. Too many of us neglect maintenance and go straight to specialists when the machine breaks down.

In spite of all this depressing (for Americans) data, Dr. Miles is an optimist: he thinks the U.S. will eventually wake up and improve health care for political and economic reasons. "The US cost of health care is so high that it is hampering our ability to sell products overseas," he told me. "Consider that about 10% of a $40,000 car made in Sweden is the built-in cost of its health-care system. For a similar US car, the health-care component is $6,800. Who will pay $2800 for an invisible car accessory?"

Probably someone who thinks that socialized medicine is diabolical, and that American health care is the best in the world.

WERE YOU BORN ON THE WRONG CONTINENT? by Thomas Geoghegan

Front

Back

Was I born on the wrong continent? Well, if you're talking bread, I'll definitely opt for the baguette. But Geoghegan (rhymes with "Reagan") says little about food, alas, in this comparison between American and Western European - mostly German - lifestyles. Instead, he looks at work, leisure, taxes, benefits, labor, management, social policy...

Don't let your eyes glaze over just yet. Geoghegan is a delightfully quirky writer who manages to convey a lot of information while making you think you're reading a chatty and often humorous travel book. Indeed, travel writing inspires him:

For years I read the front page [of the New York Times] about European unemployment, the collapse of social democracy, etc. But then I'd flip to the travel page and get the real news, the news that they don't dare put on page one, that every year in Europe, the whole place keeps getting nicer.

Geoghegan, a Chicago labor lawyer, made several extended trips to France, Switzerland, and Germany to study European socialism. He gives his conclusion in the preface:

The cover of the February 16, 2009, Newsweek announced: "WE ARE ALL SOCIALISTS NOW." The argument is that U.S. government spending is nearly as high as Europe's. A decade ago, the U.S. government was spending 34.3 percent of GDP, compared with 48.2 percent in the "euro-zone," which is Europe without the UK. Now, while the Continent is at 47 percent, we have gone up to 40.

And, in fact, I think the U.S. will close the gap. But in a sense, the more we spend, the less socialist we become. For whether it is health care or education, we use the private market to pay for the distribution of public goods. In other words, we pay socialist-type taxes so that the private insurance companies, drug companies, and, yes, doctors can profiteer.

That's the crisis of our time: we're paying for European-type socialism, without getting the equivalent payback.

Much of the rest of the book describes the European payback (and this will be counter-intuitive to a lot of American readers): Fewer poverty-stricken seniors and children. Six weeks' vacation time plus more paid holidays. Cheaper higher education, health care, day care, concerts. Paid maternity and paternity leave. Higher old-age pensions. Nursing-home benefits. Cleaner, faster, more readily available public transportation. More efficient land-use planning. Lower unemployment. More successful small businesses.

The only area in which the U.S. outshines its European counterparts is GDP - and Geoghegan offers fascinating observations as to why that actually may be making American lives more frantic and yes, even more expensive than the lives of European socialists.

Ironically, some of the structures that make German socialism work were developed by Americans during the occupation after World War II. Rather than the authoritarian, top-down socialism of the Nazis, the occupiers insisted on a bottom-up socialism where the workers themselves would have a big influence in organizational management. As a result, German businesses are much more democratically run than American businesses, who never adopted the practices themselves.

And some of the German bureaucratic regulation that Americans love to mock, says Geoghegan, has enabled Germany to become a major exporter of durable goods - really durable ones like Mercedes and BMWs - even as the U.S. has been ramping up its trade deficit. In fact, while the U.S. is increasing its debt by $1 trillion a year, Germany has no net external debt - and in fact vies with China for first place in world exports, an amazing feat for a country that has 82 million people compared with China's 1.3 billion. And yet "Americans still seem unaware that it's not just East Asia but the socialist Europeans who have outcompeted us in global markets as we sink deeper into debt."

So was Geoghegan born on the wrong continent? I don't think so. Like T.R. Reid, author of The Healing of America (a wonderfully enlightening book comparing health-care systems in various developed nations), Geoghehan wants us Americans to stop thinking we're best at everything, to start paying attention to how other countries handle vexing problems similar to our own, and to adapt their best solutions to our situation in ways that will give us happier, healthier lives. Our house is on fire, there's a fire station across the street, yet we're trying to fight the fire with buckets of water - or oil. "I know on the right and even in the center I am dismissed as a European-style liberal," he writes. "But my question for those on the right is as follows: do they care about the sovereignty of our country? Then they better start taking seriously what the Europeans do."

Social Security , individual responsibility, and the common good

Several of my conservative Facebook friends responded to yesterday's post about Social Security. I commented that "my dad, who was born in 1910, used to thank God every day for Social Security. Beforehand, he said, Grandpa too often lived in a tiny unheated room in the attic."

One of my friends responded, "LaVonne, I would be willing to bet money that your father would have done fine had he been allowed to keep what is taxed away in Social Security. What would he have been able to do had his lifetime income been 15-20% higher?"

My first response is historical: his income would not have been 15-20% higher, because payroll taxes gradually increased between 1937, when the first taxes were levied, until 1975, when he retired. Combining his tax and his employer's, he actually paid at a rate of between 1% and 5.85% (you can check the table here). If my dad had had that extra money, I'm sure he would have saved it - but it would not have financed his retirement.

My second response is practical. Yes, Facebook friend, at today's rates a person could take that extra 15% a year and finance his or her own Social Security. That is, if the person never was overwhelmed by huge educational loans, never lost his or her job, never lost a wage-earning spouse, never decided to use the extra money for the kids' college education or to pay down a mortgage or for catastrophic illness, never was disabled, and never ever spent the money on a vacation.

But now back to the real world.

Look at what's happening with 401(k)s. The theory behind 401(k)s, like my Facebook friend's theory about Social Security, was that individuals could save for their retirement more efficiently than their employers could. Maybe they could, but very few do. As I pointed out in my previous post, the average 50-something American has saved $29,000. If that person needs $50,000/year (before taxes and medical insurance) to live on during retirement, that person is going to need to have a savings account of $1.25 million dollars, or - if he or she gets the average Social Security benefit of $1164/month - a mere $900,800. According to this nifty goal calculator that takes varying interest rates, inflation, and personal parameters into account, our average wage-earner would need to save $1101.22/month for 40 years in order to save up that $1.25 million. And yes, it could be done - by perfect people in a perfect world.

My third response is moral. My dad would have provided for himself, and probably could have, since he was never jobless, had work with good benefits, was never widowed, and was retired for only 20 years, dying just before a debilitating illness completely exhausted his resources. But my dad wasn't thinking only about himself. He was thinking about his responsibility, as a Christian and as a citizen, to the people that used to be called "the less fortunate." He did not want public social programs cut - even if he would benefit by not having to pay taxes to support them - because he believed they were necessary for the common good.

Is Social Security the best way to assure the well-being of widows, orphans, the disabled, and the elderly? So far, it's the best we've got. No doubt it could be improved. There may be other, better ways to achieve the same goals: if our politicians were all working to serve the common good, their policy debates would serve to strengthen our programs. Sadly, the loudest voices in the land are preaching individual liberty without community concern, or community concern without individual sacrifice, or sacrifice for future generations but not for us.

4 reasons not to mess with payroll taxes

Now that President Obama's people have sent out glowing press releases about how wonderful the proposed tax agreement is ("A Win for Women, Mothers and Working Families"), and Bill Clinton has hailed it as "a significant net plus for the country," and even AARP has signed off on it despite earlier misgivings, may I timidly suggest that the proposal contains one really dreadful item that should terrify all of us in a totally nonpartisan way?

Reducing payroll taxes is a terrible idea.

1. The proposed reduction isn't a mere 2%, even though the amount removed from our paychecks will drop from 6.2% to 4.2%. I won't bore you with the math, but work it out (remembering that your employer will continue to pay 6.2%) or take it on faith - it's actually a 16.4% reduction.

2. Even though Congress says it will make up the difference from general operating funds, may I point out that Congress is also saying it will balance the budget? Bear in mind that Social Security is not currently part of the federal budget, but if general funds are used to keep it solvent, it will become a hostage of Congressional budget negotiations. Is that a good idea?

3. Once taxes are lowered - even if unwisely, and even if the results are devastating - it is almost impossible to raise them again. Hey, isn't that why the President and Congress are working on a tax cut agreement right now? Do we really think that people who plan to run for office in 2012 are going to suggest raising payroll taxes back to 6.2% at the end of 2011?

4. We need the Social Security safety net. If we damage it now, do we have alternate plans for taking care of seniors? Are we still thinking about privatizing Social Security the way we privatized pension plans? Now that was a big success, wasn't it! Did you know that a yearly retirement income of $36,000 requires investments of about $900,000? And that the average American in his or her 50s has saved ... (drumroll) ... $29,000?

An AARP poll last August found that the vast majority of Americans of all ages want Social Security to continue as a guaranteed benefit. Few younger people, however, think it will be there when they need it. If the payroll reduction makes it through Congress this year, Social Security's chance of survival grows still dimmer.

Folks, if we want the goods, we're going to have to pay for them. We can't keep on lowering all our sources of revenue while raising all our expectations of benefits, though a Bloomberg poll released this week shows that that's exactly what most of us want to do. And that's exactly what our politicians keep promising they'll do, even though it's impossible, and even though their efforts are already devastating our economy.

Yesterday Senate Budget Committee Chairman Kent Conrad (D-ND), referring to the Bloomberg poll, said that there's only one way for our elected officials to get us out of the mess we're in:

They have to be prepared to sacrifice their political careers to do what must be done for the nation. Look, if we fail to get our deficits and debt under control, America will become a second-class nation. We are going to slip over the abyss into a fiscal crisis that is as sure as we sit here. 

How many of our 535 voting members of Congress have enough integrity to insist that we need to keep Social Security strong and that we will pay to do so - even if this means raising taxes?

WALKING GENTLY ON THE EARTH by Lisa Graham McMinn and Megan Anna Neff

A life dedicated to God's creation is a life dedicated to loving one's neighbor.

--Megan Anna Neff

Anyone who still thinks evangelicals are anti-environmentalists should read this book. So should evangelicals and other Christians who know that our overburdened earth needs all the help it can get - but who have no idea where to begin.

Lisa Graham McMinn is a professor of sociology, the author of several books,  and a backyard raiser of chickens. Her daughter Megan Anna Neff (no relation to me) has an M.Div. from Princeton, has lived in Africa, and works as a doula. Their new (August 2010) book, Walking Gently on the Earth, is as docile as its title - often personal, usually self-effacing, sometimes lyrical. The authors do not claim to be experts or perfect practitioners of sustainable living, but they refuse to shut their eyes to reality.

McMinn and Neff base their environmentalism on a theology of abundance. Creation is good. It is as important in God's plan as redemption. When we care for the earth, we care for one another.

By contrast, when we hurt the earth - its plants, its animals, its water and air - we hurt one another and our Creator God. And when we refuse to pay attention to what's happening all around us, we become like the bureaucrats in the Harry Potter series. The evil Lord Voldemort has returned, but

the Ministry of Magic thinks announcing the news would cast unnecessary fear into people and require a rather drastic change of focus, altering life as they were comfortably living it.

The Ministers choose to ignore the facts and attack the truth-tellers. Harry Potter knows this can't turn out well.

McMinn and Neff tell the truth, gently. Their eight chapters cover (take a deep breath) creation-care theology, factory farms, fair-trade practices, locally grown food, vegetarianism, consumerism, climate change, alternative energy sources, world hunger, overpopulation, home energy audits, and ... well, quite a bit else.

In just over 200 pages of text, of course, they can't treat any topic in depth. People already familiar with today's environmental issues won't find any new information here, though they may appreciate the authors' pervasive theological theme. On the other hand, people who aren't already environmentally oriented could be overwhelmed. Too much information! Too much to worry about!

Except that Lord Voldemort really is on the move, and hiding from him will not make him go away. The ecological crisis has already begun (see my review of Bill McKibben's Eaarth in the November issue of Christianity Today or online). As individuals, we can't do much to stop it - but together we can make a huge difference in the world. And together is the best way to read Walking Gently on the Earth.

This is a book for classrooms (though it is by no means academic and would need to be supplemented if used as a college text), or for church adult education programs, or for Christian book groups. It is not at its best when read at one sitting. If an hour is all you've got, read McMinn's excellent article in the fall/winter Conversations journal, "Food for the Soul," instead.

If possible, though, join with others to read and discuss this book one chapter at a time. Walking Gently on the Earth is a feast of information and ideas, and feasts should not be celebrated alone. Divide up the links provided at the end of each chapter and bring additional information back to the group. Brainstorm ways to begin practicing the kinds of creation care McMinn and Neff recommend. Together, celebrate God's bounty as you learn to care for the earth's needs.

GIVE SMART - three ideas for making your charitable donations count

A lot of us don't have as much disposable income as we had two or three years ago. Some of us have a lot less. But Christmas is coming, and we still want to give. "It is more blessed to give than to receive," Jesus said (Acts 20:35). Giving makes us feel rich.

Giving is up in 2010, and for that we rejoice. But, warns an article in yesterday's Business Wire, "the small rebound hasn’t been enough to help many nonprofits that are grappling with staff and service cuts even as demand for their services has increased."

It would be great if we could give more. Some of us, if we're honest with ourselves, could do just that. Most of us, though, could give smarter.

How can we make our donations do the most good? Here are three suggestions.

1. Check out charities before donating.
Some charities are outright scams. Some are woefully mismanaged. Even ethical charities differ in their effectiveness - that is, in their ability to get our money to the people we're hoping to help. Before writing those checks, go to Charity Navigator and search for your favorite charities. Beware of any organization that rates less than three stars.

If you have time, browse the website. The top ten lists are especially interesting: for example, "10 Highly Paid CEOs at Low-Rated Charities" and "10 of the Best Charities Everyone's Heard Of." Or look through the entire list of 1770 (as of today) four-star charities.

Charity Navigator does not cover all charities, however. Some excellent not-for-profit organizations fall outside their specifications. If you are interested in a charity that is not listed there, check it out some other way. GuideStar offers information (including tax returns) on a wide range of charities. MinistryWatch profiles and rates primarily Christian ministries and charitable organizations. Or check out Charity Navigator's article, "6 Questions to Ask Charities Before Donating."

2. Give bigger checks to fewer charities.
If you're used to contributing to several charities, it feels somehow wrong to take several off the list. But $1000 given to one charity does more good than $100 given to ten charities, and $100 given to one charity is more effective than $10 given to ten charities. Number 9 on Charity Navigator's "Top 10 Best Practices of Savvy Donors" is this: Concentrate your giving. They explain:

When it comes to financial investments, diversification is the key to reducing risk. The opposite is true for philanthropic investments. If you've really taken the time to identify a well-run charity that is engaged in a cause that you are passionate about, you should then feel confident in giving it a donation. Spreading your money among multiple organizations not only results in your mail box filling up with more appeals, it also diminishes the possibility of any of those groups bringing about substantive change as each charity is wasting a large percentage of your gift on fundraising and overhead expenses.

See, when you give a small gift, you barely pay for the expense of all those letters that start coming your way begging for more gifts. In order to make your gift profitable, many charities sell your name to other charities, who will send still more letters. Your mailbox will fill up rapidly, but not a whole lot will be accomplished for the people or organizations you are hoping to help.

By contrast, when you give a larger gift, the charity wants to hang on to you. No way will they sell the names of their top donors - why risk diluting their gifts next year? They still have to deduct marketing costs, but a lot more remains to do its intended work.

3. Turn your favorite charity into a Christmas present.
Unless you really need more books, liquor, fruitcakes, or whatever your friends tend to get you, put your favorite charity on your Amazon wish list. It's easy to do with the universal wish list button. If you want to know more about how it works for me, read my blog post from last December 1.

In addition, instead of giving friends, colleagues, and neighbors gifts that are useless or fattening, consider donating to a charity on their behalf. Be careful if you choose this approach - be sure the charity you choose is one that will also mean something to them.

This year our parish is especially concerned about a Sudanese health clinic we've been supporting. Sudan is holding an election January 9 to decide whether the southern part of the country should remain part of Sudan, or should separate and form its own independent country. The clinic is in Renk, a border town that will certainly face violence if the vote goes as expected (Aljazeera posted a fascinating article, "South Sudan braces for trouble," today; for more background information, check out my husband's interview with Geoff Tunnicliffe, "Pray for the Peace of Sudan").

Our outreach commission is collecting funds to send to the clinic before the referendum, so it can stock up on medicine and supplies before supply channels are disrupted. Because many of us are concerned about Sudan, David and I have decided to give this card to some of our friends at church and at work. It will cost us about the same as the small gifts we've given in previous years. We hope it will do more lasting good.

FREEDOM by Jonathan Franzen

Normally my book reviews are also recommendations. I write about books I enjoyed, in case others might want to enjoy them too. This time I may be making an exception.

I'm not sure if I enjoyed Freedom, or if I think my friends ought to take the time to wade through its 562 pages. Even though Oprah said, "I am really betting that 'Freedom' by Jonathan Franzen will end up being for you, as it is for me, one of the best novels you have ever read."

See, I did manage to read all 562 pages, and I wouldn't have done that if I'd disliked the book, would I? And very often I found myself chuckling over Franzen's characterizations or political asides or snippets of conversation. The man writes well.

I also enjoyed the vast extended soap opera involving Walter and Patty Berglund; their son Joey and his girlfriend Connie; Walter's feckless parents and brothers; Patty's equally misguided parents, brother, and sisters; Walter's college roommate, the enigmatic Richard; Joey's college roommate Jonathan and his amoral sister Jenna; the highly improbable Lalitha ...

Well, it's a bit like a book Dickens would have written, if Dickens had worried, not about the oppressed poor, but rather about the self-destructive middle class.

And maybe that's why I'm not sure if I liked the book.

It is well titled: it really is about freedom. Franzen uses some form of the word about once every five pages. It is about people who want to be free, who do various things to achieve freedom, but who in the end do not know how to use their freedom to make either themselves or anyone else happy. So Freedom would be a fine choice for a book club that is patient with long books and that wants to have a philosophical discussion about what freedom is, when it is good, when it is bad, how to achieve it, what to do with it.

But since book clubs are generally attended by women, let me advise potential readers that the various stories may contain more male sexual fantasy than you really wanted to read about. Franzen's men tend to think with their dicks, and most of his women, for some reason, are willing to do anything the men want. It isn't porn, but eventually the voyeurism gets tiring.

And despite its comic-novel moments and its odd Hollywood ending, Freedom is a typical Oprah-book downer. Its characters struggle against themselves, and mostly lose. Don't say I didn't warn you.

HARRY POTTER AND THE DEATHLY HALLOWS, PART ONE (opened 11/19/10)

This is not a review of Harry Potter and the Deathly Hallows, part one. There are plenty of reviews already out there, from A.O. Scott's in the New York Times to Todd Hertz's in Christianity Today. No need to add another one, especially since I'm much more a book person than a movie person.

Indeed I have read the seven Harry Potter books about three times each, and I've listened to the Jim Dale audiotapes once or twice each, and I've watched the first six movies at least twice each - and I still feel like an amateur whenever I'm with people who really know Harry Potter backward and forward.

I'm guessing you too have read the books and/or seen the movies, and that's why you're here. So for you I have just a few observations about the new film. I don't think there are any spoilers here, but then I'm assuming you know the plot.

• The movie takes us more or less to page 477 of 759 (U.S. edition).
• I liked the slower pace made possible by splitting book seven into two parts. This movie felt richer, more complete, than the previous movies, which had to struggle to fit far too much story into far too little time. Since part two will cover only 282 pages, it should be richer still. Which is appropriate, because it contains some of the best scenes in the entire series.
• Still, if you want the total Harry experience, read the book or listen to the tape. The movie alluded to much of the content of book 7, but the book develops it in a way no film could do.For example, the film shows the Dursleys departing, but it completely ignores Dudley's amazing about-face. Harry attends Bill and Fleur's wedding as Harry, not as a Weasley cousin. Harry never reads the letter from his mother to Sirius Black. Harry never changes his attitude toward Kreacher. And so forth. I am by no means saying that the film should have included these scenes. It couldn't possibly have done so. I'm just saying the book is even more satisfying, at least for a wordperson like me.
• When I say the film is slower paced than previous films, I don't mean it drags. There are lots of action scenes, chases, explosions. Harry leaves Privet Drive pursued by Death Eaters. Harry, Ron, and Hermione leave the Burrow and encounter more Death Eaters. The three of them cause chaos at the Ministry of Magic. Harry fights Nagini in Godric's Hollow. Death Eaters attack again at the Lovegood house. The trio is captured by snatchers and taken to Malfoy Manor for torture. You know all this: you've read the book. It's still gripping to see it onscreen.
• The film also dramatizes some of the characters' interior struggles. It alludes to Harry's reluctance to continue on a path that may bring harm to his friends. It explores Ron's feelings of jealousy and inadequacy. Unfortunately, it completely skips Lupin's ambivalence about impending fatherhood, and the wonderful dressing-down Harry gives him when he tries to join the trio. That surprised me, since it seems necessary to some of what will happen in part two.
• This is not a free-standing movie. It ends in the middle. The quest will be more difficult in the final installment: Harry and his friends have not finished their tasks, but Lord Voldemort has found the weapon he covets. When the credits started to roll, a man in the row ahead of me yelled, "Oh, no!" There's no way anyone who likes part one will be able to skip part two.
• This is a very sophisticated film. I don't have the necessary film buff's vocabulary to tell you exactly why, but there's a stylized, contemporary feel to the artfully composed scenes. And despite its darkness, it has humorous moments: the dialogue is often witty.
• Though I saw the film on an Imax screen, Imax may be overkill. Mercifully, there was no 3-D to contend with (the snake attack was still terrifying). Since there are no flights on dragonback or in specially rigged Ford Anglias, the tall screen is less necessary than in some of the previous movies. Sometimes, in fact, the characters were just too large. I wanted to back up and give them a bit more room.

OK, that's enough for tonight. I hope you enjoy the movie. I look forward to seeing it again at least once before part two is released next July. And maybe I'll reread the book. Maybe I'll even reread all seven of them.

THE BATTLE OF ALGIERS (DVD)

Terrorism and torture - they're all over this week's (and most week's) headlines: "Germany tightens airport security over attacks threat." "Palestinian forces arrest Hamas cell in West Bank planning to attack Israelis." "Britain to pay ex-detainees in torture case."

Saturated with such stories since the bombings of 2001, we may think that terrorism and torture are 21st-century inventions, or at least that their incidence has greatly increased during the last decade. We need correctives like Patrick Smith's article in Slate last week: "News flash: Deadly terrorism existed before 9/11." Indeed it did - Smith lists example after example from the late 1980s. And torture, a typical response to terrorist attacks, is as old as recorded history.

Here is another corrective - a film you need to see, though not for date night. Little kids shouldn't watch it either. The Battle of Algiers is a fictionalized account of urban guerilla warfare during Algeria's bloody war of independence from France (1954-62). Winning a heap of prizes shortly after its release in 1966, it was immediately banned in France and essentially went underground for 37 years.

And then in 2003 the U.S. Pentagon showed the film to about 40 officers and civilian experts. From the flier announcing the screening:

How to win a battle against terrorism and lose the war of ideas. Children shoot soldiers at point-blank range. Women plant bombs in cafes. Soon the entire Arab population builds to a mad fervor. Sound familiar? The French have a plan. It succeeds tactically, but fails strategically. To understand why, come to a rare showing of this film.

The Pentagon showing led to renewed interest in the film, which was restored and then released in the U.K., the U.S., and France in late 2003 and 2004. The DVD version followed in October 2004. You can rent it from Blockbuster online or from Netflix.

Why should you see this film? Partly because it's so very well done. From Ali La Pointe, a disaffected Arab teenager who becomes a leader in the National Liberation Front, to Colonel Mathieu, an unbending French military man who plays by the rules, each character first draws you in and then appalls you as terrorism and torture alternate in a deadly dance. In a mesmerizing sequence, a trio of Arab women don Western garb and charm their way past French guards into the European quarter - with disastrous results. Should you laugh? Cheer? Weep? You may find yourself doing all three. The one thing you won't be able to do is look away from the screen.

Another reason to see the film is to stimulate thinking and provoke discussion about current conflicts. In The Battle of Algiers,as in the news, terrorists kill civilians. Counter-terrorists move in and do the same. Torture is used to gain information. Tortured terrorists become martyrs and incite renewed terrorist activity. Violence explodes on all sides. It sounds so very contemporary.

And yet, whatever your opinions about Iraq or Afghanistan or Guantánamo, it's hard to take sides when the film takes you into the Casbah or the European quarter or the military headquarters. You find yourself sympathizing with the Arab child who grabs the officer's microphone and tells his people to resist, with the frightened women who hide insurgents in a well or behind a false wall, with the terrified man who talks rather than face another round of torture, and perhaps even with the teenager who has lost so much and now just wants to shoot somebody.

At the same time, you cringe when European teenagers are blown to bits when all they are doing is flirting and dancing to salsa music, or when tired businessmen grabbing a quick drink after work lose their lives because they neglect to see a basket left under a bar stool. You understand the colonel's perplexity when he says to reporters:

We aren't madmen or sadists, gentlemen. Those who call us Fascists today forget the contribution that many of us made to the Resistance. Those who call us Nazis don't know that among us there are survivors of Dachau and Buchenwald. We are soldiers, and our only duty is to win

But what about torture? a reporter persists. Colonel Mathieu gives the only answer he knows:

Should we remain in Algeria? If you answer "yes," then you must accept all the necessary consequences.

Terrorism and torture have a long and sordid history, and this film does not glorify either one. Yes, the terrorists eventually win and the French are expelled from Algeria. Yes, The Battle of Algiers has been accused of inspiring violence - though it has also been used as evidence that torture does not work. It's an ethically complex film that may haunt you for days. It might even turn you into a pacifist.

What vegetarians eat on vacation

It used to be really hard to eat vegetarian while traveling, especially if you were traveling from Washington to Illinois with vegetarian children who refused to eat any food that might have been cooked on a griddle that may also have been used for hamburgers (I speak from experience).

In the thirty years since that stressful trip, America's food tastes have changed. It's now almost easier to eat vegetarian in a restaurant than at home. Even in barbecue-loving Texas, where we just spent nine days.

The easiest way to do it? Eat ethnic.

We ate Italian at Hasta la Pasta and Vespaio Enoteca, Colombian at La Palma de Cera, Ethiopian at Blue Nile, Chinese (sort of) at Panda Express, Mexican at Los Cucos and El Chile, Thai at Thai Kitchen, Middle Eastern at Pita Pit, and Indian at Udipi Café. The winner: La Palma de Cera (Katy) - and if you go there, you must try the flan, which is the best we've ever tasted. Runners-up: El Chile (Austin) and Blue Nile (Houston).

In addition, we ate lentil soup, tamales, and an eggplant sandwich at the delightful Hyde Park Bar and Grill, which despite its name has a range of vegetarian options; strange but tasty concoctions at the vegan bar in Austin's gigantic mothership Whole Foods store, pancakes and sweet potato hash at the famed Kerbey Lane Café, sandwiches and fresh fruit at the Lady Bird Johnson Wildflower Center café, and tilapia and green beans at Pappadeaux in Houston's Hobby airport. One evening we bought stuffed portabella mushrooms, Greek potato salad, and green beans at Whole Foods and ate dinner in our apartment. Another evening we went to Central Market and brought home herbed risotto croquettes, cauliflower in truffled oil, and balsamic glazed yams.

We never went hungry. We never had trouble finding good, affordable food.

Eating while traveling would probably be more difficult if we were vegans. We cheerfully eat dairy products and eggs (though we do our best to buy them from organic farms, or at least from farms that give their cows and chickens pasture time). We also eat a little fish. The term for what we are seems to be pescetarian, though we prefer a friend's neologism: vegequarium (others might call us part-time vegetarians or pseudovegetarians: you can read a vegetarian taxonomy here). We had tilapia at the Colombian restaurant as well as at the airport, and David had fish tacos at Los Cucos. Most of our meals, however, were lacto-ovo-vegetarian.

Why eat vegetarian while traveling? Well, if you're a committed vegetarian, that's what you do. But even if you aren't, there are advantages to making some of your restaurant meals vegetarian. Take your pick:

• Reduce your fat intake, which always seems higher in restaurants.
• Lower your chances of encountering food-borne bacteria.
• Enjoy interesting new tastes, especially if you go ethnic.
• Feel better, thanks to all those fruits and veggies.
• Save money.
• Save the planet.

Also, the vegetarian selections are often very, very good.

Eradicating Alzheimer's disease - if not now, when?

Are you hoping to live to at least age 85? If so, there's good news and bad news.

• The bad news - If you turn 85 in the next ten years or so, you'll have about a 50% chance of getting Alzheimer's disease.
• The good news - Researchers have never been closer to finding a cure.
• The unfortunate news - Alzheimer's research is inadequately funded.
• The hopeful news - Last February a bill was introduced in the U.S. Senate that would commit adequate personnel and resources to fighting this disease.
• The frustrating news - The bill went immediately to committee, which means it is competing with thousands of other bills for attention. Most bills die in committee.
• The scary news - The Alzheimer's Association projects that the number of people affected with the disease will increase by 50% over the next 20 years; by 40 years from now, it will have doubled or even tripled.

For me, Alzheimer's has a human face. The pictures on the left show my mother as a bride, a mother, a grandmother, and a great-grandmother. She died at age 85, a few weeks after the last picture was taken, after living for about six years with Alzheimer's. My father died four months earlier, the week before his 85th birthday, with the same disease. My mother-in-law suffered increasingly for about 10 years before dying with Alzheimer's at age 86.

I, for one, want to get this bill out of committee and onto the Senate floor immediately.

No time to waste
 We have no time to waste, say Sandra Day O'Connor, Stanley Prusiner, and Ken Dychtwald in "The Age of Alzheimer's," an op-ed piece in yesterday's New York Times:

Starting on Jan. 1, our 79-million-strong baby boom generation will be turning 65 at the rate of one every eight seconds. That means more than 10,000 people per day, or more than four million per year, for the next 19 years facing an increased risk of Alzheimer’s.

The authors argue that ignoring the oncoming wave of people with Alzheimer's is going to cost the government (and individual families) huge amounts of money. Adequately funding research, by contrast, could save trillions of dollars in Alzheimer's-related care by relegating "Alzheimer's to the list of former diseases like typhoid, polio, and many childhood cancers." Eventually Alzheimer's will be conquered - but "unless we get to work now, any breakthrough will come too late to benefit the baby boomers."

As a 62-year-old boomer myself, I would like to see this disease wiped out soon - not only for my sake, but also for the sake of my husband, children, and grandchildren.

Alzheimer's is a terrible disease. It isn't just Grandma getting pleasantly vague. As Alzheimer's progresses, a person no longer knows where she is or what she is doing there. She doesn't recognize friends, family members, or - eventually - even herself. Her emotions rage out of control. She may leave the house and wander strange neighborhoods, gather small objects and redistribute them throughout the house, forget what she is cooking and start small fires. She may become paranoid or even violent. And because she knows something is terribly wrong but she doesn't know how to get help, she is often depressed, angry, or frightened.

Some of my friends believe that the government should stay out of health care. Good health habits and private funding, they have told me, should suffice, and families should take care of their own. In dealing with Alzheimer's, however, those solutions are inadequate.

There is currently no way to prevent Alzheimer's. My parents, who both died with Alzheimer's,  did not get it because of bad habits. They ate a mostly vegetarian diet and never drank alcohol or smoked. They exercised regularly, walking three miles most days. They were sociable people who spent lots of time with friends. They were people of faith. They were well educated. They read books. My father even wrote books. The thing is, you can do everything on those how-to-prevent-Alzheimer's lists and still get Alzheimer's.

Few families are equipped to take care of a person in the middle or later stages of Alzheimer's. I wanted to take care of my parents myself, but Alzheimer's is not like other debilitating illnesses. People with Alzheimer's are a danger to themselves and to others 24/7. One daughter with two sick parents is not up to the task. One elderly father-in-law with one sick wife eventually needs help. Nursing homes can't do a good job on their own either. But a good nursing home or board-and-care home, working in cooperation with caring family members, can at least keep the patient clean, fed, safe, and somewhat socialized.

Unless one is very rich or dies very quickly, private funds will not cover the cost of necessary Alzheimer's care. Many families can't afford any paid help. If the wage-earners must continue working, they may have to leave Mom at home alone, hoping she won't get lost, set the house on fire, or break a hip. Middle-aged and older daughters often quit their jobs to care for an ailing parent, thus reducing their own retirement savings and Social Security benefits and making it more likely that their children will have to do the same for them.

My parents were fortunate - they had private insurance, including nursing-home insurance. Those funds, together with Medicare, Social Security, and their life savings, barely paid for their combined total of seven years of care, even though they received quite basic services in a nursing home that charged comparatively modest rates. (If a family wants to keep the patient at home and hire helpers, the cost is far higher.) If my parents had lived just a few months longer, I would have had to apply for public aid for them, in spite of their lifetime of frugality, saving, and wise decisions.

But there is reason to hope that one day Alzheimer's disease will be eliminated!

Researchers in the private sector are making tremendous strides toward eradicating this disease. A lot more funding is needed, however - not just for patient care (though that need is growing at an alarming rate), but especially for research so that patient care will no longer be necessary.

O'Connor, Prusiner, and Dychtwald compare Alzheimer's research today with AIDS research 25 years ago:

In the mid-1980s, when our country finally made a commitment to fight AIDS, it took roughly 10 years of sustained investment (and about $10 billion) to create the antiretroviral therapies that made AIDS a manageable disease. These medicines also added $1.4 trillion to the American economy. The National Institutes of Health still spend about $3 billion a year on AIDS research, while Alzheimer’s, with five times as many victims, receives a mere $469 million. 

That means we are spending 32 times as much on each person with AIDS as on each person with Alzheimer's, and with demonstrably good results - people with AIDS are living longer, and more money has been injected  into the U.S. economy. We were wise to commit to fighting AIDS. Now it's time - past time - to commit to fighting Alzheimer's as well.

What we can do today
If you've read this far, you probably have a personal interest in wiping out or containing Alzheimer's disease. Perhaps you already donate to the Alzheimer's Association. Consider contacting one or both of your senators as well. If one of them is among the 23 on the Health, Education, Labor, and Pensions committee where the National Alzheimer's Project Act is languishing, urge him or her to recommend its passage to the full Senate. If your senators are not on the committee, encourage them to schmooze with those who are. Here's what I've written to Senator Dick Durbin. If you wish to borrow any of my words when writing to your senators, feel free. You can find an easy-to-use e-mail form for contacting your senators here.

Dear Senator Durbin:

I'm writing in support of S 3036, the National Alzheimer's Project Act, which was introduced to the Senate last February 24, read twice, and referred to the Senate Committee on Health, Education, Labor, and Pensions.

Finding a cure for Alzheimer's disease would save untold billions of federal, state, and private dollars over the next 40 years as we boomers age and decline.

Without a strong federal commitment to eradicating the disease, however, a cure is unlikely to be developed before millions of people suffer and billions of dollars are spent, all unnecessarily.

I realize that you are not on the committee that is supposed to be studying this bill, but you know the people who are. You have consistently supported legislation that improves health and helps the needy. As an aging boomer and the daughter of two parents who died with Alzheimer's disease, I hope you will be able to influence your Senate colleagues to get S 3036 out of committee and to get moving on a strong national commitment to eradicate this tragic disease.

Respectfully yours,
LaVonne Neff

ALMOST FRENCH by Sarah Turnbull - and other books by people who straddle two cultures

Sarah Turnbull's Almost French is neither new (copyright 2002) nor unique, but it's an excellent example of a genre that never fails to attract me.

The set-up: an English-speaking writer falls in love with a foreign place or person, usually non-English speaking. Often impulsively, the English-speaker leaves home and moves to a country whose customs are quite different from his or her own.

At first the writer is thrilled and dazzled. Then reality sets in, and he or she discovers how very different the two cultures are. Food usually plays a major role in the story, as - often - does home purchase and repair.

Inevitably, the displaced Anglophone writes a memoir.

Well, it worked for Peter Mayle, an English marketer whose steady stream of books beginning with A Year in Provence set high standards for the genre. It also works for Sarah Turnbull, an Australian journalist who, entranced by a Frenchman she met in Romania, goes to Paris to visit him for a month. That was in 1994, and, as far as I know, she is still there.

One reason these two authors succeed at this genre is that neither is a navel-gazer. They write about their experiences, to be sure, but their focus is on France - the rural south for Mayle, contemporary Paris for Turnbull. Her life as an ex-pat is often lonely. Because at first she does not understand the French language, social customs, dress codes, family traditions, bureaucracy, or ways of getting around red tape, she is frequently frustrated.

At the same time, she loves "the heart-stopping beauty of Paris," its "history and tradition, passion and beauty, art and inspiration - everything that makes France a measure of civilized life." More prosaically, she also loves her sixth-floor walk-up apartment, good coffee and croissants, and even the neighborhood drunks who show "the rich diversity of life within a small circumference." She has a love-hate relationship with France, she confesses, "but it's charged with so much mystery, longing and that French specialty - séduction - that we can't resist coming back for more."

Nor can I resist coming back for more books about people who follow their dreams and become ex-pats in countries they will never quite understand. This is probably because I've had a taste of the ex-pat experience myself: as a teenager, I studied for a year in France, and in middle age, I worked for a British company. My best friend in grade school moved to Florence nearly 40 years ago and has lived there ever since. One daughter has studied and lived in Bogotà and Taipei; the other daughter has studied in Munich and Salzberg. A granddaughter is hoping to study in China year after next. My husband and I occasionally talk about retiring, at least for a year or two, in a foreign country (aren't new experiences supposed to keep brain cells young?). Given the current high price of the Euro, however, it probably won't be France or Italy.

Meanwhile, I love to read about people who straddle two cultures. Here's a list of other bicultural memoirs I've enjoyed.

• Bryson, Bill. Notes from a Small Island. Bryson, an American, lived for 20 years in the U.K. with his British wife. Here he describes his farewell tour before moving back to the U.S.
• Child, Julia. My Life in France. Love, food, France, and the indomitable Julia Child. What could be better?
• De Blasi, Marlena. The Lady in the Palazzo and various other memoirs about an American woman in Italy. Lavish, sensual, self-absorbed.
• Gopnik, Adam. Paris to the Moon. New Yorker essayist takes family to live in Paris for five years. Excellent and often very funny reportage.
• Keenan, Brigid. Diplomatic Baggage. Hilarious tales by a diplomat's wife who has been an ex-pat on several continents.
• Lenard, Yvone. The Magic of Provence.  Lenard, a French ex-pat who spent most of her adult life in California, writes about moving back to France. Instead of struggling for years (like most authors in this genre) to restore an old house, she and her husband simply hire a contractor and go back to California. When they return, their house is all ready for them. Now that is magic.
• Mayes, Frances. Under the Tuscan Sun and Bella Tuscany. Mayes is an American woman in Italy and Mayles is a British man in France, but otherwise their stories are similar.
• Robb, Peter. Midnight in Sicily. Robb, an Australian, lived in Sicily for 14 years. Here he looks at Sicilian food, history, politics, and organized crime. Among other things.
• Sanders, Michael S. From Here You Can't See Paris. An American spends a year writing about a village and its restaurant in rural southwestern France.
• Simeti, Mary Taylor. On Persephone's Island. American-born Simeti, now in her 70s, married an Italian professor in 1964 and still lives in Sicily. This now-classic ex-pat memoir was first published in 1986.

The estrogen bogeyman - why not to panic

Today's news brings yet another scare for women of a certain age. "Breast Cancer Seen as Riskier with Hormone," trumpets the oddly worded headline in this morning's New York Times, which summarizes the JAMA findings also released today.

No, this isn't old news, though it's based on the Women's Health Initiative study that was stopped several years ago because the estrogen-using participants kept coming down with dread diseases. Long-term results have recently been analyzed, and women who take Prempro are clearly at greater risk than women who do not.

But the headlines are misleading for several reasons.

First, the WHI studied only one form of estrogen--and it's the one most likely to cause problems. The WHI studied women using conjugated equine estrogens. These are laboratory produced hormones that are not biologically identical to the hormones produced in a woman's body. Premarin is based on the estrogens found in PREgnant MAres' uRINe, some of which are much more potent than human estrogens. It is somehow unsurprising to learn that long-term use of substances that do not naturally occur in the human body may have deleterious side effects.

Second, estrogen is probably not the culprit in increased breast-cancer risks anyway (though it may increase other risks). According to the National Institutes of Health, the risk does not apply to hysterectomized women who take only estrogen, not estrogen plus some form of progesterone. Since about 1/3 of all American women will have had a hysterectomy by age 60, that's a fair number of women who can apparently take estrogen without raising their risk of breast cancer - and who may need to do so, since they have lost their natural source of the hormone.

Third, biologically appropriate hormones are under-researched. Bioidentical hormones, though synthesized from plant sources, are "identical in molecular structure to the hormones women make in their bodies" (see this explanation and list of bioidentical hormone medications). Reputable studies of bioidentical hormones, however, are hard to find, and to my knowledge no longitudinal study comparable to the WHI study of Premarin and Prempro has ever been made. Are these hormones safer than hormones that do not match those our bodies naturally produce? A lot of women think so, but we don't know yet.

So what is a woman to do?

Well, if we don't need hormone replacement therapy, we certainly shouldn't use it. If we need it for hot flashes only, we should quit using it periodically to see if the need has passed. But if for some reason we need to use HRT for many years, we don't need to panic. Every medicine has potential side effects, and some risks are worth running.

To minimize the risks, we can look for hormone formulations that mimic human hormones. We can look for delivery methods, such as the patch, that appear to be safer than HRT in pill form. We can monitor those body parts that our HRT use may be slightly endangering.

And just maybe we need to consider our mortality. I'm not going to live forever. I can't avoid every possible risk. Even if I were able to give up absolutely everything that's bad for me, would I really be better off? Would I live longer, or would it just seem longer? Would I be healthier, or would I worry myself to death?

"If it feels good, do it," we boomers liked to say when we were young and immortal. Well, maybe that's not an entirely helpful philosophy. And yet feeling bad so as to avoid a very small risk may not be such a great philosophy either.

Several years ago I was explaining to a middle-aged doctor why I hoped she would prescribe an estradiol patch for me. "I have to tell you about all the potential problems," she told me. "But if anyone wants to take away my estrogen, they'll have to pry it out of my cold, dead hands."

THE CHARMING QUIRKS OF OTHERS by Alexander McCall Smith

If you're not already a McCall Smith fan, The Charming Quirks of Others - book 7 in the Isabel Dalhousie series - may not be the place to start. Most readers get hooked on the No. 1 Ladies' Detective Agency series (now up to 11 titles) before moving on to the first book about Isabel, The Sunday Philosophy Club, though the Dalhousie series is also a fine introduction to the man who surely must be Scotland's most prolific writer.

But if, like me, you're a confirmed McCall Smith devotee, you know without my telling you that, with his newest book, you're in for another evening or two of reading that's as comforting as a mug of hot chocolate.

Isabel, the kindly, rich, slightly snoopy, and incessantly worrying Edinburgh ethicist, has several things to think about. Will she be able to purchase the Raeburn portrait of her ancestors? How will she, as editor of the Review of Applied Ethics, deal with a presumptuous author she strongly dislikes? Can she - should she - help a woman she barely knows find out who has written an anonymous letter, and why? Has her niece, Cat, finally found a decent boyfriend? Is her fiancé, Jamie, having an affair?

The interwoven stories are fun - McCall Smith is a very funny writer. And Isabel's constant musings are delightful and, sometimes, thought provoking - McCall Smith is also a professional philosopher. Listen to Isabel thinking about why we are interested in genealogy, for instance:

Blood links, she thought; that was what it was about. However tenuous such links were, people regarded them as standing between themselves and the void of human impermanence. For ultimately we were all insignificant tenants of this earth, temporary bearers of a genetic message that could so easily disappear. We had not always been here, and there was not reason to suppose that we always would be. And yet we found such thoughts uncomfortable, and did not like to think them. So we clung to the straws of identity; these, at least, made us feel a little more permanent.

I love McCall Smith's storytelling and philosophizing, but even more I love his kindness. His characters are often odd and bumbling, but they mean well. They care for one another. They believe in forgiveness. They know how to love.

Isabel and Jamie, for example, having picnicked on Scotch egg pie and cucumber sandwiches, are now lazily talking. "You're very kind," Isabel says.

"Because I love you so much," he said. "That is why I like to be kind to you."

"And that is why I shall bring you all the flowers of the mountain," said Isabel. "For the self-same reason."

She went on to say something else, but Jamie found his attention drifting. He was feeling sleepy, for it was warm, and he could lie there for ever, he thought, listening to the sound of Isabel's voice, in the way one listens to the conversations of birds, or the sound of a waterfall descending the side of a Scottish mountain; sounds for which we cannot come up with a meaning, but which we love dearly and with all our heart, and loving anything with all your heart always brings understanding, in time.

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To read my reviews of other McCall Smith books, click here and then click on the titles that interest you.

Dear Candidate: Would you mind talking about your goals?

It's midterm election time. How are you going to vote? Well, it's obvious, isn't it? Your side - whichever it is - is the only one that will save America from utter financial and moral collapse. The other side - whichever it is - is full of liars and hypocrites controlled by unscrupulous cabals who, for financial reasons, are willing to ruin the common man. And woman.

I am so tired of political invective. I have come close to unfriending some very nice people on Facebook because they are always saying nasty things about the only party of truth and light, i.e., the one I favor. (Though nasty internet comments are certainly not limited to discussions of politics: I just read through a long list of vicious personal attacks that had to do with the genetics of an Airedale terrier.)

Can we for a moment lay aside our overweening sense of personal righteousness and talk reasonably about goals?

Politics is a process of people working together to achieve goals that are good for everybody. Often we agree on the goals, though we disagree violently about how to achieve them. For example, I imagine we all think that if Great-Grandmother develops Alzheimer's disease and becomes difficult to care for, she should not be left in the street to fend for herself. We probably agree that all children who have the capacity to read and write should be taught to do so. The vast majority of us think it's a good idea for a large country like ours to have an interstate highway system. Nearly all of us would like to live in an economy where jobs are plentiful and wages are adequate.

Where we disagree, of course, is how to achieve our goals, and a two- or multi-party system can stimulate our thinking by challenging our presuppositions and enlarging the range of options we consider. It's hard to believe, but several decades ago Democrats and Republicans often discussed issues respectfully and worked together to arrive at solutions. The Internet would allow us to do this again, if only we would stop calling names.

How are you going to vote in November? How about setting party labels aside and asking some goal-oriented questions of your candidates? And since many candidates are good at spinning their answers, how about setting campaign rhetoric aside and looking at what your candidates have actually accomplished in each area?

Here are ten goals that are important to me, with questions I need to consider:

1. Which candidate's policies are more likely to help people escape from poverty? (I put this in first place because I am a Christian, and the ethical issue that receives the most space in the Bible is concern for the poor. I believe each party has a valid contribution to make to this issue, and I'd like to see both parties make it one of their major goals.)
2. Whose policies are more likely to create long-term jobs?
3. Whose policies will have a better effect on public health?
4. Whose ideas are more likely to provide high-quality education for children of all socioeconomic levels?
5. Whose ideas will better help us restore our decaying infrastructure?
6. Who is more likely to handle finances responsibly, keeping budgets balanced and planning for the future?
7. Who is more likely to show responsibility for the environment, keeping in mind not only our present needs but also the needs of generations to come?
8. Who is least likely to bow to the special interests that are financing his or her campaign? Who is least likely to be influenced by lobbyists? For that matter, which special interests are behind which candidates? (Open Secrets is a nonpartisan site that will help you follow the money that is following your candidates.)
9. Who is more likely to make accurate public statements? (Fact Check is a nonpartisan site that helps to sort out fact from fiction.) Note: It is possible to make an inaccurate statement without lying, but you probably don't want either a liar or an ignorant person representing you.
10. Who has the better understanding of the common good - that is, that society depends on our working together, especially to help those who can't help themselves and to build that which we can't build alone - and not just on our getting the best possible deal for our individual selves?

I don't believe either party has a corner on morality, justice, truth, intelligence, or good will. There are a few people of integrity and a lot of scoundrels leading both parties. I'd like to see us stop bickering about means and get to the important questions - what are we trying to accomplish in our towns, counties, states, and nation? And how can we work together to reach those goals?