Ed Friedlander, M.D., Pathologist

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

I am presently adding clickable links to images in these notes. Let me know about good online sources in addition to these:

Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at KCUMB for making it possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!


More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
What is Cancer?
Cancer: Causes and Effects
Immune Injury
Other Immune
HIV infections
The Anti-Immunization Activists
Infancy and Childhood
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Violence, Accidents, Poisoning
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Alternative Medicine (current)
Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB

A bone to the dog is not charity. Charity is the bone shared with the dog, when you are just as hungry as the dog.

If more of us valued food and cheer and song above hoarded gold, it would be a merrier world.

If you say to people, "Go in peace, be warm and fed", but do not give them what the body needs -- what good is it?

A hungry man is not a free man.

If the misery of the poor be caused not by the laws of nature but by our institutions, great is our sin.

It is better to ask some of the questions than to know all of the answers.

KCUMB Students
"Big Robbins" -- Environmental / Nutritional
Lectures follow Textbook

QUIZBANK: Nutrition

Trauma / Environmental / Nutritional
Iowa Virtual Microscopy
Have fun




PROTEIN-ENERGY MALNUTRITION ("marasmus-kwashiorkor")

{46292} kwashiorkor
{46293} kwashiorkor
{46294} fatty liver in kwashiorkor

{46291} marasmus

VITAMINS: catalysts that the body cannot synthesize by itself.

VITAMIN D: (NEJM 357: 266, 2007; Am. J. Clin. Nutr. 87: 1080-S, 2008; NEJM 364: 248, 2011; Mayo Clin. Proc. 86: 50, 2011; Mayo Clin. Proc. 88: 720, 2013; Lancet online Jan 10, 2014)

        Women in countries where they are required to remain veiled when they go outdoors are at greatly increased risk for rickets (Eur. J. Clin. Nutr. 50: 315, 1996; in sunny Kuwait, can you believe it?!).

{12027} rickets, x-ray with bent bones
{15919} rickets, sub-periosteal bone is forming strangely
{15921} rickets, rib; that growth area just doesn't look right....
{38183} rickets, bow-legs

{15932} infant purpura; vitamin K would have prevented this

{05940} scurvy, mouth
{46398} scurvy, sub-periosteal hematoma; this hurts
{38195} scurvy case, bone, osteoid has formed poorly (tiny trabeculae), there is a bleed

Scorbutic rosary, bleeding gums
McGill Center for Tropical Disease

Typical rash
New England Journal of Medicine



I have more flesh than another man, and therefore more frailty.

They are as sick that surfeit with too much as they that starve with nothing.

{07135} obesity

WORLD HUNGER (See CMAJ 173: 279, 2005): Still our world's most serious problem.

As used by social scientists, POVERTY means a total income less than three times the cost of a healthy, varied diet. ABSOLUTE POVERTY means a total income less than the cost of a diet sufficient to allow the person to work at his or her maximum capacity. Presently, one human being in seven lives in absolute poverty. The DEMOGRAPHIC TRANSITION is the transformation of a society from high-birth-rate, high-mortality to low-birth-rate, low morality, along with all the changes that happen as a result (adequate nutrition, peace, safety, more opportunities to lead satisfying lives, public health, a cleaner environment, the rule of decent law).

KCUMB students: The rest of this handout is "totally for your information" rather than the upcoming exam. Don't be surprised if it impacts not only your discussions with friends, or even your own future.

It is very difficult to 'love thy neighbor' when basic resources such as clean water, energy, land, work, health care, and food are severely limited. These resources become daily more scarce because of the policies of the leaders of [---] and [---]. A huge "underclass" exists on a global scale and is evolving even within the richest nations. To organize an equitable distribution of basics worldwide seems impossible; and we face a future of even more nationalism, racism, ethnic and religious fanaticism, and ecological disaster. How to solve these problems nobody knows, but one thing is clear -- that the larger the world population, the more difficult it will be to achieve peace and justice on earth.

Neglect of an effective birth control policy is a never-failing source of poverty which in turn is the parent of instability and crime.

All wars arise from population pressures.

Beyond a critical point within a finite space, freedom diminishes as numbers increase. This is as true of humans in the finite space of a planetary ecosystem as it is of gas molecules in a sealed flask. The human question is not how many can possibly survive within the system but what kind of existence is possible for those who do survive.

"Big Robbins" eloquently describes the problem of people simply not having enough to eat. There is a great deal of bad information about the causes and possible remedies for world hunger, and there are many opportunities for people with agendas to lie with statistics.
    Goya Famine picture
    Goya, "Famine"

The most important event of the twentieth century was the DEMOGRAPHIC TRANSITION, the change throughout much of the world from high-fertility and high-mortality to low-fertility and low-mortality. In a majority of today's nations, people now have a reasonable expectation of living, and having their children live, through healthy middle age. And there is far greater personal security and many more opportunities for a person to choose his or her path through life. Antibiotics, safe surgery, sanitation, immunization, and reliable birth control have made this possible. And of course real democracy is at the heart of the change. As a result, fertility drops to zero-total-growth. Today, the populations of the US, Northern Europe, and Australia-New Zealand grow only by immigration. And as once-poor countries such as Mexico, Brazil, India, and Indonesia industrialize, the fertility rate has been dropping dramatically.

In 2008, the highest fertility rates were in the poorest nations of sub-Saharan Africa, with 48 births / 1000 population each year. Even with enormous childhood mortality, populations will double every 25 years or so. Palestine, Afghanistan, and Yemen also have very high birth rates. In the Western Hemisphere, Haiti, Guatemala and Bolivia have the highest rates. Each of these nations has special problems that have prevented the demographic transition. The lowest birth rates (around 8 per 1000) are in the emerging Soviet-block nations, with older populations and transitionining to a first-world economy.

In 1950, half the people in the world went to bed hungry. Today, only about 1 person in 7 goes to bed hungry. In 1960, the average person got 1900 calories per day; in 2000, it was up to 2700. In the developing world, grain production per capita has grown from 155 kg/person in 1960 to 225 kg/person today; the rise has been basically steady. Much of this is the result of the "green revolution" of the 1970's that developed and introduced strains of staple plants that grow more food when subjected to intensive irrigation and fertilization.

Only a fool or an ideologue could believe that we could feed our 6+ billion people without chemicals and other technology. And the Green Revolution has not been without its problems. Radical irrigation programs have contributed to the expansion of the world's deserts. So has the kind of overcultivation that leads to the washing away of soils. And even fertilizers, of course, damage soil over the long run. You'll hear many different claims about just how serious this is; I have noticed that very little is being written in refereed scientific journals about soil depletion as a long-term threat. I do expect that there will be some new conflicts over water availability in the next decade, especially in India, Pakistan, North China, and the Middle East. When (not "if") we run out of petroleum, we will need an alternative source of cheap energy to continue producing fertilizer. (I'm hoping for controllable nuclear fusion, but this may never be possible. Perhaps I'll live long enough to see construction begin on the huge solar panel in the Sahara...)

Somalia, early 1990's
The bottom line is that in today's world, all hunger is political. Until 2007, there was a global food surplus, i.e., plenty of food to feed everyone, including the children. The problem was in the distribution -- and herein lies the ongoing problem. Today's world food shortage should be remediable in the short-run, but the problems remain the same, and will only get worse as long as it is in the interest of people in the poor nations to have large families. Yes, it's baffling (J. Am. Diet. Assoc. 103: 1046, 2003) -- especially if you don't think the near-unthinkable -- and realize the truth. Right or wrong (or neither), hunger remains the major means of keeping people under control throughout the poor nations. Wherever there is widespread hunger, it is because people with guns are preventing good people from the rest of the world from bringing in food.

Most of the suffering is borne by children (Br. Med. J. 304: 1423, 1992); in fact, as recently as the 1980's, around 40% of the children in the developing world died before reaching age 5 (Med. J. Aust. 154: 227, 1991), and in the large majority of cases, malnutrition is at least a major contributing factor. How the new, more-effective UNICEF does its work today: Lancet 364: 1801, 2004. (New term: a "complex emergency" means a war using hungry civilians as pawns.)

The world population is growing by perhaps 80 million per year, almost entirely in the poor nations. In some poor countries, population has historically doubled every 17 years (Lancet 33: 1705, 1990), with hunger providing the principal brake on an even more rapid rate of increase. The U.S., Canada, Northern Europe, and Australia have populations that grow only by immigration. We learn with hope of a spectacular drop in fertility during the 1990's throughout the historically poor nations of East Asia and Latin America as young adults see a future of greater economic opportunity and personal freedom in the new democracies. We can hope that someday that this will be true everywhere. In countries in which the average woman has 7 children and there is 40% chld mortality, the population still doubles every 25 years (Science 266: 771, 1994). In Jamaica (in our own back yard), simply alleviating hunger in the classroom makes for vast improvements in learning (Am. J. Clin. Nut. 67: 790-S, 1998).

In the early 1990's, health care and quality-of-life standards plummeted as sub-Saharan Africa went broke (Lancet 345: 182, 1995). There was talk about "the malthusian ceiling" being approached (Lancet 341: 669, 1993). And not surprisingly, famine, epidemic disease, and race wars ("ethnic conflicts") followed. In the early 1990's, the single country with the worst numbers was Rwanda (Br. Med. J. 311: 1651, 1996); we all saw what happened. In the 1994 edition of these notes, I predicted the explosion in Sierra Leone, which soon followed and which the world ignored. (The "rebels" in this weird war had a special fetish for performing machete amputations on children. War crimes trial began 2004.) Likewise, the world has ignored the ongoing war in the Congo despite many millions of deaths, mostly civilians caught in fighting between rival warlords. The Taliban kept the ordinary people of Afghanistan under-nourished (JAMA 286: 2723, 2001). In the past few years, several of the sub-Saharan countries have made dramatic turn-arounds. In 2000, crop failures in Ethiopia were massive but there was no famine as the world relief agencies were able to come in unhindered (JAMA 286: 563, 2001; Lancet 358: 498, 2001; Lancet 362: 1808, 2003). Rescuing children from famine in Guinea-Bissau: Am. J. Clin. Nutr. 80: 1036, 2004. At the same time, Kabila's famine claimed the lives of at least 2.5 million people in the Congo alone, where misgovernment, population pressures, famine, economic collapse, and civil war perpetuate one another. Then came Mugabe's famine in Zimbabwe, Mwanawasa's famine in Zambia, the genocide in Darfur (NEJM 351: 2574, 2004; Br. Med. J. 330: 110, 2005; Lancet 364: 1315, 2004; JAMA 293: 1490 & 2212, 2005), and the Niger famine (the world's poorest country; the aid from 2004 was taken by profiteers and sold to the highest bidder: Lancet 366: 1067, 2005; the ongoing problem Lancet 375: 1151, 2010; Lancet 376: 579, 2010.) Starvation in "the new South Africa": Lancet 363: 1110, 2004. Eritrea refused to accept food aid in 2009 in the hopes of getting its excess population to emigrate to Ethiopia and Somalia. The rest of the world does not even seem to be paying attention. The 2010 Sahel famine: CMAJ 182: E555, 2010; finding donors proved extremely difficult. A drought precipitated the famine in the Horn of Africa from 2011-2012; and in the Sahel in 2012.

The world has only recently begun talking straight about the problem, especially in sub-Saharan Africa. Even today, there are still outcries from extremists on both Right and Left against condom distribution. (The last bastion of anti-condom activism now resorts to obviously false claims, i.e., that sperms and HIV viruses easily penetrate the membrane: Nat. Genet. 9: 1443, 2003). Events like the 1992 "Earth Summit" produced enormous documents about how to "conserve the environment", "maintain wilderness areas", and "preserve species diversity" while keeping strict politick silence on population growth to please certain powerful politician-ideologues. One spectacular change was the embracing of thoughtful population-control policies by mainstream Islam: Lancet 343: 583, 1994. The Islamic Republic of Iran has a longstanding, extremely strong and highly successful family-planning program: Stud. Fam. Plan. 31: 19, 2000.) The taboo about talking of population: Br. Med. J. 315: 1441, 1997; even in 2008, a realist points out that you're still not allowed to say, "People shouldn't be having babies they can't feed" (Lancet 372: 206, 2008 -- this even has a name "The Hardinian taboo").

The era of cheap food is over. In the past year, the cost of wheat has risen by 130%, rice by 120%, with corn and soya not far behind. As a result, millions of people are starving.... After the collapse of the US housing market, investors are ploughing trillions of dollars into commodities, such as food and raw materials, resulting in a "commodities super-cycle" where commodity price inflation feeds on itself leading to hugely inflated prices.... Biofuels once perceived as the green alternative to fuel have recently been discredited. After the agricultural displacement effects of these fuels are taken into account, emissions from biofuels are many times worse than those from fossil fuels. Yet in the drive to make the USA self-sustaining for fuel production, massive ethanol subsidies and millions of acres of American corn have led to a boom in biofuels. American cars now burn enough corn to cover the import needs of 82 food-deficit countries...

Disaster struck in late 2007, with the sudden skyrocketing prices of basic foodstuffs (which had already been rising for a few years as investors saw the coming "opportunity" presented by a hungrier world -- BMJ 336: 1336, 2008.) In early 2008, there were food riots among the poor throughout much of the developing world. Especially hard-hit were Burma / Myanmar (which had just been devastated by a cyclone), North Korea, most of East Africa, Afghanistan, and Tajikistan. Nina Fedoroff, George Bush's administrator for the US Agency for International Development, gave what I thought was a halfway fair account -- a combination of using grain for biofuels (J. Am. Diet. Assoc. 107: 1870, 2007 -- producing 25 gallons of ethanol for fuel consumes 450 lb. of corn, enough to feed a poor man for a year), a lack of fertilizer in the poor nations, and most of the world's misguided rejection of genetically modified crops (Science 320: 425, 2008). Notice that this is a reversal from Bush's call in his 2007 State of the Union address for a fivefold increase in the production of biofuels in the next ten years. Understandably the spokesperson did not point out the rest of the ugly truth. She didn't mention the ongoing population explosion in the hungry nations, or the likely impact of global warming on weather, or the US sub-prime mortgage fiasco of 2007 that drove investors into the commodities market ("the commodities boom"), doubling the prices of food in the poor nations (Lancet 371: 1648, 2008; J. Am. Diet. Assoc. 108: 615, 2008). Things are unlikely to improve much in the near future -- in the developing world and in the United States. And in the meantime, the high prices of both food and fuel to deliver it have caused a massive drop in the ability or willingness of the rich nations to deliver food aid (BMJ 336: 1397, 2008).

Following Virchow, and most reasonable people nowadays, I still place most of the blame for today's world hunger and overpopulation on misgovernment in the poor nations. Today's medical literature is no longer keeping silent, either: Lancet 359: 2030, 2002. The economic disparities between rich and poor in today's kleptocracies far exceeds those under colonialism. Too many countries are still governed by hoodlums toting cast-off U.S. and Soviet-made machine guns. Governments are indifferent to the well-being of the governed, and "aid for International Development" usually hasn't reached the poor (Br. Med. J. 311: 72, 1995). Our military campaign in Somalia ("Operation Restore Hope") was undertaken to end a famine, and ended with our realizing the horrible truth -- tyrants don't want famine to end. See JAMA 272: 386, 1994, CMAJ 149: 1522, 1993; Lancet 342: 190, 1993. In the late 1990's, Zimbabwe's Mugabe collapsed his own country's economy by calling for "justice" and seizing the productive land for his family and friends (CMAJ 163: 1616, 2000; Lancet 359: 455, 2002). And in 2002, during a famine in his country, Zambia's president Levy Mwanawasa simply impounded the maize that the US donated and let it rot. Of course, he claimed to be outraged because the maize had been genetically modified, just the same as people in the United States and Canada eat every day. ("I refuse to allow my people to be used as guinea pigs." "There's no justification for feeding people 'poison'." "We may be poor and experiencing severe food shortages, but we aren't ready to expose our people to ill-defined risks.") See Lancet 360: 1261, 2002, and draw your own conclusions. In 2008, a "complex emergency" caused famine in Ethiopia, and when Unicef called for desperately-needed food aid, the Ethiopian government called them liars (BMJ 336: 1397, 2008).

The US intervention
in Somalia was
intended to protect
food relief workers.

Under this misgovernment, a large family offers the only economic security or opportunity for personal satisfaction, and a family's survival often depends upon child labor (especially in rural areas, Sci. Am. 272(2): 40, 1995). Here only 1 couple in 3 uses any kind of birth control (reports vary widely, though, from nation to nation; for example, in Nigeria the large majority of teenaged girls are sexually active, only 5% have ever used a modern contraceptive, and 25% have had an elective abortion: Lancet 345: 300, 1995 -- the figures have probably changed little). Most rich and most poor people want access to birth control, regardless of their religion (Lancet 342: 447, 1993; article contains blunt talk); yet certain religious denominations use their political clout in the poor nations to make this hard-to-get (Lancet 342: 473, 1993; more blunt talk; this article sparked a fire-storm and was part of the basis for review by the Islamic leaders). Especially as we face climate change, physicians have issued strong calls for universal access to family planning (BMJ 337: 247, 2008)

Overpopulation, hunger, and poor health clearly work in the interests of the hoodlum governments. On the flip side, the people now running most of the world (i.e., the capitalists of the global economy) are quite content with widespread poverty and hunger, since it keeps labor costs down in the sweatshops where the poor people make the rich people's luxury goods.

In addition to overt protein-calorie malnutrition, hungry people are more subject to a host of infectious diseases, including measles, malaria (Am. J. Trop. Med. 71(S2): 55, 2004), and the parasitic infestations.

As with all discussions of science and policy, public discussion of world hunger is marred by disinformation campaigns by the "right", the "left" and the "greens". In particular, you will hear the current "green / animal rights / vegetarian" claims that world hunger is caused largely by animal farming. Historically, it was clearly not true (Nature 355: 582, 1992), and the disinformation campaigns transparently false (Sci. Rev. Alt. Med. 1: 36, 1998). One reason among many for rising cereal prices over the past few years has been the increasing taste of the new middle-classes in China and India for meat (BMJ 336: 1336, 2008). However, the effect seems to be minor compared with the biofuels fiasco and overpopulation. It is still dogma in many left-wing circles that cattle ranching in the United States is the basis of both world hunger and global warming. And this is still obvious disinformation. What do you plan to do with semiarid range land if you do not raise grazing animals? Think about the alternatives (i.e., millions of unmanaged herd animals, dying of old age and rotting where they fall -- while hungry children starve in the rest of the world. What's this about "cruelty"?) And even the one scientific publication I could find on the subject of methane in cattle flatus causing the greenhouse effect estimated the contribution at "a little less than 2%" of the total (J. Animal Sci. 73: 2483, 1995). And the much-missed buffalo herds didn't f*rt? And so forth, ad nauseam.

Of course, ideology has had a terrible impact on global hunger. The greatest famines of modern times were brought about by the stupidity of the Communist superstates. Stalin's biology guru was Thaddeus Lysenko, a left-wing kook who was repelled by scientific biology's vision of a competitive world (too much like capitalism). Lysenko (and Stalin) believed that "living things strive for higher perfection" (harmony-in-nature, cabbages want to be good socialists, etc., etc). Stalin killed the bioscientists who dared to disagree. Lysenko's beautiful mysticism led to moronic agricultural policies (much of Russia was planted with crops -- including some weird hybrids -- that could not possibly have grown where they were planted), enormous crop failures, and the deaths of around 10,000,000 Soviets. The Holodomor ("extermination by hunger") was a Soviet-made famine that caused the death of about 7.5 million Urkainians in 1932-3 -- Stalin's people seized the food supplies. During Mao Zedong's "Great Leap Forward" in 1959-1961, between 36 and 50 million Chinese died as a result of similar ill-advised land-management policies, frustrating Mao's intention to overpopulate China and use the surplus as cannon-fodder as he had done so successfully in the Korean war. (The awful population increase came later, with government policies encouraging large families.) Mao sought (as he put it himself) to "conquer nature". Mao actually announced that he was going to exterminate sparrows and field mice. Lysenko sought "harmony with nature". Neither actually UNDERSTOOD nature. I'd welcome a talk in lab (instead of doing a patient case) on this important topic. The North Korean famine of the 1990's was also caused by government policies that seem to be deliberate: Lancet 345: 291, 1999. They named it "the arduous march" and "honored the people who suffered bravely." Now they are doing it again (Lancet 379: 602, 2012). Al Shebab, an extremist pseudo-Islamic group that controlled much of Somalia until late 2012, actively prevented food from being delivered after the 2011 drought, prevented a people from leaving, and killed dozens of relief / health-care workers, i.e., this was planned genocide (Lancet 378: 17, 2011; BMJ 343: d4696, d6729 & d4949, 2011). Less ideological... Saddam Hussein prevented good people from bringing food to Iraqi children in order to mobilize world opposition to sanctions against his regime: Ann. Int. Med. 132: 155, 2000; Lancet 355: 1851, 2000. And malnutrition among Palestinian children in the Gaza strip is far worse than in most other poor nations (Br. Med. J. 325: 1057, 2002). Again, this is orchestrated by politicians for show.

The answers to world hunger have come from science, reasonable security, and reasonable freedom. Mainland China's introduction of limited free enterprise resulted in greatly increased agricultural output. Food production literally doubled as soon as individual farmers were allowed to manage their own farms and make a small profit; Vietnam had the same thing happen beginning in 1986, when private farming replaced collective farming. China became self-sufficient in the 1990's, feeding 1/5 of the world's population on 1/15 of the farmland. The result was substantial growth for its children (NEJM 335: 400, 1996), especially in the capitalist urban zones, though the socialist rural zones are still lagging.

In Cairo (1994, review Lancet 353: 315, 1999), most of the world (even the kleptocracies) paid lip-service to population control, sought cost-effective forms of birth-control and laughed (publicly) at the anti-contraception religionists. Curiously, delegates didn't complain much (though some did) about "Western cultural imperialism" as the cause of the worldwide "redefining of sexual roles" (i.e., a woman can decide whether or not to have sex before marriage, who and whether she will marry, and about birth control inside or outside of marriage). We'll hear about the "Cairo Mandate" in the future, and it may help.

I would prefer real democracy (i.e., the ability of the world's poor to force their governments to become representative) to any other solution. You will need to decide for yourself about the current left-wing "good cause" of debt-relief without accountability for past or present kleptocracies, in the hopes they will pass the benefits along. The late unlamented Mobutu Sese Seko's $5 billion dollar estate would be enough to pay the foreign debt of the Congo, the nation that he looted during his decades in power. The Africans themselves will tell you that "neoliberal policy" (i.e., the developed nations providing financial support for the corrupt governments) has been a major cause of the declining standards of health and nutrtion, and that the current "debt relief initiative" is just more of the same (Int. J. Health Serv. 33: 607, 2003). By contrast, debt relief for governments that actually give evidence of governing responsibly and caring for their people is a policy that has been in place for a decade, supported by a major act of Congress and occupying much of the focus of the International Monetary Fund and World Bank (Health Policy & Planning 18: 138, 2003; Bull. WHO 80: 151, 2002).
Sudan, 1994.
A vulture waits for a child to die.

The generally-left-wing anti-hunger group Oxfam has taken the position that it's best to have the governments of the poor nations, rather than private donors, provide health care to the needy, i.e., give the governments the money (BMJ 338: b667, 2009). They note that the worse the health care in a poor nation, the greater involvement of private individuals, NGO's and the World Bank. The "Oxfam fallacy" is obvious -- the poorer the care provided by governments, the harder good people work to make up the difference. Go figure. On Oxfam, see also BMJ 338: b1202, 2009 and "The Economist" Nov 7, 2006 ("economic illiteracy" behind Oxfam's campaign against Starbuck's). Over the years, Oxfam has taken widely varying positions on biotech crops, to my eye as the political winds shift. All this would be a subject for a good report in lab.

In the next decade, pay special attention to individual nations, and how government policies affect hunger. When individuals are guaranteed the right to their own land and to the profits from farming, the demographic transition will take place, and the world will be astonished. When governments (using whatever excuses) interfere, expect continued famine. I would hope that the world financial institutions do what they can to make governments choose the right path for their people. Ultimately, I would hope for a world in which it is the norm for people to be able to find satisfaction, fulfillment, and security without having babies they can't afford to raise, and enjoy a reasonable chance for a healthy life. Dr. Virchow's prescription of "true and complete democracy" is also my prescription. There has never been a famine in a real democracy, no matter how poor. Democratization requires breaking the cycle of poverty, tyranny, corruption, maladministration, frustration, violence, and stupid right-wing and left-wing ideologies. Can this happen? After 30 years as a physician, I think I'm finally seeing it. And so do others (Am. J. Pub. Health. 90: 1838 & 1841, 2000). But I do know that physicians are the natural leaders in understanding and clarifying the problems that cause world hunger, and in finding solutions.

If, of all words of tongue and pen,
The saddest are, "It might have been,"
More sad are these we daily see:
"It is, but hadn't ought to be."



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Teaching Pathology

Pathological Chess

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