When Drug Companies Commit Crimes, Should CEOs be Held Accountable?

A recent Businessweek article reminds us of the illegal activities that have become common among drug companies, and the issues associated with holding them accountable for their crimes. The article by Dune Lawrence provides us with this list of recent settlements with the Department of Justice, mostly involving marketing drugs for unapproved uses.

2007: Bristol-Myers Squibb: Abilify: $515 million
2008: Cephalon: Gabitril, Actiq, Provigil: $425 million
2009: Pfizer: Bextra, Geodon, Zyvox, Lyrica: $2.3 billion
2009: Eli Lilly: Zyprexa: $1.4 billion
2010: Allergan: Botox: $600 million
2010: Astra-Zeneca: Seroquel: $520 million
2010: Novartis: Trileptal, Diovan, Sandostatin, Zelnorm, Exforge, Tekturna: $422.5 million
2010: Forest: Celexa, Lexapro, Levothroid: $313 million

Drug companies are forbidden from directly marketing their products for applications for which they do not have FDA approval. Unfortunately, there is no restriction on what doctors can do. They are allowed to prescribe any drug for any application. Drug manufacturers try to skirt the legal restrictions by paying doctors to do their marketing for them.

The seemingly heavy fines that have been levied are really quite small in terms of the cash flow that companies derive from unapproved usage. Of what value is a fine if it does not affect the practice it is trying to punish? The Office of Inspector General (OIG) handles waste and fraud cases for the Department of Health and Human Services. It fears that drug companies see these fines as just another cost of business that can be passed on to the consumer. OIG is contemplating inserting a small level of accountability by letting it be known that they are considering holding executives of the offending companies responsible for the illegal behavior. It is thought that Howard Solomon, CEO of Forest Laboratories, will be the first target, with OIG “excluding” Solomon from participating in government programs. This means that Forest Laboratories would be excluded unless Solomon is fired.

“Exclusion is common enough; the Health and Human Services Dept. punishes about 3,000 people a year this way, often because of criminal convictions. Solomon stands out because the Justice Dept. has never charged him with wrongdoing, nor has he ever admitted to wrongdoing, not even in Forest’s $313 million settlement last year on charges related to the marketing of antidepressants and the distribution of an unapproved drug, the thyroid medication Levothroid.”

Some are aghast that the leader of a large business should be held responsible if he was not personally guilty of direct criminal behavior. Before we weigh in on this issue, let’s see exactly what Forest has admitted to, and learn more about the nature of their actions and the consequences of their illegal activities.

“....Forest Pharmaceuticals pleaded guilty to three criminal charges and settled civil claims filed by the Justice Dept. Forest admitted it obstructed the FDA by concealing information, distributed an unapproved thyroid drug, and illegally promoted Celexa for use by children and adolescents. While Forest applied to the FDA for pediatric use of Celexa and was eventually denied, the company admitted it had marketed the drug to doctors by hiring speakers to tout its benefits for young patients. Forest also admitted it had suppressed the negative results of research in Europe that found Celexa was no more effective in treating depressed children and adolescents than a sugar pill. Fourteen young patients in that study attempted suicide or contemplated suicide, compared with five in the placebo group, court records show.”

To find out more about Celexa we will turn to Marcia Angell’s New York Review of Books article: The Epidemic of Mental Illness: Why? Angell refers to three recent books on the subject of psychoactive drugs:

The Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis by Daniel Carlat.
I have read the latter two books and highly recommend them.

First let us listen to what Carlat, a psychiatrist, has to say about drug companies and their marketing practices. He points out that while companies often claim that their large R&D costs justify the prices they charge for their product, they actually spend twice as much on marketing (in 2007 alone: R&D: $30 billion, marketing: close to $60 billion). It is incredible to assume that a CEO of a drug company would not have any personal responsibility for an activity twice as large as its R&D effort.

Carlat further adds that some 90% of these marketing costs are directed at convincing or bribing doctors to use their products. As a psychiatrist, Carlat is well aware of how this activity affects his profession. Celexa is an antidepressant. There is no scientific justification for its use as an antidepressant, and as we shall see, there is no evidence that it acts in any beneficial manner other than as a placebo. Yet there is a lot of money to be made by confusing both the public and medical professionals. That is the function of marketing. Again, from Carlat:

“Since all the drugs within a therapeutic class seem equivalent, there is little scientific reason to choose one over another. And where there is a scientific vacuum, drug companies are happy to insert a marketing message and call it science. As a result, psychiatry has become a proving ground for outrageous manipulations of science in the service of profit. Many of the leaders of our field have allowed themselves to become paid puppets of the pharmaceutical industry....psychiatry is in the midst of a crisis in ethics, and it is not clear if the profession will survive this crisis intact.”

One might conclude that some over exuberance in marketing is allowed if the drug provides some benefit. But doe a drug like Celexa provide a benefit? Angell turns to Irving Kirsch’s book for an answer.

To get a drug approved by the FDA, one needs two clinical trials showing a benefit. However, companies are allowed to have as many tries as necessary to get those two positive results. Tests with negative results are considered proprietary information and are not available to the public. They can be buried, while the drug companies go on to write numerous articles about only the positive results.

Kirsch was troubled by two findings from the available data. The first indicated that placebos (sugar pills) were 75% as effective as the antidepressant drug in treating the depressed subjects. Kirsch obtained all the data drug companies had submitted to the FDA through the Freedom of Information act. There were 42 studies for the six most widely used antidepressants: Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor. Most of the studies yielded negative results. Kirsch determined that the placebo was 82% as effective as the antidepressant based on this data set.

The second finding that puzzled Kirsch was that in treating depressed subjects, any medications

“such as synthetic thyroid hormone, opiates, sedatives, stimulants, and some herbal remedies —were as effective as antidepressants in alleviating the symptoms of depression.”

These tests are performed in a double blind mode. Subjects are told that they may receive a placebo rather than a drug, but neither the participants nor the tester know who receives which. Kirsch hypothesized that these seemingly irrelevant drugs were working because they produced a side effect. If a subject took a pill and observed a side effect they could reasonably conclude that they had received the drug rather than the placebo. The net result is that a placebo with a side effect is a “super placebo.” Kirsch demonstrated this effect by doing a study where the placebo was laced with something that would provide a dry-mouth sensation. This placebo worked just as well as the drug.

Others have performed similar studies and reached the same conclusion: if you tell a person with a mental problem that you are giving them a pill that should make them feel better, they will tend to feel better even if there is no real medication present.

These types of studies form the basis for the statement above that claimed that antidepressants like Celexa were no better than a placebo. But a placebo is harmless, antidepressants are not.

Let us now turn to Whitaker’s book.

Drugs like Celexa are referred to as SSRIs: selective serotonin reuptake inhibitors. Serotonin is a neurotransmitting chemical used to transmit signals from one neuron to another across the synapse separating them. Serotonin is the chemical chosen by evolution in several regions of the brain. It is produced when needed and either reabsorbed for reuse or discarded. Celexa will alter the level from a normal level to an abnormal level; it does not correct for an abnormality as generally believed. It is not surprising that a drug like Celexa will cause a new set of symptoms to appear which can in some cases appear to be beneficial. However, the brain tries to respond to these enforced new serotonin levels by modifying its own serotonin management system. The longer these modifications are in place the less likely they are to be reversible. In other words, long-term usage can lead to addiction and increasingly adverse outcomes including cognitive impairment.

Whitaker’s thesis is that the drugs prescribed for mental illness are actually causing more harm than good and contributing to outcomes requiring a lifetime of drug dependence and functional disability. He points out that conditions such as depression were once rare, episodic, and usually self-limiting before the introduction of drugs. Depression is now common (depressingly so), it tends to be chronic, and the outcome is often partial or total disability.

Consider this study by the National Institute of Mental health (MIMH).

From Whitaker:

“In 1955, there were 38,200 people in the nation’s mental hospitals due to depression....Today, major depressive disorder is the leading cause of disability in the United States for people ages fifteen to forty-four....it affects 15 million American adults....58 percent of this group is “severely impaired.” This means nearly nine million adults are now disabled, to some extent, by this condition.”

Not everyone who is now disabled is so because of the recurring bouts of depression. Long-term effects of the SSRI medications like Celexa also play a role.

“SSRIs cause a multitude of troubling side effects. These include sexual dysfunction, suppression of REM sleep, muscle tics, fatigue, emotional blunting, and apathy. In addition, investigators have reported that long-term use is associated with memory impairment, problem-solving difficulties, loss of creativity, and learning deficiencies.”

Forest and its executives, researchers and marketers cannot be unaware of these results. Also recall that the crime Forest admitted to was the illegal marketing of Celexa to children and adolescents. How would you feel if someone tried to give your child a pill that produced the long-term effects listed above?

Businessweek presents a rather balanced article on Howard Solomon and Forest Laboratories, but it is still sympathetic to Solomon’s plight (he is eighty-three years old and may be forced to retire). I am not. The behavior of the drug companies is so reprehensible and harmful that a much more extreme measure is appropriate. Solomon is responsible for criminal behavior and for the irreparable harm caused by his company’s activities. Criminals should be treated as criminals—even eighty-three year old criminals. Until drug company executives begin spending some time in prison, there will not be sufficient motivation for them to change their business practices.

Psychoactive drugs can alter the behavior of a patient, but they cannot cure the patient. There are ill people who are so out of control that they are a danger to themselves or others. It is an appropriate short-term solution to render such people harmless and controllable with medication. Prescribing drugs to less severely symptomatic patients, while convenient and profitable, is a dangerous practice. As Carlat pointed out, there are serious ethical issues associated with the alliance between the profession of psychiatry and the drug companies.

I was surprised to learn that this is the eleventh article I have written related to drugs and mental illness. I am sorry if some find this subject less compelling than I, but my sense of outrage is undiminished. I believe I have one more article left in me—at least. Please bear with me—and share the outrage if you feel it.

Europe, China, Economic Instability, and National Security

Europe, China, economics and national security are a lot to cram into one title. And it is a lot to cover in a few pages of text, but Mark Blyth pulls it off in an article in Foreign Affairs: China’s European Shopping Spree? The subtitle is more explanatory: How Austerity in the EU Creates Investment Opportunities for Beijing. Blyth’s plot might be summarized as “The eurozone is headed for a crash followed by fire sale prices on assets, and guess who is walking around with the thickest wallet in the world?”

Blyth sets the stage by pointing out that China has been sending out emissaries to be friendly and supportive of Europe in its time of need. He also points out that China has $3 trillion of assets in US dollars.

“If China were to buy only half of all outstanding Greek sovereign debt (a bargain at around $220 billion, a fraction of China's dollar assets), it would not only resolve the eurozone crisis and add to Chinese prestige but it would help give Beijing the sort of reserve asset that it needs to diversify its holdings out of dollars.”

Obviously china will act in its own self-interest, so there must be more at stake in the future.

“For one, China probably has as little faith in the EU's ability to solve its debt crisis over the long run as do the rest of the world's financial markets, more bailouts notwithstanding. But another answer is possible -- one that links the 2008 financial crisis and the 2011 European bond market crisis to a possible Chinese end run around the 2007 Foreign Investment and National Security Act. This U.S. law makes it hard for China to diversify out of its $3 trillion-plus holdings of U.S. dollars and buy sensitive U.S. assets such as aerospace, technology, and defense-related companies.”

“As a result of the unintended consequences of U.S. and European actions in financial markets, there is now the possibility that....China could buy such sensitive assets from Europe, at fire-sale prices.”

The simplest solution to the eurozone crisis is, and always has been, for the European Central Bank (ECB) to buy up the debt that Greece (and others) cannot handle. But the ECB was never given that kind of authority or resources. Instead, such a move would have to be financed by the wealthier countries to support those in trouble. Since democracies are unwieldy beasts, such approval is unlikely. The best that has been done thus far is to lend more money to the debt-ridden countries.

The only options for a country like Greece are default or austerity. Default would be a disaster for everyone, while austerity is only a disaster for the country on which it is imposed. Therefore we have austerity. Blyth, who will be publishing soon a book titled Austerity: The History of a Dangerous Idea, believes such a path is doomed to fail.

“Austerity is a form of internal deflation through government cuts that reduces wages, prices, and public spending to restore the external financial balance. Such a system of financial adjustment was tried before, from 1870 to around 1914: the gold standard. It, too, was based upon deflating domestic wages and prices in order to bring a national economy into balance with its external financial position, as the eurozone is demanding of its periphery states today.”

“But such regimes have a fatal flaw: they cannot work in democracies because electorates
have a strong incentive to vote against imposing austerity measures, and instead seek to pass the costs of deflation on to the bondholders.”

Banks are aware of this dynamic, so it is in their interest to encourage severe and immediate austerity measures to protect their assets. The countries most able to help financially, Germany and France, are also those whose banks are holding a majority of the Greek debt. They cannot help Greece without hurting their own banks. And when banks get in trouble, their debts usually end up being transferred to the national debt ledger. So the counties take the least immediately painful path available and make Greece suffer the consequences.

“Notwithstanding the latest bailout, Greece today can never grow its economy fast enough to pay back what it owes, and new borrowings serve only to add debt to debt. Simply piling on more austerity measures cannot work, since voters are likely to reject such a regime at some point, triggering a default.”

This ‘inevitable” default will be disastrous.

“....if one of these periphery states (Greece, Ireland, or Portugal) were to default on its debt, the crisis would soon spread to the large EU states. Holders of periphery debt would try to stem their losses by dumping good assets in order to cover their bad exposures, as happened in the U.S. market in 2007 and 2008. This would create a financial contagion in the form of a bank run through the bond market, which would end up back on the balance sheets of the biggest core European banks: the banks with all those periphery exposures. This would be a disaster for Europe and would at the very least require expensive bank recapitalizations, which already bloated state budgets can ill afford.”

Banks around the world hold pieces of these debts as well. The economy of the US and many other nations would be affected by the economic damage in Europe. The path to China and national security lies in the fact that Europe currently has limits imposed on what can be sold to China, but no good way of enforcing them. Blyth fears that China will take advantage of the situation by using its immense reserves to purchase from Europe the sensitive technologies and capabilities that it cannot obtain from the US.

If this seems a bit convoluted, it is, and Blyth recognizes that. He has chosen to use an extreme example to garner our attention to problems about which we should be spending more time worrying.

“This scenario may seem far-fetched, but it is possible. It also suggests a few things to think about: that the global financial system is more fragile and more interconnected than often understood, that financial fragility may be more of a national security issue than often thought, and that pursuing austerity in a democracy may not be the solution that policymakers think it is.”

“Regardless of whether China's rise to dominance is distant or close, Western powers have not helped themselves by turning their financial systems into a generator of unintended consequences that may prove to be very bad for the United States and Europe, and very good for China.”

If Blyth’s concerns about national security do not particularly distress you, the notion that a country like Greece, an economic afterthought, could bring down the world economy should. The similarity between the accumulation of bad debt by European financial institutions now, and bad debt generated by US financial institutions a few years ago is troubling. Equally troubling is the realization that nothing much has changed in the interim.

Blyth is correct in pointing out that one way or another, China stands to be a big winner. It just has to bid its time until our financiers are again shown to be greedy fools.

Greece, Germany, and the Euro

One hesitates to comment on the economic situation in Europe when stories come out daily from multiple sources indicating new activity. But new activity does not necessarily indicate progress. An article by John Lanchester in the London Review of Books, Once Greece Goes..., indicates that the troubles are far from over, and while solutions might be obvious, they may not be attainable. Lanchester provides valuable insight and a prospective that will help interpret events as they take place.

Lanchester provides this short course in Greek economic history.

“Greece joined the EEC in 1981....and subsequently the Greek government created a client state in which direct subsidies and transfers from the EEC were supplemented by easy loans from Western European banks. Money poured into Greece, and was used to fund a huge boom in public-sector jobs, most of them linked to political patronage. Various forms of corruption permeated the system, where cash gifts in fakelaki or ‘little envelopes’ were a fact of life, and where, crucially, the rich regarded paying tax as something that only the poor and stupid would ever choose to do. This latter fact meant that Greece was in certain vital respects a country without a functioning version of the social contract.”

When it became clear that Greece had accumulated more debt than it could possibly repay, a loan was provided to the country on the promise that expenditures would be drastically cut and revenues would be increased. It was hoped that these austerity measures would hold down the cost of borrowing money and diminish the national deficit. Unfortunately, no one bought this gimmick. The cost of debt continued to rise, and the austerity measures caused the economy to continue to crash.

It is well known that the Greek people are not happy with the situation. Demonstrations and strikes are frequent occurrences. Lanchester is worried that this confrontation between the Greek government and its citizens is entering a more serious phase. Demonstrations began with leftist protestors, but are now beginning to spread to the middle class, who Lanchester refers to as the Indignati.

“The Indignati are not stupid....the ‘bailouts’, as they are always called, are no such thing. Taxpayer-funded capital injections into otherwise bankrupt banks were bailouts. The Greek ‘bailouts’ are loans, pure and simple. The money will have to be repaid, and repaid at ungenerous rates of interest: 5.2 per cent for Greece, 5.8 per cent for Ireland. These short-sighted and grasping interest rates, motivated by the need to provide political cover for other governments, make an already critical problem significantly worse.”

French and German banks hold a large share of the Greek debt. The need for these countries to keep their banks solvent is not lost on the Greeks.

“The Indignati do not find that a compelling reason to embrace a decade or so of abject misery. They want the Greek government to default, and the banks to accept losses for loans they shouldn’t have made in the first place.”

The thought of such a default is frightening to the rest of Europe—and to the rest of the world as well.

“Any abrupt form of Greek default, caused by the lenders’ failing to lend or the Greeks’ missing a bond payment, would be what is known as ‘disorderly’, an eventuality that would play out as anything from a mild local spasm to a full-scale continent-wide meltdown, featuring the collapse first of the euro and then of the EU itself.”

Why such dire and uncertain outcomes? Lanchester says it is because the world financial sector is little changed from the situation in 2008.

“Who owns that Greek debt? As I’ve said, mainly French and German banks. Yes, but banks insure their debt via the use of complex financial instruments. Insure it with whom? Don’t know: some of it is insured with British banks as counter-parties to the risk, but that risk will be insured in its turn, so that the identity of the person holding the parcel when its last layer of wrapping comes off is a mystery. That mysteriousness was the thing that made Lehman’s collapse turn instantly into a systemic crisis.”

The direst of the possible outcomes arise if a Greek default puts other countries with debt problems at risk.

“The euro was not designed to default, so when Greece does, other European countries who have had to ask for non-bailout bailouts – Ireland and Portugal – will have their ability to repay their debts questioned. If one or other of them undergoes a ‘rollover’, or ‘restructuring’, or ‘rescheduling’ of its debt – all polite words for default – the next country in line will be Spain, and that is where everything changes. The ECB/EU/IMF ‘troika’ can write a cheque and buy the Greek economy, or the Irish economy or the Portuguese economy. But Spain is the world’s twelfth-largest economy, and the ECB can’t just write a cheque and buy it. A Spanish default would destroy the credibility of the euro, and quite possibly the currency itself, at least in its current form.”

Lanchester is also worried that the frustration experienced by the Indignati is shared with a number of states where austerity has been imposed.

“....the general feeling about this new turn in the economic crisis is one of bewilderment. I’ve encountered this in Iceland and in Ireland and in the UK: a sense of alienation and incomprehension and done-unto-ness. People feel they have very little economic or political agency, very little control over their own lives; during the boom times, nobody told them this was an unsustainable bubble until it was already too late. The Greek people are furious to be told by their deputy prime minister that ‘we ate the money together’; they just don’t agree with that analysis. In the world of money, people are privately outraged by the general unwillingness of electorates to accept the blame for the state they are in. But the general public, it turns out, had very little understanding of the economic mechanisms which were, without their knowing it, ruling their lives. They didn’t vote for the system, and no one explained the system to them....”

“Greece has 800,000 civil servants, of whom 150,000 are on course to lose their jobs. The very existence of those jobs may well be a symptom of the three c’s, ‘corruption, cronyism, clientelism’, but that’s not how it feels to the person in the job, who was supposed to do what? Turn down the job offer, in the absence of alternative employment, because it was somehow bad for Greece to have so many public sector workers earning an OK living? Where is the agency in that person’s life, the meaningful space for political-economic action? She is made the scapegoat, the victim, of decisions made at altitudes far above her daily life – and the same goes for all the people undergoing ‘austerity’, not just in Greece.”

Everyone who comments on the current economic difficulties arrives at the same conclusion: Europe needs greater fiscal unity. As in the United States, there are stronger states and weaker states, and funds necessarily flow from the strong to the weak. The United States can issue bonds with the backing of the entire country, Europe needs to be able to issue bonds backed by the Eurozone as a whole.

Lanchester singles out Germany as having the dominant role in these issues.

“There is one country in particular where this disconnection between the political, the personal and the economic poses an acute threat to the world economic order. That country is Germany. The economists speak of ‘macro-economic imbalances’, the fact that German interests and, say, Greek or Irish or Spanish interests are not in alignment. The German economy is too big and too powerful for the health of its neighbours, unless European monetary policy is somehow ameliorated to help the smaller, weaker countries stay in step. Interest rates which, during the first decade of the euro’s existence, suited German manufacturers, caused toxic credit bubbles to grow in Greece and Ireland and Spain. The consequences of those credit bubbles could take another decade to unwind, ten years of hard times for the citizens of those countries, who will spend most of it sweating to earn the tax money to pay back the German banks whose lending fuelled their bubble.”

Most business for Germany’s vaunted export sector is derived from its European neighbors.

“German savings go to German banks to lend to other countries so that they can buy German goods from German companies who then save their earnings in German banks who lend it to … and so on.”

“This system is not elegant but it is probably sustainable, as long as German taxpayers are willing to pay for the busts and bailouts which will inevitably ensue. Their economy is so big that they can pick up these bills if they want to.”

The current indications are that the German taxpayers do not wish to assume this responsibility. Lanchester sees this as a dangerous tendency.

“....if the euro is going to continue to exist in its current form. Germany has to put the broader European interest on the same level as its own national interest, or the euro is toast.”

Lanchester finds a great deal of irony in the current situation.

“During the 20th century, the greatest danger to European stability was Germany’s sense of its special destiny. During the 21st century, the greatest danger to European stability is Germany’s reluctance to accept its special destiny.”

Many things have to fall into place, and many sacrifices have to be made by both nations and individuals if Europe is to emerge from this situation in a healthy state. The alternatives are not ones one would wish to contemplate.

The Pink Hijab Generation

Robin Wright has written an article for The Wilson Quarterly titled The Pink Hijab. She presents the story of the women who helped set the stage for the political tumult of the current year and who are trying to live a life of increased personal and political freedom, yet stay within the construct of their heritage and their religion. Wright refers to these women as the “pink hijab generation.”

The term hijab has a detailed Muslim history that can be found here. It has come to mean, in most cases, a covering for the female that includes everything but the face and hands.

Wright chooses Dalia Ziada, a 29 year-old Egyptian women as her avatar.  Ziada’s sensitivity to her rights, or lack thereof, arose at the age of eight when she was forced to undergo a traditional (not religious) “genital mutilation” imposed on Egyptian women. She was determined to try to make sure no other women in her family had to suffer the same fate. A defining moment came at age 24 when she finally succeeded at convincing an uncle to spare a cousin that fate. This victory convinced Ziada that she might be able to accomplish other things.

“Ziada soon became a leading activist among the pink hijab generation, young women committed to their faith, firm in their femininity, and resolute about their rights. With three college classmates, she launched a campaign to educate women about genital mutilation and domestic violence. Then she moved on to human rights. And she ended up at Liberation Square.”

One of her first projects in the human rights area was to produce an Arabic translation of a pictorial document called The Montgomery Story. This told the story of the civil rights activities led by Martin Luther King in 1955, and it includes a lesson on nonviolent civil disobedience. Ziada’s translation was eventually distributed throughout the Middle East.

“’When I read this story, I learned that someone must take the risk for others to follow,’ Ziada told me. ‘I wanted to be the Martin Luther King of Egypt!’”

Her next big project was to organize what Wright describes as “the first human rights film festival in the Arab world.” This was not an easy task in Mubarak’s Egypt. Her second effort was surprisingly successful.

“In 2009, facing the same obstacles, Ziada managed to sneak in 20 movies for the second Cairo human rights film festival. To get around official obstacles, she provided the wrong schedule and imaginary venues. In a country with one of the region’s most autocratic regimes, Ziada showed films such as Orange Revolution, about the 2004 uprising in Ukraine, and, most daringly, four Egyptian films. One dramatized a well-known incident in which police used a broomstick to sodomize a young man who had intervened when his cousin refused to pay the police a bribe. Another was a Romeo-and-Juliet tale about a young Christian boy who falls in love with a Muslim girl he can never marry. The most potent movie, however, was also the shortest. Please Spare Our Flowers is a one-minute film about female genital mutilation that shows ragged pinking shears slowly snipping off the tops of dozens of beautiful flowers, one by one by one, just as they’re blooming—each producing a piercing scream from an unseen girl child or baby.”

Last year Ziada began organizing civil disobedience workshops for Egyptians and activists from other countries.

“Among the trainees were two Tunisian bloggers who, only months later, played critical roles in flashing the story of Mohamed Bouazizi’s self-immolation in Tunisia across the Internet and beginning the Arab Spring.”

Wright described the political situation in Egypt in her 2008 book: Dreams and Shadows: The Future of the Middle East. That was an excellent introduction to the various nations in the Middle East. Wright made it clear in that earlier publication that there were many men and women struggling to improve human rights and personal freedoms. Ziada was not alone. Wright opens her section on Egypt by quoting the anthropologist, Margaret Mead

“Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it is the only thing that ever has.”

How true!

How has traditional women’s dress fared across this period of political upheaval? How does Ziada dress?

“In public, she wears hijab coverings in bright florals, rich patterns, or fake designer prints; she changes her scarf daily. She is an observant Muslim, so not a wisp of hair shows. Judging from her eyebrows, her hair must be dark brown.”

“’Hijab is part of my life,’ she told me. ‘I would feel naked without it.’ She often jokes, with a robust laugh at herself, that her scarves are the most interesting part of her wardrobe. Yet her religious commitment defines her life.”

What about others who wish to maintain their religious and traditional ways while still demonstrating that they are individuals with rights and personalities?

“As the pink hijab generation gradually chisels away at centuries of restrictions, the young women are also redefining what it means to wear hijab—as a declaration of activist intent rather than a symbol of being sequestered. The change is visible in virtually every Muslim country. The young are shedding black and gray garb for clothing more colorful and even shape-revealing, albeit still modest. Pink is the most popular hue. Women in their teens, twenties, and thirties also flavor their faith with shades of pastel blue, bright yellow, and rustic orange, occasionally trimmed with sparkles, tassels, or even feathers. Hijab stores from Gaza to Jakarta now carry everything from long denim dresses with rhinestone designs to frilly frocks with matching scarves. Hijab Fashion, an Egyptian monthly magazine, was launched in 2004 for the pink hijab generation. It has nothing to do with religiosity. But it is also not just about fashion or vanity.”

Wright also provides some interesting and encouraging data on educational attainments of women in Muslim countries.

“A 2008 Gallup poll not only found that literacy is the rule rather than the exception among Muslim women, but that they are a growing proportion of university students even in countries with strong religious sentiment. In Iran, 52 percent of women told Gallup they had at least some postsecondary education, while in Egypt, Saudi Arabia, and Lebanon about one-third did. Surprisingly, Gallup also reported that more women had postsecondary educations in Pakistan (13 percent) and Morocco (eight percent) than in Brazil (four percent).”

The political future in Egypt is anything but certain. One can only hope that the political and personal liberties that Ziada and others have struggled for are ultimately attained.

China and Its Population Trends

The Economist, in what is their equivalent to an editorial page, excoriated China because of its continuing attempt to apply its one-child policy. The lead to the article launched this charge:

“The one-child policy is not just a human rights abomination; it has worsened a demographic problem.”

We have discussed China’s attempts at population management elsewhere. We will grant the author that China’s policy is harsh, unevenly enforced, and subject to corruption. It may also not be very effective because fertility rates were declining before one-child implementation went into effect, and the increased affluence of the population would have driven fertility rates down anyway. What seems contentious is the claim of a worsening demographic problem.

Since The Economist is what it is, economics is a major focus. They are concerned that limiting births will contribute to the aging of the population, a trend that china may not be in a position to accommodate.

“Between 2000 and 2010, the share of the population under 14—future providers for their parents—slumped from 23% to 17%. China now has too few young people, not too many. It has around eight people of working age for every person over 65. By 2050 it will have only 2.2. Japan, the oldest country in the world now, has 2.6. China is getting old before it has got rich.”

The author and many economists seem to equate economic health with the number of wage earners. Apparently, the belief is that since greater wealth and better healthcare will allow older people to build up in ever greater numbers, ever more workers will be required to contribute to their well-being. The only way this can happen is if China continues to grow its population. Do they really think that hundreds of millions more Chinese is doing anyone a favor—particularly the Chinese? China already has plans to build cities to accommodate 400 million more of its inhabitants. The materials, energy, water, and wealth required are of a scale with world-wide ramifications. They already have more people than the world can cope with.

The United Nations has posted its 2010 population prospects. Let’s assume these projections are accurate and see how China is doing—and compare it with its neighboring behemoth, India.

China’s population is expected to begin to decline around 2030. India’s is expected to continue growing. Between 2010 and 2050 China’s population will decrease by 46 million, while India’s will increase by 468 million, a number about equal to the current combined populations of the United States, Mexico, and Canada. Which country is being a good citizen of the world? With food prices at or near all time highs, food production growing at a declining rate, and climate change coming upon us, introducing population explosions is not good policy. So if China has managed to limit its growth, then good for them. If the result required harsh methods, then one should recall that the traditional means of reducing population—disease, war, and famine—are even harsher. If The Economist wishes to excoriate someone, let it be India.

The article also propagates the notion that an aging society is something that society will have trouble accommodating. That is not necessarily true. Japan is listed as an example of an aged society. My understanding of the country’s problem with their old people is not that they require so much attention, but that they are sitting on a huge amount of wealth that they refuse to spend. The real problem with an increasing number of retirees arises when these people are poor. Supporting an aging population is really a problem of wealth distribution. My guess is that in China a plan is in place to insure that the poorest elements of the population will see significant income growth. My suspicion is that India is probably considering about forty-seven options for accomplishing that goal.