Book reviews

NOBEL PRIZE WOMEN IN SCIENCE: THEIR LIVES, STRUGGLES, AND MOMENTOUS DISCOVERIES, by Sharon Bertsch McGrayne, is available again, with a new ISBN number in paperback.

The book, published in hardcover in 1993, is a collection of biographies of 15 women who either won a Nobel Prize in science or played a critical role in a Nobel-winning project. This inspiring book reveals the discrimination that women scientists faced—and the passion for discovery that enabled them to succeed.

The paperback added a new chapter about Christiane Nuesslein-Volhard, the latest woman to win a science Nobel.

The 15 women are Marie Curie, Lise Meitner, Emmy Noether, Gery Cori, Irene Joliot-Curie, Barbara McClintock, Maria Goeppert Mayer, Rita Levi-Montalcini, Dorothy Hodgkin, Chien-Shiung Wu, Gertrude Elion, Rosalind Franklin, Rosalyn Yalow, Jocelyn Bell Burnell, and Christiane Nuesslein-Volhard.

Sharon Bertsch McGrayne, a former newspaper reporter and writer/editor on physics for Encyclopaedia Britannica, personally interviewed most of the women featured in this book, and 250 of their colleagues, associates, and family members.

Women in Chemistry and Physics
A Biobibliographic Sourcebook
Edited by Louise S. Grinstein, Rose K. Rose, and Miriam H. Rafailovich
Foreword by Lilli S. Hornig
Greenwood Press. Westport, Conn. 1993. 736 pages
LC 92-40224. ISBN 0-313-27382-0. GWH/ $130.00 (Reference Book)

Biographies of women scientists are few in number. This volume fills that gap in the literature. It includes extensive profiles, arranged alphabetically, of 75 women from different countries who have been influential in the development of chemistry and physics. Subjects were chosen on the basis of their advanced degrees, innovative research, influence in teaching, leadership in the profession, and scholarly publications. Each profile includes a biography, a career discussion, and a bibliography of works by and about the subject. Biographies provide personal information with special attention to influences on the subject's career. The career discussions indicate the significance of the subject's contributions in language accessible to the layperson. The work provides a valuable contribution to both women's studies and the history of chemistry and physics and should serve as an inspiration to young women seeking a career in the physical sciences.

"...This valuable resource recounts the contributions of women to science. Biographies of 75 women whose work spans nearly three centuries reflect their struggle to study in a chosen field, gain admission to professional societies, and the lack of funding support. ...Because of the limited resources available on women scientists, this book should be acquired by academic and secondary school libraries; public libraries should consider purchase too."

The New England Journal of Medicine -- October 26, 2000 -- Vol. 343, No. 17
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The Door in the Dream: Conversations with Eminent Women in Science
By Elga Wasserman. 254 pp. Washington, D.C., Joseph Henry Press, 2000. $24.95. ISBN 0-309-06568-2

Equality in the workplace and equal access to leadership positions for women are issues that have stirred considerable debate among scientists during the past several decades. Despite affirmative action, several well-publicized cases of discrimination, and organized efforts to raise awareness, women still lag behind their male colleagues. An increasing number of young women aspire to careers in research science and pursue and complete graduate training. However, only a few emerge as strong contributors, and still fewer rise to leadership positions. Even in the biologic sciences, which are chosen by more women than the physical sciences, mathematics, or engineering, only a fraction of the women who earn their degrees or finish postdoctoral training find independent positions in academia, government, or industry and advance further. Indeed, Wasserman, who holds a doctoral degree in organic chemistry from Harvard but went on to obtain a law degree from Yale, is herself an example of the many women who complete scientific training but find success in other careers.

Wasserman examines these complex issues through the experiences of women who have been elected to the National Academy of Sciences. These 86 women, who constitute about 5 percent of the membership of the Academy, are the elite women of American science; their accomplishments clearly identify them as having succeeded in a traditionally male-centered environment. Do the career paths taken by these women provide a formula that can be followed by young women who strive to reach the same heights?

Wasserman contacted all the women in the Academy. Most of them chose to participate in her survey and were interviewed in person or by letter. A subgroup of these women are profiled in detail, in brief biographies that are eminently readable and that convey insights into the personal and professional hurdles each woman overcame. These are presented in chronological order, beginning with women born before 1920 and ending with those born in the 1940s and later. This approach allows the reader to appreciate the progress that has been made since the early days, when women were actively discouraged from pursuing science, to more recent days, when this message has sometimes been delivered in more subtle ways.

Each woman's experience is refreshingly different. However, some important parallels can be found among most of the stories. Talent, intelligence, flexibility, and incredible perseverance are traits that shine through in every instance. Most of the women profiled in the book received critical encouragement, often from a family member who made it clear that it was not only acceptable but also highly desirable to ignore convention and find security through a career. Others received support from at least one mentor who likewise was willing to ignore convention and provide encouragement at a crucial juncture. Of paramount importance to the women who married was the active support they obtained from their spouses. As one of the women interviewed commented, "If a husband does not support his wife's career,... the wife has only two choices -- give up her career or give up the husband."

Some long-prevailing myths concerning the path to a productive scientific career are dispelled in this book. For example, most of the women married, and most raised a family; thus, the idea that success in science almost always involves total devotion, at the expense of other activities, cannot be correct. However, as noted by several of the women, choices have to be made, and the use of all of one's energy for family and science, at the expense of other personal pleasures, is a sacrifice that will probably have to be made. In addition, many of the women who raised families did not follow a conventional career path but, instead, either took time off or worked part time when their children were young. They managed successful reentry in different ways; strikingly, however, many of these women were married to highly successful scientists, who helped smooth what otherwise might have been a rocky path.

The book clearly illustrates that women can both be successful and enjoy full, rewarding family lives, but it also raises sobering issues. The flexibility enjoyed by the women who were able to spend time away from research is becoming increasingly unusual. The ability to divide all of one's energy between family and bench research is not afforded to most junior faculty members, who often bear heavy teaching and administrative responsibilities while trying to establish and fund their research programs. Combining these pressures with the unrelenting biologic clock that limits women's childbearing years and the often self-driven conflict between caring for one's children and managing one's career remains a heavy burden. Nearly every woman interviewed identified the availability of support during these years as critical if women are to make a larger contribution to scientific research. As the vignettes of women coping with these issues today illustrate, creative solutions are difficult to find.

Reading the stories of women scientists who have risen to the top of their profession should provide hope and inspiration to those who strive to make the climb themselves. Mentors, both male and female, will gain a new appreciation of the positive and negative influence their actions can have. The book should also heighten our awareness of the job that lies ahead. Constructive suggestions, such as fostering the creation of more job-sharing positions, implementing improved child care, and adopting a tenure clock that recognizes the need for family leave, are issues that all scientists need to espouse, actively and vigorously. Most of the elite women profiled in the book recognize their responsibility to future generations of women scientists. The Door in the Dream should remind other senior women researchers who enjoy established, productive scientific careers of their obligation to follow suit.

Being Human at Work, published by North Atlantic Books, is a collection of twenty-three authors, all of whom studied in depth at Strozzi Institute and have integrated somatics into their specific disciplines. The areas covered are Career, Leadership, Organizations, Education, Dying, Trauma and Addiction, Therapy, and the Military. These are moving and informative stories about the need and power of bringing the mind/body/spirit unity into our personal and professional lives. In his introduction, Richard writes: "This sensibility is rooted in the fundamental virtues of self-reflection, respect for life, commitment to action, the primacy of relationship, and a collective vision for living a properly human life. Appreciating and engaging these issues invites us into the art of being human."

Ruth Otte, former president of The Discovery Channel: "Being Human at Work shows that human accomplishment emanates from the wisdom of the body, soul, spirit, and mind. When we operate as though it is only from our intellect, we use a fraction of our capacity. This book shows that when we allow people the full _expression of their "selves" at work, breakthrough results occur."

Sartaj Alag, president of Capital One Canada: "Beware of picking this book up. The authors' expertise in catalyzing transformational change in their professions will challenge each of us to step up to the plate to lead from our authentic core to meet challenges with steadfastness, dignity and grace."

Being Human at Work (listed at $16.95) is available at Amazon.com, North Atlantic Books (1-800-337-2665), and your local bookseller. Autographed copies are available for $23.22 (tax, shipping, and handling included) from Strozzi Institute, 4101 Middle Two Rock Rd., Petaluma, CA 94952.

A new book unravels some of the mystery for women about graduate school programs in science and engineering-and offers insights to administrators and advisers on keeping them in the program.

Women with dreams of a doctorate in science or engineering would be well served to forget what mama always said about playing nice. If females want to succeed in graduate school, they've got to be just as pushy, bossy, and aggressive as their male lab partners. Says one doctoral student in physics: "You really can't survive if you're timid."

That's just one of the lessons in the new book, The Woman's Guide to Navigating the Ph.D. in Engineering & Science, recently published by IEEE Press. In this day and age, it's hard to fathom the necessity of such a tome. But one look at the numbers and you'll understand why: According to the National Science Foundation, women earned less than half of the doctorates in science in 1998. Of those, only 16 percent were in engineering.

Culture is to blame for some of that imbalance, as society seems to rubber-stamp males as the brainiacs of math and science. Women who excel in those disciplines are oftentimes considered anomalies. However, some of the bleak showing in the statistics lies in the nature of the doctoral programs. Co-author Barbara Lazarus, associate provost for academic affairs and adjunct professor of educational anthropology at Carnegie Mellon University, says the testosterone-laden fields of science and engineering are booby-trapped with all sorts of stereotypes and hidden barriers. "Women need to learn how to maneuver in a predominantly male graduate school environment, how to think like academics, and how to be politically astute," she explains in the book.

Doctoral candidates aren't the only ones who will find the insider secrets spelled out in the book to be illuminating. If higher education is serious about attracting more women to engineering, then administrators, advisors, and professors of both sexes must critically examine what's going on in their own backyards.

That's crucial, says Lazarus, because "there are all kinds of little ways in which the system does not work for women." It could a good old boy atmosphere that short-changes female opinions and contributions. It could be that the male doctoral candidates gather for informal lunch bunches, unwittingly trading inside knowledge much like key business gets conducted on a golf course. It could be that department meetings are held at a time when, say, children need to be picked up from school, a disadvantage to someone who has a major role in child rearing-typically the female half of the parenting duo. It could be a dearth of female role models or inequality in financial backing.

Lazarus et al have divided their counsel into four sections that reflect the graduate school experience: How a Ph.D. program operates; making it work; potential perils and pitfalls; and, last but not least, life after the Ph.D. (In other words, finding a job.) Sprinkled throughout the various chapters are instructive vignettes from current doctoral students and women in leadership positions in academia, like Lydia Villa-Komaroff, associate vice president for research administration and professor of neurology at Northwestern University. During graduate school, Villa-Komaroff purposely avoided contact with anyone who didn't think women belonged in the world of science. "I guess that was a blessing because I never felt like I didn't belong or shouldn't be pursuing something that I loved. I learned early on that it's a very good ploy to act confident even when you're not because then people perceive you as confident, and that makes a big difference."

One of the most important strategies in a successful doctoral journey is working with the right adviser, one that will help develop a student's full potential and remain a lifelong sponsor. Lazarus and her co-authors highlight what makes such a relationship tick. A faculty member who shares the same interests and philosophies tends to make a candidate feel more comfortable. An adviser should be able to communicate honestly and effectively. After all, the pairing may last several years. Of course, senior faculty members are no doubt better connected, but may not be able to spend as much time with the student as a junior faculty member. But what if the match isn't made in heaven? Changing advisers might be tough. Perhaps other faculty can fill the void in the existing twosome. In any case, remember to approach the problem with tact. You never know when you'll need to rely on your former adviser. The chapter also provides insightful tips and nitty-gritty advice on acing qualifying exams, choosing a dissertation topic, and developing a thesis action plan. For example: "Plan far ahead when ordering equipment for experiments. It may take a long time for it to arrive."

Women graduate students with low self-esteem will find the book chock full of ways to exude confidence, a major prerequisite when defending research, abilities, and accomplishments. As most professors and students in science and engineering are male, woman may need to bring in reinforcements. Lazarus suggests building a support group, seeking counseling, joining professional organizations, participating in student activities, and attending conferences. Above all, get a grip on the realities of graduate school. "It's not a sign of weakness to need a supportive environment," say the authors.

Women might also find the learning method in graduate school unfamiliar, intimidating, or difficult. No more lecture-study-test that defines the undergraduate years. In graduate school, learning stems from critique and discussion. Some women tend to feel browbeaten when bombarded with seemingly harsh questions or consider them personal affronts. Negative feedback should be viewed as part of the process. Learn to evaluate criticism (opinion) and decide if it's valued, say the authors. Females also tend to internalize problems, which leads to discouragement and feelings of self-doubt. The man "is more likely to think the equipment was bad or the gods were conspiring against him," says Lazarus. "He is more likely to externalize the problem."

Women students who strive to balance school and private lives may also find their doctoral sojourn a smoother ride. Learn to focus on the task at hand, prioritize, and set realistic goals. Everyone-not just graduate students-occasionally feels overburdened and anxious. Again, turn to friends and colleagues for support and advice. "Find a group of confidants whom you can trust." And, for goodness sake, ride a bike, sit down to dinner with the family, or take a vacation.

Making use of a newly earned Ph.D. can be a challenge, so the book's final chapter helps students decide what type of job they might like, how to approach and conduct the job search, and how to go about the all-important task of networking. "No one should be left out of your circle; you never know who can give you a promising lead on the perfect job," say the authors. Facing an academic or industry interviewer? The book spells out how they differ. There are examples of what sorts of questions a student might expect and shouldn't expect ("Are you pregnant?" is a no-no) from a potential employer and how to be a model interviewee. "Always have at least a few questions for the interviewer. It shows your interest in the job and in the process."

Of course, one of the most important questions in the job search is usually saved until last: salary. For women, negotiating an offer can be a daunting task. But consider this, says Lazarus: A man and a woman are offered the same salary in the same department. "She will say thank you very much and take the job. He will say, is that your best offer? He will get another $4,000 and she won't." That smaller sum can haunt a woman during her career, as increases are typically percentages of current compensation. Who says talk is cheap?

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Margaret Mannix is a freelance writer based in suburban Washington, D.C. She can be reached at mmannix@asee.org.

Ceel Pasternak and Linda Thornburg. Designed to introduce girls to career opportunities in construction, this book follows the stories of ten women who have found success and happiness in construction. It provides information about benefits, salaries, personal experiences, disadvantages, and social issues pertaining to women in this field. Impact Publications 1999. www.impactpublications.com ISBN 1-57023-131-1

Women's Studies Quarterly: Building Inclusive Science, connecting women's studies and women in science and engineering

A twice-yearly compilation. This issue addresses the history of women in science; current status of women within the professions; inclusions and exclusions; gender differences and diversity among women; revealing male subtexts and building alternative models; theory into practice; feminist science studies in the daily lives of women scientists; and book reviews. Available by subscription: $30 for one year; paperback, 336 pages, The Feminist Press at the City University of New York. ISSN: 0732-1562

Getting It Right: How Working Mothers Successfully Take Up the Challenge of Life, Family and Career

The posting below is a commentary on a new book: Getting It Right: How Working Mothers Successfully Take Up the Challenge of Life, Family and Career, Pocket Books, 2001, by Stanford University professor , Laraine Zappert. It is from the April 25, 2001 edition of the Stanford Report http://www.stanford.edu/dept/news/report/ Reprinted with permission.

Rick Reis reis@stanford.edu UP NEXT: America's Teenagers, Motivated but Directionless

If there's one thing Laraine Zappert would like working mothers to know, it's this: You're not the only one eating dinner off your dashboard.

"Everyone struggles," said Zappert, a clinical professor of psychiatry and behavioral sciences at the School of Medicine and author of Getting It Right: How Working Mothers Successfully Take Up the Challenge of Life, Family and Career, published by Pocket Books in February. At Stanford, Zappert also directs the university's sexual harassment policy office and women's support programs in the graduate schools of business, law, medicine and engineering.

Zappert has talked to many women struggling to combine work and family responsibilities who assume everyone else has everything under control. They imagine others are blithely heading up companies and raising small children, "all while doing a little brain surgery and building a house on the side," Zappert said. "That's a fantasy. One doesn't know what goes on in other people's lives."

After two decades of clinical and research practice, however, Zappert knows more than most. In addition to the experience of the women with whom she's worked in her private practice, Zappert drew on a 1996 research study conducted with three generations of alumnae of the Stanford Graduate School of Business. For the study, more than 300 women answered 10 pages of questions about their home and work lives.

Since more than half the women she surveyed work more than 40 hours a week, Zappert had worried that the questionnaire's length might discourage women from responding. Instead, more than half the women who received the survey returned it with the margins covered with scribbled comments or accompanied by more pages filled with comments. "We touched a nerve, " Zappert said. "These are issues women love to talk about."

Her book is not just about the experience of MBA moms, but includes experiences of female teachers, engineers, writers, doctors, lawyers and stay-at-home mothers, she said. But it doesn't address the problems faced by working mothers with lower levels of education and expertise, she said.

"I think what it says is that there's a certain universality of experience that women have. If you make a decision to have children, whether you have an MBA or an M.D. or not, they are a potent, important aspect of your life."

Along with the rewards of motherhood, "working mothers feel despair, anxiety, anger and conflict. But we are not alone in doing this. And too often we try to deal with this in isolation."

It's a common assumption that psychologists research their own neurosis -- and Zappert, the mother of two grown children, said she's no exception. The first woman in the organizational behavior doctoral program at Cornell University in the 1970s, she already had developed an interest in women's issues when she came to Stanford in 1977 with a 3-year-old daughter. Her second child, a son, was born in 1981.

"I remember walking into the VA hospital as an intern, with a cookie plastered to the back of my skirt. We used to laugh about the 'Cheerio line,' which is how far up your suit leg the kids could reach."

Juggling parental and professional roles was difficult for most of the women Zappert surveyed. More than half said they suffered "a great deal of stress" in meeting the demands of career and family. Even so, the mothers in the sample were overwhelmingly happy with their decision to have children -- virtually all of them said it definitely was the right decision. "Clearly, children are primary in the life of professional women," Zappert said.

The women in her sample were making tremendous sacrifices, often at their own expense, Zappert said. "What we do is really hard and we do it well. But we pay for it in terms of our own psychological well-being."

Zappert devotes an entire chapter to guilt, from the "driveway remorse" working mothers feel as they leave their house in the morning to the guilt stay-at-home mothers feel about not using their education. "That's the chapter that most women are focusing on," Zappert said, judging from the e-mail messages she's gotten from readers.

The women in the study wrote to Zappert lamenting their messy houses and the pressure they felt to do things like hosting elaborate birthday parties for children, "to stage Ben-Hur while working 60 hours a week," Zappert said.

Women are likely to feel guilty no matter what they do -- or don't do, Zappert said. Guilt is "very hard to escape, but it wastes a lot of time and energy." The key is to determine for yourself what you and your family need, she said.

The advice that mothers in the survey most frequently offered to other women thinking about having children was to be prepared to spend money to get the childcare and household help they need. Some even suggested that it was worth going into debt to get adequate help, Zappert said.

Finding good childcare was the most significant stressor for many of the women in the study, who earned on average $100,000 a year. "Childcare was a tremendous strain," she said. Even for the high-earning women in the sample, it was not uncommon for women to spend a significant portion of their after-tax earnings to pay for childcare, she said.

Not everyone in the sample was highly paid, Zappert said. Many of the women talked about the stress of diminished financial resources after cutting work hours to part time or having not gone after top-flight positions because of their children.

But even when resources are short or there is very little money, people can allocate resources differently, she said. "Do whatever you can do to take care of yourself. Indulge yourself in ways that aren't financial," she suggested. "Put more money into childcare or household help, if it's at all available, instead of saving it for a rainy day. This is the rainy day."

Parents also should "keep up the pressure on institutions to do better on childcare," she said. Although many organizations and corporations now give childcare issues serious consideration, it takes time to turn talk into action, Zappert wrote.

In the study, the women who had worked the longest were most optimistic about the chances of women successfully integrating work and family, Zappert reported. "Everything doesn't have to happen at once," a Business School graduate from the 1960s wrote. "Taking a longer-term perspective on things is important."

Most women surveyed said that there is no definitive "right" time to have children, although the prevailing wisdom is that women should get their credentials out of the way first, Zappert said.

The youngest women in her survey were planning to have children when their careers are established, but early enough to avoid fertility problems. Many women wrote very poignantly about trying to get pregnant later in life, Zappert said. "It's a huge issue for many women."

Many Stanford women suggested a "sequencing" plan, where women establish their professional credentials first, gear downto less demanding or part-time work while raising children, and then ramp up their careers again later. There's not much information about how that works in the long term, since part-time work wasn't a practical reality for women until recent decades, Zappert said.

In spite of the difficulties they faced, 80 percent of the women in her sample reported being in excellent spirits, Zappert said."This was a very positive group. Most professional women have an enormous store of energy."

The New England Journal of Medicine -- March 15, 2001 -- Vol. 344, No. 11
Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER

By Pamela Grim. 307 pp. New York, Warner Books, 2000. $23.95. ISBN 0-446-52423-9

"I, Dr. Grim, will kill you if you touch this IV." This is the sign taped by Dr. Pamela Grim above the sickest patients in her makeshift intensive care unit -- a fly-ridden tent -- during a meningitis epidemic in Nigeria, where she works as an emergency physician with Medecins sans Frontieres. Here she relies on little more than chloramphenicol, fashions most of her own instruments, and steps over the bodies of patients she is unable to save. By contrast, in an American emergency room, she deploys a dazzling array of high-tech drugs and equipment to resuscitate her patients, many of whom are victims of violence and themselves combative. In Just Here Trying to Save a Few Lives, Grim tells the stories of patients in both these places, as well as in eastern Europe. Everywhere, her objective as a doctor remains the same: she must bring the wounded and the dying back from the brink of death, often with little more than instinct and sheer determination.

Grim describes the treatment of patients who enter the emergency room at her urban American hospital with caustic wit and fearless honesty. This is not the emergency room depicted on television and in romance novels, where every doctor is attractive and every aorta is easy to spot. In fact, Grim seems to take satisfaction in destroying these notions. This is the messy world of violent injuries and unexpected catastrophes, where a crowd of nurses and technicians frantically collect vital data from wrecks of human beings while she guesses at diagnoses, scours her memory for drug indications, and stares at the electrocardiogram, praying for a sign of life. Peering into a patient's open chest, she says simply, "The truth is, you can't see anything. Nothing is textbook." In the emergency room, there is no time for theorizing or for judging or casting blame. Grim thus also deconstructs the myth of the physician as all-knowing. We come to see the good doctor as a human being who is able to manage an impossible crisis under extraordinary pressure, and we are grateful for it.

In fact, Grim makes it clear that she would accomplish nothing in the emergency room without the help of her colleagues and assistants, whom she portrays in detail and with humor and admiration. There is the ever-present cadre of nurses, whose no-nonsense attitude, quick wit, and even quicker hands provide the reality check much needed by both patients and physicians; the terrified obstetrics intern who struggles bravely to perform a cesarean section on a woman whose head is perforated with bullet wounds; and the police officer who calms an enraged cocaine addict by singing a Cole Porter tune. There is the fellow physician who, during an emergency thoracotomy in a gunned-down teenager, refuses to stop working despite a needle-stick injury. "'I let go,' he tells you, 'then this kid dies. Now sew up the goddamn hole.'"

None of these accounts, however, would have the same impact without Grim's descriptive language and her vivid narrative style. Her first-person voice often shifts to the second person and the present tense, so that we as readers experience the crises exactly as she does: "You are up to your coat sleeves in the blood in this boy's chest. The blood has cascaded down onto the floor. There are two inches of blood where you are standing. Your shoes are soaked in it." Seeing through her eyes, we also sense the intense turmoil in her mind. "Think, think," she prods herself as she tries every conceivable way to restore a normal rhythm to a woman's fluttering, failing heart. Even as she outwardly assumes command of the resuscitation effort, Grim freely exposes the private pressures and uncertainties of each passing moment during the "golden hour" -- the first, critical hour when a patient may either live or die. And although she may acknowledge the "glow" that comes from averting death, she gives credit to her coworkers, to chance, or to cosmic oversight. "I thanked God... for saving my sorry ass once again," she says after one case, making it clear that the work she performs is much larger than herself.

In stark contrast to the pressures -- and luxuries -- of the urban American emergency room, Grim reports the mass illness and suffering she sees in Nigeria as well as in Bosnia, where she administers vaccines to hundreds of children, and in a no man's land between Kosovo and Macedonia, where she drifts in a sea of ghostlike refugees, looking for those who are ill and too weak to seek help. In Nigeria, she encounters a man who lies wracked with pain, his joints locked and his head cradled in the lap of his brother. Grim manages to diagnose tetanus, and after reviving him on her own -- "Praise God but pass the penicillin" -- she must argue with local medics in an unsuccessful attempt to save him, grieving over the lack of proper means to relieve his suffering. In the United States, people injure themselves and one another deliberately and are treated with the most advanced care; elsewhere, thousands suffer silently.

Grim's book will make fascinating reading for anyone with an interest in emergency medicine. Without breaking the flow of her narrative, Grim translates terms that may be unfamiliar to lay readers, such as "tension pneumothorax" and "Foley" catheter, into colloquial terms. Her colorful definitions are worthwhile reading for all: an agonal rhythm is "the heart's electronic death rattle," and the rib-spreading tool named after Fienchetto is a "physician's ghost" in the thoracotomy tray. Only for "anencephalic" does she first resort to the dictionary to explain why the image of one infant she delivers lingers especially long in her mind. With humility and clarity, Grim manages to convey the unthinkable horrors, and the epiphanies, of walking the line between life and death. "Here it is, the naked heart," she says. "And even though you've seen this before, even though you think it should be no big deal, it feels absolutely unearthly." So it will to her readers as well.

Getting It Right: How Working Mothers Successfully Take Up the Challenge of Life, Family and Career

Pocket Books, 2001, by Stanford University professor , Laraine Zappert. It is from the April 25, 2001 edition of the Stanford Report http://www.stanford.edu/dept/news/report/ Reprinted with permission.

If there's one thing Laraine Zappert would like working mothers to know, it's this: You're not the only one eating dinner off your dashboard.

Along with the rewards of motherhood, "working mothers feel despair, anxiety, anger and conflict. But we are not alone in doing this. And too often we try to deal with this in isolation."

Most women surveyed said that there is no definitive "right" time to have children, although the prevailing wisdom is that women should get their credentials out of the way first, Zappert said.

The Door in the Dream: Conversations with Eminent Women in Science

WOMEN SCIENTISTS TAKE VARIED PATHS TO THE TOP

It's an annual rite of spring, and it was no different this year. On May 1, the National Academy of Sciences (NAS) announced the names of its new members. Of 72 people elected to NAS, seven were women. Last year, of 60 new members, eight were women.

The history of NAS and women is not a very good one. The academy was founded in 1863 by 50 men. It was not until 1925 that the first woman was elected. She was Florence Rena Sabin, who carried out important research in human embryology. In all, of more than 1,900 living NAS members (U.S.), only about 7% are women. Most of these women work in the biochemical and biological fields. As an aside, this year there were no women elected to the Chemistry Section of the academy. The numbers for the National Academy of Engineering are much the same--of 74 U.S. members elected in February, seven were women. Only the newer Institute of Medicine has a better track record: Of 60 new U.S. members elected in October 2000, 20 were women. Progress for women has been slow, painfully slow.

Members of the academies are the elite of the elite in U.S. science. Do the small number of women who are selected for this honor have anything in common To find out, Elga Wasserman contacted more than 80 NAS members (several have since died). In "The Door in the Dream: Conversations with Eminent Women in Science," she provides a unique and intimate glimpse into the lives of many of them, with a special focus on 26 of these women.

Do we really need another book about the struggles that women scientists have making it to the top Yes, we do, because the obstacles for women scientists who aspire to the very top of their profession still exist. What distinguishes this book from others that address these issues (see, for example, the review of "Athena Unbound: The Advancement of Women in Science and Technology," in C&EN, April 23, page 61) is its overall optimism, especially its lack of bombast and whining. While much has been written about barriers to women in science, very little celebrates the wisdom and insights of women who have made it to the top. Wasserman has let the women in her book speak from their hearts, with little editorial comment on her part. This was a wise move, because the stories ring true. And they are interesting reading.

Wasserman also tells the reader quite a lot about her own background--and this is important for understanding the context of what follows. Indeed, her story is as interesting as the stories of the "academy women." Wasserman arrived in the U.S. in 1937 at the age of 12, having left Germany to escape Hitler. Her parents settled in Great Neck, on Long Island, and she graduated near the top of her class and went to Smith College. Betty Friedan was a senior at Smith College when Wasserman was a freshman, but Wasserman's own interests lay more in civil rights than in women's rights. None of her friends were science majors, and she herself loved many areas, including art history and French, but she chose to major in chemistry.

Although she had an interest in medicine, she decided to do graduate work in chemistry, partly because it was easy to finance and partly because she believed a career in medicine would confront her with the dilemma of choosing between a family or pursuing a career. When she entered Harvard University's chemistry department in 1945--technically, she was a Radcliffe student--as a graduate student, she was one of only two women. She worked with a young and brilliant Harvard organic chemistry professor who later won the Nobel Prize--none other than the legendary Robert Burns Woodward. According to Wasserman: "He agreed to supervise my dissertation research on the condition that I not cry. A woman student of his had dropped out in tears the previous year, and he evidently wanted no repeat. I accepted these terms and kept my promise."

After marrying Harry Wasserman, a chemist, the two headed off for Yale University--he as an instructor (and now an emeritus professor) on the chemistry faculty, she as a research assistant. She soon had a family and was able to keep her hand in chemistry by taking part-time positions in industry and by teaching in community colleges at which there were no research opportunities. After three children, however, Wasserman realized that she could not keep up her chemistry, and she accepted a position as assistant dean of the Yale Graduate School--a position that enabled her to work part time and look after her family.

Then in the fall of 1968, Yale decided to admit women to its undergraduate college and the Yale president, Kingman Brewster, wanted a woman administrator. "I naively expected," she writes, "that I would transfer my status as assistant dean from the graduate school to the undergraduate college. I was promptly informed that the assistant deans at Yale College--all of whom were male--would be too threatened if a woman were to join their ranks as a fellow dean and thus as a quasi equal." And so she became "Special Assistant to the President on the Education of Women and Chairman of the Committee on Co-Education."

The rest of Wasserman's history is fascinating, as she became an agent for change at Yale. She became friends with many other women who were doing the same kind of pioneering work at other institutions and became "all too aware of the unique problems women face and was determined to set them right." By 1973, when Yale's initial transition to coeducation had taken place, Wasserman "could not persuade Yale to hire the women it claimed could not be found and were not needed." She moved on, becoming a student at Yale Law School, where she received a J.D. degree in 1976.

But she was forever sensitized to the issues. Against this backdrop, she began to explore how women have made it to the top despite the hurdles. And thus was born this book--she contacted the 86 female members of NAS in the biological, physical, mathematical, and engineering sciences who had been elected to the academy between 1957 and 1996. She asked them three questions: To what factors do you attribute your success in science In your opinion, was your career affected by the fact that you are a woman and, if so, how If you had money and power, what policies would you implement to facilitate science careers for women

Wasserman obviously hit a responsive chord, receiving replies from 66 of the women. And not just responses--but candid, eager, helpful responses. She interviewed 37 in person or by phone and received letter replies from 24 others. All of this information infuses her conclusions, but the richness of their collective experiences is provided in 26 individual narrative profiles. She organized these profiles by the decade in which the women were born: before 1920, the 1920s, 1930s, and those after 1940.

Among the women with chemically related careers whom Wasserman profiles are Gertrude B. Elion, now deceased; Isabella L. Karle; Maxine F. Singer; Judith P. Klinman; Susan S. Taylor; and Pamela A. Matson. But all of the stories are equally interesting--and extremely candid. Wasserman avoids a cookie-cutter approach to their stories, and thus the reader will occasionally find a piece of information missing--for example, the date of birth. But it is easy enough to figure out approximately when the women were born from the information provided, and this is, in any case, nitpicking. These are stories that will have both women and men nodding in recognition of their own situations.

After the profiles, Wasserman provides two chapters that focus on common threads that emerge from the academy members. "Women elected to the National Academy of Sciences tend to be rugged individualists pursuing their personal hopes and dreams," she writes. "They are pioneers as scientists and as women. As revealed in their profiles, the careers of women scientists are closely tied to the era in which they grow up and work, and the careers of the older generations of women differ in important ways from those of younger members." And yet they do have things in common.

Among those commonalities is the importance of parental influence. Many women remarked that their parents made them feel as though they could succeed in any endeavor. Those that didn't have parental enthusiasm found role models in their teachers and friends. Many women were hooked on science and research after reading about Marie Curie or Rachel Carson, a visit to a zoo or museum, a hands-on experience in the lab, or encouragement from a wonderful mentor in high school or college.

A passionate commitment to research--absolutely essential to success in science--characterizes all the women. But there were hurdles. Many women commented about pressure from parents who wanted them to get married and have children. Women in general have been taught to be nurturing, compliant, and to put the needs of others before their own. This works against women in highly competitive scientific fields. As Wasserman relates, the late Marian E. Koshland, a microbiologist, observed: "When something comes along and is really important to your career and important to science, important enough so that lots of other people are working on it, you have got to do it in a short time. You have got to get in there and run experiments quickly and get published. That is the killer instinct. I do not think women have that part of it. Part of it comes from sports. It's like scoring a goal."

The dominant theme in all the interviews no matter the age or discipline is the "dilemma women encounter in balancing career and family responsibilities," Wasserman writes. "The tension between personal life and career exists for men and women but is especially acute for women in competitive professions such as scientific research and was a significant issue for all the women I contacted--whether married or single, with or without children."

Almost four-fifths of the women she interviewed were married, and more than three-fifths had children, dispelling the notion that women scientists cannot succeed if they marry and have children. But it isn't easy, and these women's stories are instructive.

One of the most helpful chapters is titled "Righting the Balance." Here, Wasserman summarizes the major issues holding women scientists back and provides suggestions from the women she interviewed for lifting the barriers to advancement. Among the suggestions are policies designed to encourage more young women to become scientists and to overcome internal barriers rooted in traditional attitudes; adoption of family-friendly policies by institutions in order to attract and retain scientists who are currently leaving academia for positions they view as less pressured and more compatible with other responsibilities; and policies designed to promote more women to senior positions and to equalize other opportunities by including women in significant numbers at all levels of decision-making. The list of references in the book is also extremely helpful.

This book should be required reading for all students majoring in science but especially young women aspiring to a science career, their parents, their teachers, and their guidance counselors. From "The Door in the Dream," readers will gain fresh perspective and insights into the complex issues confronting contemporary women scientists and other professionals. But they will also enjoy reading about a group of brilliant, highly dedicated, and, quite importantly, appealing women who have made it to the summit through native intelligence, hard work, perseverance, and a bit of luck.

Madeleine Jacobs, editor-in-chief of Chemical & Engineering News, has been writing about gender issues in science for more than 30 years.

Why So Slow? The Advancement of Women
In her recent book, Why So Slow? The Advancement of Women, Dr. Valian takes a cool, calm, and rational look at gender discrimination and asks the question: Why are women underrepresented in the upper levels of the professions in which they work? She will demonstrate that we all have nonconscious biases that influence both our behavior and our evaluations of one another. Dr. Valian enlivens her material with personal anecdotes, and offers both personal and societal solutions for reducing subtle gender discrimination brought about by our nonconscious assumptions about each other. Virginia Valian, Ph.D., is a Professor of Psychology and Linguistics at Hunter College and City University of New York Graduate Center.

Trust and Betrayal in the Workplace: Building Effective Relationships in Your Organization by Dennis S. Reina and Michelle L. Reina

Put Your Science to Work: The Take- Charge Career Guide for Scientists (2001 AGU).

Peter S. Fiske, author of the just published Put Your Science to Work: The Take- Charge Career Guide for Scientists (2001 AGU).
Further information about the book read below and for an order form are available at http://www.agu.org/careerguide/ "Career development remains a primary issue for young scientists," says Fiske. "In one survey we conducted of young AGU members, we found that concern about the job market was the number one most cited reason why some students had considered leaving graduate school. It's an important issue not only for young scientists but for the health of the discipline as a whole." Fiske, a research scientist at the Lawrence Livermore National Laboratory, is something of a guru for young science graduates seeking interesting careers, thanks to a previous career guide, To Boldly Go (1996 AGU). He says the situation is vastly better than it was just five years ago, in that there are many other good options for scientists than conducting research in a university laboratory. But, he adds, "universities and Ph.D. programs are still not providing the sort of information and guidance newly-minted Ph.D.s need to hit the ground running." Science graduates are now in demand in a variety of fields, including business, industry, journalism, government, and Congressional staffs, Fiske notes in his new book. But many students believe that their advisors consider inquiries in such directions as tantamount to treason. The question arose at his Fall Meeting session. "I respond that students need to understand that they are in charge of their training and their professional development," says Fiske. "While an advisor can provide a stimulating and nurturing environment in which to do research, the student ultimately must chart his or her own direction. Most often, students are overly nervous about discussing career issues with their advisor. Just because advisors are unfamiliar with other career paths does not mean that they are hostile." In Fiske's view, the best approach for a young scientist is to explore all career options by devoting a small portion of every work week to exploring new areas and by building an active professional network. That is what Put Your Science to Work is intended to facilitate. It provides advice from potential role models in a variety of scientific fields and professions, along with suggestions for learning about good job openings in unexpected places, writing winning resumes, successful interview techniques, and many other elements of the job search.

Handbook of Women's Health: An Evidence-Based Approach

The term "women's health" is best used to describe an approach to the care of a woman by her health providers rather thanto denote a specialty. Editor Jo Ann Rosenfeld sets out to consider"the woman and her health needs in her position in her life cycle,her family, andsociety."

Her book is well organised and has sections on preventive care, sexuality, genitourinary medicine, breast disorders, psychologicaldisorders, and common medical problems. Eating disorders, breastconditions, urinary incontinence, female cancers, and depressionand premenstrual syndrome get special emphasis. There are separatechapters on lifestyle issues such as smoking and exercise. Ofparticular value are the chapters on issues with lesbian patients,woman battering, and breastdisorders.

However, although this is a comprehensive text on women's health, it is neither useful as a handbook (being too large to carry)nor does it take the current evidence based approach. Its authorsrefer predominantly to organisational publications, position statements,and reviews for specific recommendations, often neglecting toidentify the original or landmark studies. They rarely give thelevels of evidence for making clinical recommendations or gradetheir recommendations. Also, there is little evaluation of thequality of the studies that theyreference.

There are notable exceptions, however: the chapter on breast cancer screening evaluates the evidence and grades some of itsrecommendations, and the chapter on lesbian patients includesexcellent clinical recommendations and approaches with a clearreference to the lack of quantity and quality of much of the dataand the need to depend upon "bestknowledge."

This book points out the societal as well as the biological differences between men and women. As such it makes a welcomeaddition to the office library of any doctor interested in women'shealth. I recommend it as a well referenced text rather than asan evidence basedhandbook.

Women's Heart Institute, Cardiovascular Medical Group of Southern California Judelson@cvmg.com

The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America

If you wonder why American women pin pink ribbons to their jackets and go in their thousands in "runs for the cure," thisbook will give you thehistory.

In a readable style with realms of research, Barron Lerner, an associate professor, medical historian, and practising physicianin New York, outlines the history of the diagnosis and treatmentof breast cancer in the 20thcentury.

Lerner describes the first battles: over surgical treatment for breast cancer, then over statistics versus clinical experience;over the biology of individual cancers; over randomised controlledtrials; and over the patient's role in decidingtreatment.

Surgeons such as William Halsted of Johns Hopkins tried to remove every bit of tissue that might have been invaded by cancer.Did the surgery improve survival? Lerner explains the problemof comparing studies. At first, women presented with large tumours.The American Cancer Society urged women to see their doctors ifthey found a lump: earlier detection meant better survival, butthe reward was a grossly disfiguring operation. Breast cancersurvival statistics remained about thesame.

Lerner describes the revolution when breast cancer treatment, along with society, changed in the 1960s. Barney Crile, a surgeonat the Cleveland Clinic, questioned whether drastic operationssaved women's lives; he listened to British, Canadian, and Europeaninvestigators, and he spoke to the public in a book, articles,and on television, when previously doctors had kept their doubtsin professionalcircles.

Lerner explains how Bernard Fisher of the University of Pittsburgh promoted randomised controlled trials, which revealed theimportance of chemotherapy if a cancer became systemic early.Biology determinedsurvival.

Women's involvement became incendiary in the early 1970s, when well informed women journalists developed breast cancer, challengedtheir doctors, and wrote about it. Other prominent women

the president'swife, Betty Ford, the vice-president's wife, Happy Rockefeller

wentpublic with their breastcancer.

Lerner reports that the only randomised controlled trial of mammography screening in the United States showed that screeningsaved lives. To see benefits for younger women, doctors had torely on overseas trials. The better mammography became, the moresuspicious findings it turned up. Genetic testing brought newquestions.

Lerner notes that when women demanded to be involved in decision making, state laws required doctors to describe all optionsfor treatment. Women demanded greater funding and got supportfrom American corporations, many of whom were involved in breastcancer treatment. A curious situation: the more breast cancer,the greater corporateprofits.

In the last century, surgeons offered a quid pro quo, Lerner writes

come early and we will cure you. Today, he concludes,there is no quid proquo.

By Michael J. O'Dowd
Parthenon Publishing Company
Copyright 2001
455 pages
ISBN 1-85070-02-8
$85.00

The purpose of The History of Medications for Women is to demonstrate the historical, not the technical, details of the various medical aspects of reproductive health and herbal and conventional medicines used primarily for female diseases and conditions during the past 5000-6000 years. This excellent book by Michael J. O'Dowd, a Consultant Obstetrician Gynecologist in Galway, Ireland, easily illustrates how the "spread of medical wisdom" was possible in the ancient world.

He begins by discussing the first recorded prescription records of 2100 BC, Assyria, and emphasizes the important role of the printing press, which enabled the publication of medical and nonmedical books on reproductive issues and herbal medicines.

O'Dowd then presents a detailed history of midwifery and male midwives, the forerunners to the male obstetricians/gynecologists. The first title on this subject, Gynecology, written by Soranus of Ephesus in AD 2000, outlines midwifery, herbals, and delivery techniques such as breech extraction, which was "lost after his time until reintroduced to obstetric practice by [surgeon] Ambroise Par� of France in the 16th century." This is not the only item to disappear and resurface; it also happened to herbal medicines, as described later in the text.

The History of Medications for Women shows the changes in the practice of childbirth, such as the transition from having a physician present at childbirth to the use of midwives. Survival of the species (female reproduction) was the primary women's health issue for early civilizations, until family planning began to be addressed in the early 20th century. O'Dowd gives a detailed account of the unconventional physician, herbalist, apothecary, and astrologer, Nicholas Culpeper, and his Directory for Midwives, an English text written in 1651. He discusses in detail how Culpeper integrated medical, herbal, astrologic, and numerologic information into his practice.

The book goes on to describe the decline of herbal medicines during the 18th and 19th centuries, when the "pharmacopoeias were stripped of many ancient and unproved medications." This started with the publication in 1745 of William Heberden's Antitheriaka: an Essay on Mithridiatum and Therica, which denied the efficacy of these natural drug products. One questions the rationale of the cleansing of books that outlined the use of herbs, minerals, and animal parts during this supposed "Age of Reason," especially given the popular resurgence of herbal medicines in the latter part of the 20th century.

A substantial section of the text is devoted to synthetic medications that have emerged in the past 100 years. The author states that the drugs included in this book are listed purely for historical interest and that the text is not intended to be a reference for botany, pharmacology, pharmacognosy, or therapeutics.

Since The History of Medications for Women concentrates primarily on the female reproductive cycle, diseases that may affect any aspect of this are mentioned. However, the text does not address gender-based medicine, an American-originated theme that gained attention after the Institute of Medicine issued its report, Exploring the Biological Contributions to Human Health: Does Sex Matter? (Spring 2001).

This chronicle is well organized and has an exceptional index that guides the reader through disorders affecting females, herbal medicines from various civilizations, gods and goddesses that were associated with health and healing, male and female physicians through the ages, and significant women's health textbooks and pharmacopoeias.

Most healthcare professions lack courses on women's health or even an integration of women's health into the lectures. The History of Medications for Women would be an excellent choice, along with others particular to a health field, for inclusion in the curriculum of an orientation course. This book could also be used in an interdisciplinary course in a women's studies department.

Mary Berg is a Professor of Pharmacy at the University of Iowa, Iowa City, and a member of the Board of Directors of the Society of Women's Health Research in Washington, DC. She was a charter member of the Advisory Committee to the Office of Research on Women's Health (ORWH) at the National Institutes of Health (NIH), 1995-1999.

Hearts of Wisdom: American Women Caring for Kin, 1850-1940

By Emily K. Abel. 326 pp. Cambridge, Mass., Harvard University Press, 2000. $49.95. ISBN 0-674-00314-4

The history of private care for the sick or disabled is an area much neglected by historians of health and medicine. It is a rich history, however, and one that also has a place in the history of private life, the family, and community relations. If it is a neglected history, however, it is also an undervalued one, especially in the history of health and medicine. Private care for the sick by family members and neighbors has always been the primary form of nursing care, and it remains so in poor countries. Care as a gift relationship lies at the core of family life in most cultures, and care as a fundamental human relationship is the subject of Emily K. Abel's fine book, Hearts of Wisdom.

Abel writes her history from the perspective of those within these care relationships, working from diaries and letters, both private correspondence and public letters of pleading to governmental agencies and care institutions. The words are largely those of the caregivers rather than those of their patients, although one important voice in the book makes the painful transition from caregiver to dependent. Abel's is a partial story, confined to the testimony of the few who wrote diaries and letters that passed down to posterity, but it is no less valuable for that. Not all her correspondents and diarists are comfortable with literacy, however, and neither are all of them admirable women; on the contrary, some are all too human.

Abel recreates the world of private care, especially as it existed far from professional help in remote, pioneering communities. The poor and the isolated depended on each neighborhood's or community's having at least one woman who was good at delivering babies, nursing the sick, and laying out the dead. Many women did become very handy in the sickroom, skilled at the feeding, toileting, and bathing of invalids and even at the management of catheters and drains. Abel is quick to quell any romanticizing of lay nursing or midwifery, but there is no question that many women possessed a natural flair for both the physical and the emotional care of those who were suffering.

However, the time span of this history -- 1850 to 1940 -- also encompasses the ending of this world of private care as a result of the rise of biomedical expertise, the professionalization of nursing, and the growth of hospitals and asylums. Private care gave way, not always willingly, to professional care. The disinterested expert trained in the universal, standard care of the universal, standard patient supplanted the voluntary caregiver recruited to the task through familial or community bonds. The appeal of biomedicine, of course, sprang from the reality that even before antibiotics, nursing care did have something special to offer to the sick and injured: supportive care of the sick so that the natural powers could effect healing. This is another neglected area of the history of medicine. Abel pays some attention to the actual tasks of home nursing, such as bathing and turning, but more needs to be said generally about the improvements in nursing care by the end of the 19th century that were really beginning to save lives.

Nurses in hospitals and trained private nurses working under medical direction could be very skilled in keeping dangerously ill patients alive. This care was astonishingly intimate and emotionally charged. In the days before intravenous drips, constant verbal and physical encouragement was needed to keep patients sucking ice, sipping stimulants, and swallowing morsels. Catheters and drains, especially before the invention of rubber, required constant vigilance. Enemas (including nutrient enemas), douches, and irrigations took considerable skill. Patients had to be turned, washed, powdered, and rubbed with methylated spirits. Poultices were complicated; suppurating wounds had to be dressed. All of this required touching and talking, and even in hospitals, nurses often "specialled," forming a powerful commitment to particular patients, and the touching and talking were often vital to recovery.

What Abel tells well is the story of the influence of germ theory on care in the home, and wisely, she chooses tuberculosis for her case study. No contagious disease caused as much private anguish as this one, once it was discovered that people with tubercular infection were dangerous to those around them. The accounts of struggles between officials who sought to isolate infected patients from their families are painful to read. So also are the accounts of interactions between institutional authorities and mothers of those who were deaf, "feeble-minded," or epileptic.

Abel's Hearts of Wisdom is more than a history; it is also a moral reflection on the meaning of caregiving in private life. If the welfare state in its various forms was initially needed in part to provide a safety net of care for those without families, its rise may also have diminished the moral value of private care. Throughout her book, Abel emphasizes the moral growth and emotional enrichment that caring induces in most of us: it is one of the most important things that make us human, and we neglect it at our shared peril.

Plague Time: How Stealth Infections Cause Cancers, Heart Disease, and Other Deadly Ailments

By Paul W. Ewald. 282 pp. New York, Free Press, 2000. $25. ISBN 0-684-86900-4

Plague Time is about the likelihood that infections cause atherosclerosis, some cancers, and other chronic diseases. This is certainly a current theory, and the book could be useful to readers who have not followed the literature in support of this thesis. Among the conclusions presented are that most of our diseases are caused by unrecognized infections and that more money should be spent on research on infectious diseases.

I laud these conclusions, yet I cannot applaud the book. Ewald is guilty of overkill. A constantly recurring theme in the book is that the medical establishment has been too slow to recognize new ideas and to effect change. An example is that successful antibiotic treatment of peptic ulcers was first tried in 1955, and the fact that it took 40 years for the medical establishment to accept the notion that peptic ulcers are a treatable infectious disease has caused many to suffer and die. Another is that of cervical cancer and the "high-risk" subtypes of human papillomavirus. Ewald argues that thousands have probably died from cervical cancer because it was treated as bad luck rather than as a preventable sexually transmitted disease.

Ewald believes that there is a bias against attributing diseases to infectious causes. The credo he recommends to modern-day microbe hunters is to investigate the chronic diseases that most experts do not think are caused by infection and figure out how to control them. Ewald believes that the emphasis of modern genetics is misplaced and that the Human Genome Project is a case in point. The important genes, he believes, will turn out to be those of infectious agents and those that control the human response to infection.

Ewald argues that we set the standard for the acceptance of such theories too high and that we should lower our thresholds. He wants anecdotal information, screened by some good method, to be used more effectively. But we already live in a world in which everything gets published somewhere. If you believe something, you can certainly find some report, somewhere, to support it.

A number of conditions are discussed extensively, including atherosclerosis, which, notes Ewald, may be caused by Chlamydia pneumoniae, a very common infection. This issue is currently the subject of intense international research activity, but researchers have yet to prove a causal relation.

The bottom line is that the contentions here are carried too far. Ewald seems to believe that any deviation from the norm could be caused by an infection -- even, he suggests, artistic creativity. I find this way of thinking frightening.

Ewald also stresses that the supposition that the infectious agent and its host will, over time, put selective pressures on each other toward the persistence of both and the least damage to either is not necessarily true. The evidence against this principle comes from situations in which the rapid transmission of an organism occurs, with selection for increased virulence -- for instance, in locations where there is a high degree of crowding, mobility, and sexual contact as well as poor sanitary conditions. Ewald discusses such short-term success of highly virulent organisms as a revelation of "evolutionary biology." However, Sir Macfarlane Burnet, one of the leading proponents of the theory that successful host-parasite relationships adapt in the direction of benignity, actually discussed it about 50 years ago: "If the microorganism causing an epidemic is susceptible to variations in the direction of higher virulence, then opportunities for rapid spread in susceptible persons will cause an apparent increase in virulence by selection of the fittest, i.e. most virulent, bacteria" (The Natural History of Infectious Disease. Cambridge, United Kingdom: Cambridge University Press, 1953).

This book has a somewhat self-congratulatory tone -- the author likes to assert that he made predictions and then to congratulate himself for having been right, as in the case of an accurate prediction that the Spanish influenza strain would not reappear during the 1990s. That a population becomes susceptible to the epidemic spread of an infection because acquired immunity has waned does not necessarily mean that the pathogen is still sitting there, waiting to reinfect people.

There are also some errors and misinterpretations in this book. For example, Ewald asserts that the transmission of genital herpesvirus infections is caused by stress, which induces the replication of the virus, the formation of blisters, and the subsequent transmission of the virus from lesions. The current understanding, however, is that inapparent infection and the asymptomatic shedding of virus are probably responsible for transmission in most cases. In trachoma, blindness is not caused by "puffiness" of the conjunctiva but is, rather, secondary to the scarring of the conjunctiva. Genital chlamydial infections (with secretions, Ewald supposes, contaminating the garments of persons in areas where trachoma is endemic) are not considered to have a role in the transmission of trachoma. The model Ewald presents of the replication of human papillomavirus in his discussion of cervical cancer probably has little relevance for the actual transmission of that virus. Young, sexually active women have very high rates of inapparent infection, and long-lasting dysplasia reflects a persistence of infection. That women with multiple sexual partners have a higher prevalence of infection with the "high-risk" types of human papillomavirus need not reflect increased virulence (there is no evidence of changes in the virulence of specific types of the virus); it can, instead, be easily explained by increased exposure and the more persistent nature of the infection caused by these types of the virus. The bottom line: an important subject, a disappointing book.

The World of Caffeine: The Science and Culture of the World's Most Popular Drug

By Bennett Alan Weinberg and Bonnie K. Bealer. 394 pp., illustrated. New York, Routledge, 2001. $27.50. ISBN 0-415-92722-6

This book covers the history and social effects of the principal beverages that contain caffeine, notably coffee and tea. Products of cacao, chocolate that is eaten and drunk, and the soft drinks that contain caffeine (principally colas) are also covered. The historical origins of coffee, tea, and cacao are described, as are the various fascinating ways they made their way into world culture. Some of the main features of this story are told with a theme of geographic spread and with a description of effects of the arrival of "the drug," as the authors often refer to caffeine, on existing cultures. How the different beverages were received (or rejected) by different cultures and by different strata and segments of each culture makes a rich and exciting story. Insights emerge as to how the various civilizations worked. The pleasure of reading is enhanced by the authors' eye for beauty and the many appropriate half-tone illustrations. The scholarship is impressive; many of the most famous figures of the past 500 and more years make brief appearances. Among them are Chinese emperors, Zen Buddhist monks in Japan, nameless Olmecs of Mesoamerica, and then Cortes and Montezuma and Charles V. The conquest of Europe by the drug from Turkish and African sources is also covered. The familiar names of great historical figures appear on almost every page, tying this account in with our knowledge of history and making it more real. The text is rich with information, yet it is easy and pleasant to read.

Social factors are discussed. For example, there are comparisons of the tea culture of England with that of Japan and comparisons of both with the coffee culture of the United States. The duality of the culture of coffee (as in coffee houses) and the culture of tea (as in tea shops, tea gardens, and afternoon tea) is emphasized and illustrated with a list of more than 30 word pairs. One word in each pair is labeled the "coffee aspect" and the other the "tea aspect." The list of coffee aspects starts with "male," "boisterous," and "bohemian" and ends with "Balzac," whereas the list of tea aspects starts with "female," "decorous," and "conventional" and ends with "Proust." Cola beverages are said not to have a long enough history to have features as well differentiated as these, but they do have distinctive associations, such as "youth, high energy, America, pop culture, and 'good clean fun.'" Although the authors emphasize that all these popular beverages contain the drug caffeine, the diversity of the cultures associated with the different beverages suggests that caffeine is only one factor leading to their consumption.

True to its title, the book has little to say about alcohol, but the authors do make the important point that, at least in Europe and North America and at least in the large towns, raw water was not fit to drink until late in the 19th century. The increase in tea and coffee drinking offered an alternative to the usual beverages: beer, gin, and rum. The authors credibly associate this shift with a decrease in alcohol intake, to the benefit of society.

In the second half of the book, the nature of the story changes. The urbane historical perspective gives way to more recent concerns, including a discussion of what might be called huckstering by purveyors of caffeine products. Almost the final third of the book is devoted to the chemistry, pharmacology, and medical aspects of caffeine. I do not think that in a book of this size it is possible to present enough of an understanding for readers to reach their own conclusions on adequate grounds about the health and safety aspects of caffeine, and in many instances the original sources must be scrutinized for the adequacy of the evidence. In addition, there are errors. For example, a woman is said to have had a serum caffeine concentration of almost 300 mg per milliliter, which is many times the solubility of caffeine. Readers can remain confused, they can accept the often implicit conclusions of the writers, or they can opt out and simply trust the Food and Drug Administration (FDA).

A number of minor matters follow. Pure caffeine is variously described as "highly toxic" or "extremely toxic." An agent that can be ingested in amounts of several grams with relative impunity would not customarily be considered very toxic. A number of common foods -- dry mustard, horseradish, or cayenne pepper, for instance -- would not go down well as boluses of several grams. The poison of the puffer fish, whose flesh is eaten in Japan, is highly toxic, being hazardous in quantities thousands of times smaller than ordinarily consumed quantities of caffeine.

Finally, the authors aver that the International Life Sciences Institute (ILSI) was founded to help forestall efforts to regulate caffeine. But the FDA was regulating caffeine long before the ILSI was formed. The Caffeine Technical Committee of the ILSI was formed by interested companies to sponsor research on questions on caffeine raised by the FDA and others. It is prohibited from lobbying.

Peter B. Dews, M.B., Ch.B., Ph.D.
New England Regional Primate Research Center
Southborough, MA 01772-9102

The Story of Taxol: Nature and Politics in the Pursuit of an Anti-Cancer Drug

By Jordan Goodman and Vivien Walsh. 282 pp. New York, Cambridge University Press, 2001. $27.95. ISBN 0-521-56123-X

For anyone wanting all the details of the development of paclitaxel (Taxol) from its very beginning until it was marketed as a new, natural-product anticancer drug, this book is an excellent source of information. It is carefully researched and detailed, and as someone who was at the National Cancer Institute (NCI) during part of the development of Taxol, I found it factually accurate.

In the book, Taxol and the source of Taxol, the bark of the tree Taxus brevifolia, are treated as unique characters in a historical novel. The authors weave the story of the discovery of this drug and the intricacies of developing it from its natural source with the politics and effects of harvesting the tree from the forests of the Northwest. The book ends with a discussion of the impact of harvesting T. brevifolia on the local economy and the negative repercussions of the successful development by Bristol-Myers Squibb of a semisynthetic process for producing the drug.

Here, however, perception departs from reality. For example, cancer chemotherapy and the drug-development program of the NCI are wrongly portrayed as Goliaths in cancer treatment at the time, as compared with surgery and radiotherapy. The drug-development process is portrayed as having gone awry with Taxol, and Bristol-Myers Squibb is depicted as a robber baron who ran off with the credit for its discovery and with the rights for a drug developed with the public's money. Worst of all, after two decades during which methods for refining the harvesting process without continued damage to the forests were sought, the synthesis of Taxol by Bristol-Myers Squibb is said to have deprived a depressed economy in the Northwest of a source of income.

The actual story is quite different. First of all, although Taxol is a very effective natural product, it is not unique. There were other drugs before Taxol and some after it with equal effects and equally compelling stories. Some of them, like the vinca alkaloids and the epipodophyllotoxins, have been associated with bona fide cures of major cancers. Then there is the fascinating story, spanning three decades, of the development of the camptothecins, three of which are in clinical use. This is a far more intriguing story than that of Taxol and matches it in terms of integrating issues of forestry and drug development.

The NCI drug-development program, including the natural-products program, was established and maintained by pioneers such as Ken Endicott, Murray Shear, Jonathan Hartwell, Gordon Zubrod, and others for the purpose of finding new and effective treatments for cancer at a time when screening for anticancer drugs was largely derided by the academic community. All of them are mentioned in the book, but out of context, and in history context is all important.

The development of Taxol did not go awry at all. It worked according to plan, despite long odds and near misses. For example, had not the NCI drug-screening program been changed in the early 1970s to include human tumor xenografts in nude mice, the drug might have been abandoned for lack of activity in the old screening programs. It was also a small miracle that the crude extraction techniques used at the time could actually isolate activity from natural products. It was also remarkable that the people responsible for sending out teams to isolate bark for annual collections had the foresight to continue the collections while clinicians pondered whether the drug was worth it. A misstep could have cost additional years, at a minimum, or could have stopped the development process altogether.

From the beginning, the NCI drug-development program for both natural products and synthetic agents was intended to take the risks that pharmaceutical companies could not take to establish whether drugs could actually cure cancer (until recently, this was a hotly disputed issue) and whether there were drugs in nature that could be useful anticancer agents. It also was intended to determine whether there was a market for these drugs (also a disputed issue). It was never the intent of the NCI to stay involved in the development of any of the drugs it discovered or developed in collaboration with industry, nor was it possible for it to do so. It meant to offer such drugs at the earliest possible moment to established companies for development and marketing. Always included were plans to find ways to develop reliable methods for synthesizing very complex molecules to ensure a steady supply.

All this worked. When the program was established, there was no anticancer-drug market. Now, this market is profitable enough to attract major companies, and accordingly the amount of taxpayer money used by the NCI for this purpose over the years has declined substantially, as its need to be the risk taker has diminished. Most important, drugs can cure cancer, and thousands of lives have been saved or extended. Bristol-Myers Squibb has profited from its association with the NCI, but so have Americans who have cancer, and Bristol-Myers Squibb was one of the first companies to make a substantial investment in the development of anticancer drugs. The company is more a trailblazer than it is a robber baron.

With regard to credit: the chemists who initially extracted Taxol from the bark of T. brevifolia are fine and dedicated scientists. In truth, however, they were not the discoverers of Taxol in the usual scientific sense. The bark was given to them for extraction. The real "discoverers" were, once again, the people who supported the process of drug development, according to what appeared to be a utopian concept. They developed a relationship with the Department of Agriculture for collections, and they established contracts with natural-product chemists to extract active materials from collected plants. They defended the program annually before the Office of Management and Budget and the Congress, despite the fact that for many years, because of the long delay between discovery and application, the program was mostly regarded as a failure. It is really they who discovered Taxol and many other drugs.

Although this is an excellent and well-written book, its focus on the environmental and economic issues surrounding the extraction of drugs from forests clouds the history of a unique government program established by a handful of visionaries in the 1950s and 1960s.

Vincent T. DeVita, Jr., M.D.
Yale University School of Medicine
New Haven, CT 06520

Breast Cancer: Society Shapes an Epidemic

Edited by Anne S. Kasper and Susan J. Ferguson. 388 pp. New York, St. Martin's Press, 2000. $27.95. ISBN 0-312-21710-2

Is breast cancer a social problem or a medical disease? Of course it is both, but by posing such a dichotomy, Breast Cancer: Society Shapes an Epidemic raises disturbing questions and obscures potential answers. At times, this book degenerates into prejudice against men and the biomedical establishment. At other times, it provides a trenchant analysis of the social, economic, and political dimensions of breast cancer. Most edited collections of essays suffer by definition from a lack of consistency, of a single voice. This book is part shrill and part skill, part polemic and part indictment. It addresses social and economic dimensions of breast cancer in a manner that is by turns inspiring, infuriating, disturbing, and dismaying.

The introduction is meant to lay the groundwork for a deep and empathic understanding of breast cancer as viewed "through a social lens." Lenses can magnify, but they can also distort. The editors insist that the social view supersedes rather than supplements the biomedical one, noting that we are "moving away from the biomedical model of disease toward a social model of illness." In doing so, the authors create a false dichotomy, a situation once referred to by Justice Felix Frankfurter as the "cross-sterilization of disciplines." The social perspective is important enough that it does not need to be presented as an alternative to the biomedical one.

The book's editors take some cheap shots at medicine, saying, for instance, that Vincent DeVita "was willing to do away with breast cancer study sections" when he was the director of the National Cancer Institute. Did he do so? Were grants for research on breast cancer treated better or worse in the study sections to which they were transferred? The editors also attack another unlikely target when they write that "the breast cancer stamps have been a public relations boon for the U.S. Postal Service, but it is not yet clear how much money has gone to breast cancer research." Well, it ought to be clear, and the editors should have found out how much money has been spent rather than casting aspersions in the absence of data.

In a pretentiously titled five-page section, "What is known about breast cancer," the editors focus on ethnic and socioeconomic differences in breast-cancer incidence and survival but do not mention recent evidence of genetic vulnerability to certain types of breast cancer. There is a page devoted to "sexuality differences," about the important issue of lesbian women with breast cancer, but there is no mention of the fact that men also get the disease. The editors have a clear agenda to "promote positive social action." How well does the book succeed?

In one chapter, Lerner argues that breast cancer is a social construct, approvingly citing Charles Rosenberg: "A disease does not exist until society decides that it does -- by perceiving, naming and responding to it." This statement invites the obvious rejoinder that women (and some men) died of breast cancer for thousands of years before anyone knew what it was. The statement represents an epistemological confusion between the thing known and the act of knowing. Lerner goes on to review the often-troubling history of the Halsted radical mastectomy and cites two medical pioneers, George Crile and Oliver Cope, who challenged the procedure. Bernard Fisher's crucial work with the National Surgical Adjuvant Breast and Bowel Project showing evidence of early systemic spread is also mentioned. Lerner notes that it was a combination of medical "whistle-blowers" and increasingly activist patients that forced a reexamination of the needlessly disfiguring approach. Thus, history teaches that biomedicine and social forces can, and indeed do, often complement one another.

Ferguson decries the "medicalization" of women's experience, "such as childbirth, premenstrual syndrome, and menopause." She understandably attacks the popularity of breast-augmentation surgery, but goes overboard by claiming that "small breasts have been labeled as 'diseased' by members of the medical establishment." The reference she cites is a critique of the medical establishment, not evidence for the claim. Ferguson ignores the reality that physicians have in fact "medicalized" the inappropriate concern with body appearance -- for example, with the diagnosis of "body dysmorphic disorder" now included in the Diagnostic and Statistical Manual of Mental Disorders. This diagnosis describes the inappropriate preoccupation with minor physical abnormalities. Furthermore, the social sanctioning of the alteration, even the disfigurement, of women's bodies antedates any medical involvement with such practices: foot binding in China, neck bracelets in Africa, and tattoos are but three examples. "By suggesting that reconstruction is a natural part of breast cancer treatment," writes Ferguson, "physicians contribute to the belief that women with one or no breasts are unnatural." Is medical neglect better than this kind of attention? Although many of the patients with breast cancer I have known have chosen not to have reconstruction, I do not know one who resents having the option available to her. Ferguson cites Marcia Angell, a former editor of the Journal, in a rather odd way, using her to document a connection between studies of the safety of silicone breast implants and manufacturers. In fact, Angell has vigorously attacked what she perceives as exaggerated claims of the dangers of breast implants, and her book on this topic was not cited, although several other works of hers were. Angell's position is much better summarized in Rosser's rather strident chapter on "Controversies in Breast Cancer Research," although here Angell is attacked for being too biomedical and insufficiently feminist. In addition, Rosser's discussion of tamoxifen could easily mislead readers because she does not point out that breast cancer is far more common than uterine cancer, so even a small reduction in the risk of breast cancer could well be worth a larger percentage increase in the risk of uterine cancer.

Shaffer contributes a forceful chapter on changes in the health care system that is all the more powerful for its emphasis on fact and economic analysis and its lack of ideology. Shaffer's review of regional disparities in the proportion of the lumpectomies performed in the United States is disturbing, and her clear-eyed analysis of the loss of control over choices of treatment in the new system of managed care applies far beyond the realm of breast cancer. She has a way of summarizing complex issues lucidly, stating, for example, that "it is clear that the market does not reward competition based on quality." She adds that "the market is not an adequate system for achieving systemwide reorganization in the interest of coordinated services.... This is hard news for the health-related corporations that siphon off 30 percent of every health care dollar for administration and profit." Amen.

Zones provides an indictment of the industry forces that overemphasize benefits and minimize the risks of breast-cancer treatments. But she overlooks the real clinical problem: what makes sense from a statistical perspective for a large population may not be the desired or best solution for a given person with breast cancer. Patients want the most vigorous treatments with the best possibility of cure, even if the incremental advantage is small. The limitations of current treatments are well described, but the criticism is not equally distributed. Zones cites a 1984 book by a prominent advocate for patients with breast cancer in claiming that "most of the time, oncologists do not even see their patients during regular, routine appointments" and that they are therefore not concerned with the side effects of treatment. This is not true, and the references Zones cites do not offer evidence for the claim. Similarly, she later refers to a book and a Greenpeace report to prove that "radiation causes about 75 percent of new cases of breast cancer in the United States." Would that she were as critical of the data she likes as she is of the medical profession.

There is a lot of anger in this book -- at doctors, at companies, at social attitudes -- and it is understandable. Some of the targets are appropriate, but some of the anger would be better directed at the disease itself and at its intimation of mortality, as compellingly described in the chapter on women's experiences. "I compare it to being raped, actually," says one woman. "You go through the process of trying to escape, trying to deny it. And then you say, 'My God, I really have this. This is really happening to me.'" This chapter also provides important information about the value of support groups in helping women to normalize an abnormal experience by discussing it with others who are in the same boat. It ends with a touching epilogue written by and about a woman who died. She called her disease what it was -- a "tragedy.... I've lost some of the carefreeness of youth. I feel older. There's some regret. There's also a lot of peace. Bittersweet." Brenner also provides a compelling history of the recent development among women with breast cancer of groups for mutual support and political action.

Kasper documents telling examples and studies of the adverse effects of inadequate or substandard care offered to poor women with breast cancer. Weisman provides an excellent overview of recent policymaking regarding breast cancer at the federal and state levels, including a balanced and thoughtful summary of the pros and cons of a single-issue focus on breast cancer. Steingraber gives us a fact-filled and well-written brief for a fuller consideration of the role of environmental toxins in breast-cancer incidence. Fosket and colleagues review the discussion of breast cancer in women's magazines and note correctly that there is a fine line between teaching responsibility (for breast self-examination, for example) and blaming the victim.

The editors' conclusions combine useful recommendations with wrong premises and ideals that are beyond our grasp. They state that "a male-defined, biomedical, scientific world... has little interest in understanding breast cancer." This is pure nonsense. They then go on to recommend prevention rather than treatment as the goal of research. Prevention has always been the stepchild of medicine -- the benefits are theoretical, and we are still faced with the obligation to treat those for whom prevention has not worked. Clearly, the prevention of breast cancer is a consummation devoutly to be wished. Until it is achieved, scapegoating the men and women who devote their lives to treating those with the disease will get us nowhere. There are good recommendations in this book, including a call for universal health insurance, more research on possible environmental causes of the disease, and the telling of the stories of women who struggle with the disease but die of it, not just those of the "victors." The best outcome will come from empathy for those with breast cancer and their families, trenchant criticism of the data and methods we now have, and respect for the men and women who research and treat the disease.

David Spiegel, M.D.
Stanford University School of Medicine
Stanford, CA 94305-5718

Decoding Darkness: The Search for the Genetic Causes of Alzheimer's Disease

By Rudolph E. Tanzi and Ann B. Parson. 281 pp., illustrated. Cambridge, Mass., Perseus, 2000. $26. ISBN 0-7382-0195-2

The writing in medical journals is deliberately devoid of emotion, which may explain why writers of books about science are flourishing these days. They can add drama and elucidate complexities. A scientific autobiography written with a journalist can be a winner, as illustrated by Decoding Darkness, which could have been subtitled "Alzheimer's Research Goes Molecular." Rudolph Tanzi is director of the Genetics and Aging Unit at Massachusetts General Hospital. Ann Parson is a professional writer.

As autobiography, Decoding Darkness commands attention. In 1980, after having graduated from the University of Rochester, Tanzi was playing keyboard in a rock band and writing best-selling songs. Fifteen years later, he had won two prestigious awards for research on Alzheimer's disease. The transition was not direct.

When Tanzi returned to Boston in 1980, he answered a bulletin-board advertisement and became a technician for James Gusella -- hunting for the Huntington's disease gene. Their success led to a lasting friendship, more than the typical relationship between mentor and student. Tanzi was there from the beginning -- from the setting up of the laboratory through the historic mapping of the gene in 1983 that made Huntington's disease the first disease to be mapped without knowledge of the gene product. At Gusella's suggestion, Tanzi took on a side project -- developing markers for chromosome 21. That chromosome is home to the gene for Down's syndrome, and people with that condition are at high risk for Alzheimer's disease. Tanzi therefore began to work on the laboratory's collection of DNA from families with Alzheimer's disease.

Gusella advised Tanzi to take graduate courses in neurobiology, not genetics. In 1985, Tanzi left the laboratory to become a graduate student. He left his Alzheimer's project to Peter St. George-Hyslop, who was first Tanzi's trainee and then, simultaneously, a partner and competitor.

In addition to being an autobiography, the book is a primer of molecular genetics. Tanzi thought the biologic villain in the Alzheimer's story must be the accumulation of insoluble amyloid in plaques throughout the brain. Before long, he was joined by dozens of competitors who sought mutations in the gene for the amyloid precursor protein on chromosome 21. Tanzi describes the tedium and long hours of fruitless searching as well as the joy when a linkage was found. He explains the methods he and his colleagues used and provides simple figures to explain how the mutant gene works.

There are no human villains among the investigators, but there is drama aplenty. George Glenner first characterized the amyloid in the cerebral Alzheimer's plaques; he himself died of amyloidotic heart disease. Charles Epstein, a leader in recognizing the connection between Down's syndrome and Alzheimer's disease, was seriously injured by the psychotic Unabomber. Research partners split up over arguments about patent rights. Friends became mutually wary. A German scientist publicly accused U.S. investigators of practicing "murderous science" in their development of a rapid autopsy program to provide brain tissue for research; one Jewish leader took personal offense. Commercial companies contributed transgenic mice that carry mutant amyloid genes and develop plaques like those in humans, but these companies sometimes refused investigators access to the mice and promoted competitive secrecy. Tanzi himself is more than a consultant to one company; he has "an equity interest."

Tanzi seems blessed with an amiable disposition. He receives bruises but makes no enemies and bears no long-term grudges. He describes the anguish of knowing he is in a race with other investigators without being aware of how many or who they are -- he names 47 investigators who contributed to the progress in this field, but there are more. Tanzi lost one race when he had almost reached the goal himself, and his marriage was threatened when, racing, he spent Christmas and New Year's Day in the laboratory.

Tanzi himself is no braggart, and he acknowledges that the genetic discoveries seemed to come simultaneously in reports from many laboratories. However, he was one of the first to map the gene for the amyloid precursor protein to chromosome 21. He ruled out mutations in that gene among the families studied at the Massachusetts General Hospital; he provided one of the first genetic maps of the chromosome; and he came so close to identifying the gene for presenilin 2 that he was included as an author in the report that did so. After the book was published, Tanzi described a locus on chromosome 10. Four other genes had been implicated: the amyloid precursor protein, two presenilins, and the susceptibility-factor allele APOE-4. Tanzi and his associates were at the forefront of three of those achievements.

Funding for research on Alzheimer's disease increased from $13 million in 1980 to more than $400 million per year in the 1990s. Therapeutic trials based on the amyloid theory are in progress, investigating a vaccine against amyloid, inhibitors of the proteases that produce the amyloidogenic peptides, and drugs that lower the levels of zinc and copper in the brain. The story is unfinished.

By the time you finish the book, you will hope that Tanzi and the others will make further progress, because Alzheimer's disease is the great white whale of age-related neurodegenerative diseases. There are 4 million victims now -- a disaster for their loved ones and their caretakers, at an annual cost of $100 billion for the nation. The situation is destined to become worse as people live longer. The dominant theory is that genetic susceptibility interacts with environmental factors to cause Alzheimer's disease. Head injury increases the risk, whereas the use of estrogens and nonsteroidal antiinflammatory agents may be protective. By the end of the book, you will also hope that we will see more progress in therapy, so that Tanzi and Parson can give us an upbeat second edition.

Research on Alzheimer's disease did not begin with molecular genetics, and sporadic cases account for more than 95 percent of all cases. However, the genetic clues to amyloid formation apply to the sporadic disease as well as to familial Alzheimer's. Fifty years ago, not much was known about Alzheimer's disease; modern research began in the 1960s. For readers who are interested in the days before molecular genetics, oral-history interviews have been recorded by Robert Katzman and Katherine Bick, themselves pioneering investigators (Alzheimer Disease: The Changing View. San Diego, Calif.: Academic Press, 2000). You do not have to be a geneticist or a neurologist to enjoy Decoding Darkness; Alzheimer's disease is a commanding problem for all of us. The story is invigorating, the progress is fantastic, and the writing is lively.

The Quest for Immortality: Science at the Frontiers of Aging

By S. Jay Olshansky and Bruce A. Carnes. 243 pp. New York, W.W. Norton, 2001. $25.95. ISBN 0-393-04836-5

In 1990, biodemographers Olshansky, Carnes, and Cassel published a review in Science entitled "In Search of Methuselah: Estimating the Upper Limits to Human Longevity" (250:634-640). In the article they argued that, despite the astounding increase in life expectancy during the 20th century (increasing, in the United States, from a mean age of 45 at the beginning of the century to 78 at its end), it was doubtful that we would witness an increase in longevity to ages older than 85 during the foreseeable future. This, they argued, reflected "entropy in the life table": it would be far more difficult to increase life expectancy by curing illnesses in elderly persons than it had been to nudge life expectancy upward by reducing infant mortality. Any increase above the age of 85, they insisted, would require biomedical breakthroughs in our ability to affect the basic processes of aging itself and not just in our ability to treat diseases. Their pessimism, while controversial, provided a much-needed shot of realism in a field in which some researchers were seriously predicting that life expectancy would soon rise above 100.

In The Quest for Immortality, Olshansky and Carnes present their work for the general public and discuss life expectancy, the causes of aging, and the efforts (both legitimate scientific research and bogus claims for alternative therapies) to prolong life and delay aging. The book is well written and is pleasant to read, with a folksy and unpretentious style. For instance, as case histories of how medical interventions have delayed untimely deaths and produced what the authors call "manufactured survival time," they turn to Carnes's own father's bypass surgery and the removal of Olshansky's own pilonidal cyst.

For readers interested in aging and longevity, this small book clearly explains the major concepts in the field. Olshansky and Carnes show how natural selection promotes health during the reproductive period but contributes little benefit over the age of 60. They point out that it is only in the past 100 years that most humans have begun to outlive their reproductive years; diseases of aging are a recent development. Our genetic heritage, they explain, has left us with bodies like cars that were designed to perform flawlessly in the Indy 500 but whose drivers insist on continuing many miles beyond the end of the race, until parts inevitably start to fail. Aging is not a disease that can be cured. The authors describe the free-radical theory of aging and the possibility that genetic manipulation and antioxidants may affect the aging process and, at the same time, decry the often outrageous claims currently made for antioxidants. They review ancient myths of longevity and discuss diets and dietary supplements aimed at averting aging. They point out that proponents of such treatments, in fact, have died at the expected age and of the usual causes.

Olshansky and Carnes also discuss possible scientific approaches, primarily genetic manipulation, that might affect human aging, and they lay out common-sense recommendations for a healthy life while revealing the illogic of claims made by proponents of antiaging treatments. Though targeted for the lay audience, this book will provide a useful introduction for physicians and prepare them to answer their patients' questions about longevity. The authors have an enviable ability to phrase technical issues and arguments in clear, nontechnical language.

Though extremely enjoyable to read, this book has one important flaw that will detract from its usefulness for physicians: a lack of references. The decision to forgo references, suggestions for further reading, and footnotes is unfortunate. The lack of references will largely restrict the audience for this book to the general public and prevent it from being used as a classroom aid for interested medical students and residents.

Fat: Fighting the Obesity Epidemic

By Robert Pool. 304 pp., illustrated. New York, Oxford University Press, 2001. $27.50. ISBN 0-19-511853-7

The mystery: people in industrialized societies are growing ever fatter, and attempts at sustainable weight loss often prove fruitless. The sleuths: scientists who, over the course of a century, arrive at some understanding of the complex interactions among genes, environment, and behavior that establish a person's body-weight "set point." The set point, moved upward by the successes of industrialization, appears recalcitrant to long-term change. But is it?

Robert Pool weaves a wonderful and balanced tale, linking the important 20th-century discoveries that led to the idea of the set point and our current understanding of the regulation of body weight. This is no simple reiteration of well-known history. Pool adds rich new details to the epidemiologic, psychological, and molecular discoveries behind one of the most interesting stories of modern biologic science. The author integrates this complex information in an entertaining manner, and he advances his own views about future research and policy. This book is a must for anyone interested in the history of science, public health, or the related epidemics of obesity and type 2 diabetes mellitus.

The odyssey meanders through the developments of the past century to arrive at our current view of the regulation of body weight. Pool uses the story of a patient in a Turkish study to introduce this view. Patient 24, a hyperphagic, morbidly obese man, was unusual among the obese subjects enrolled in the study. At age 22, he was prepubertal, had little facial or pubic hair, and had hypogonadism. Pool links the condition of Patient 24 to that of the obese (ob) mouse that was identified in 1950 at the Jackson Laboratory in Maine and was shown in 1994 to harbor the mutation that causes a failure of leptin synthesis. The cause of obesity in Patient 24 was not a lack of willpower, notes Pool, but rather the "near-absolute power this genetic mutation seem[s] to hold over [its] victims."

This story is not, however, solely about the genetics of body-weight regulation. The author traces, with ample and interesting detail, the psychoanalytic theories that the influential Hilde Bruch advanced in the early 1960s and Stanley Schachter's imaginative "externality" theory that followed. A later section examines Stunkard's classic Midtown Manhattan Study, which revealed for the first time the close link between socioeconomic status and body weight. The behavior-therapy approach initiated in 1967 by psychologist Richard Stuart is woven together with the studies of Pavlov, Skinner, and Schachter. Moreover, rather than relegate these studies to mere historical footnotes, Pool returns to them toward the end of the book as he develops his own view of a somewhat plastic set point that might permit the lowering of body weight.

In support of this view, Pool does trace advances in biology as well as psychology. The story of the book's central theory of the brain's regulation of body weight begins with the 1840 observation of a woman who grew progressively fatter in the last year of her life and was found on autopsy to have a large pituitary tumor. Then came Froehlich's 1901 report of obesity and hypogonadism caused by a pituitary tumor and the observation in 1939 that ablation of the hypothalamus in rats caused obesity. In 1973, Coleman's seminal experiment in ob mice showed that there must be a circulating satiety factor produced by fat cells. Additional support for the regulatory control of body weight was provided by the studies of overfeeding and underfeeding in humans that were conducted by Leibel and Hirsch. The molecular door was finally opened in 1994, when Friedman and his colleagues discovered that leptin, a previously unrecognized hormone secreted by fat cells, is absent in the ob mouse. As Pool traces these advances, he also gives fascinating insights into the investigators' personalities and working environments.

Anyone, whether clinician or patient, who is interested in the pharmacologic management of obesity should read the chapter entitled "One Pill Makes You Larger, and the Other Makes You Small." Pool shows, with strong historical support, that greater drug-induced weight loss is usually accompanied by greater side effects and can be fatal. However, he does not close the door on drug treatment for obesity, but, rather, reviews some encouraging ongoing research on such medications. This engaging book tells a fascinating story that extends far beyond the information available in journal articles and asks how we, as an advanced society, can fight the obesity epidemic.

Steven B. Heymsfield, M.D.
Columbia University College of Physicians and Surgeons
New York, NY 10025

The Mediterranean Diet: Origins and Myths

By Dario Giugliano, Michael Sedge, and Joseph Sepe. 266 pp., illustrated. Naples, Italy, Idelson-Gnocchi, 2000. $79.90. ISBN 1-928649-06-8

Three types of diet are widely reputed to be associated with good health and longevity, mostly on the basis of ecologic and geographic evidence: the Chinese, the Japanese, and the Mediterranean diets. Though it is not easy to compare these diets directly with respect to their healthfulness, there is good evidence that the Mediterranean diet is the realistic choice for people who engage in moderate-to-low levels of physical activity and consume moderate-to-high levels of dietary lipids. The evidence for this recommendation has been widely embraced by experts in the field.

There are several definitions of the Mediterranean diet, but in essence it emerged when poverty in the region limited access to all but locally produced plant foods. The addition of olive oil facilitated the consumption of raw or cooked vegetables, legumes, wild greens, and even cereals.

The association of the Mediterranean diet with some of the greatest ancient civilizations -- Egyptian, Phoenician, Greek, Etruscan, and Roman -- may have been coincidental, although the pioneering British nutritionist John Waterlow has argued, "It is difficult to conceive how the Greeks and Romans could have achieved such remarkable feats, which involved far more than a small elite, if they had not in general had an adequate and nourishing diet." This theory cannot be refuted by the fact that some key elements of the modern Mediterranean diet, notably tomatoes and some fruits, were introduced into the region much later; the defining elements of the diet -- olive oil, grains, and wine -- have been in the region for millennia.

The task of tracing the origins of the Mediterranean diet is fraught with difficulties. Diet is not a popular archeological or historical subject, and memorable events depicted in ancient artifacts do not, in most cases, refer to the everyday activities of the average person. Nevertheless, with The Mediterranean Diet, Giugliano and his colleagues have produced a delightful book that is pleasant to read and educational in various ways.

The book presents the health effects of diet with a simplicity that does not seriously compromise scientific accuracy, and it treats the various Mediterranean cultures with respect, notwithstanding some unattractive dietary habits (Seneca is quoted as saying that Romans did not hesitate to induce vomiting in order to indulge again in the pleasure of eating). The reader will also be enchanted by the magnificent illustrations of farming, traditional festivities, symposia, and wine drinking.

The book has other less obvious, but equally impressive, qualities. The authors explicitly stress that the benefits of no diet can be evaluated in isolation from physical activity. Indeed, the rise and fall of the Roman empire are seen to be paralleled by a cultural change from a physically active life to a sedentary life and hedonistic habits. It may or may not be intentional, but most of the illustrations in the excellent chapter on exercise and body care are based on images from classical Greece at its prime. Moreover, the authors emphasize that the health advantages of the Mediterranean diet may be enhanced by the traditionally relaxed lifestyle and social coherence of the Mediterranean peoples. Indeed, the illustrations in the last three chapters are a tribute to rural Mediterranean life.

The book does have some weaknesses, but for the most part they are trivial. The authors state that dietary lipids should not exceed 30 percent of the total energy intake, but they ignore the fact that most Greeks consume 40 percent of their total energy intake in the form of lipids (mostly olive oil) and are at least as healthy as Italian or French people. Also, the authors do not adequately focus on diet-related health problems and mortality from other than cardiovascular diseases.

This is a book that is worth owning and reading: the text is valuable, the illustrations are magnificent, and the production overall is excellent. The Mediterranean Diet will enrich the library of any educated person, not only those with medical backgrounds or Mediterranean roots.

Antonia Trichopoulou, M.D.
University of Athens Medical School
GR 11527 Athens, Greece

Advanced Therapy of Breast Disease

Edited by S. Eva Singletary and Geoffrey L. Robb. 344 pp., illustrated. Hamilton, Ont., Canada, B.C. Decker, 2000. $79.95. ISBN 1-55009-106-9

Every year in the United States, approximately 180,000 women receive a diagnosis of breast cancer. Almost no one is untouched by an association with the disease. Clinicians who provide care for women with breast cancer realize that their patients have a surprising degree of scientific sophistication regarding their illness and are often well versed in the current literature on the disease. There is a good deal of advocacy for education and research in breast cancer and for bringing current medical opinion and information directly to the people affected by breast disease.

In 1998, the Food and Drug Administration approved a change in the labeling of tamoxifen to include its use for reducing the risk of invasive breast cancer in women who are at high risk for the disease. This change placed women with strong family histories of breast cancer, those with premalignant lesions on breast biopsy, and all women over the age of 60 in line for preventive treatment of breast cancer. Suddenly, primary care clinicians were being asked even more questions about the risk, prevention, and treatment of breast cancer.

The opportunities and controversies surrounding breast-cancer screening and prevention, as well as the growing advocacy for awareness of these issues, have made breast cancer a matter of concern for clinicians in all fields of medicine. Physicians in the primary specialties of surgery, internal medicine, gynecology, and family practice, as well as subspecialists in medical and surgical oncology, cancer genetics, and radiation oncology, all need concise, up-to-date information on breast disease. Singletary and Robb have effectively addressed this need in Advanced Therapy of Breast Disease. The book is well organized and discusses many aspects of breast disease, from the benign forms to the malignant.

Singletary and Robb, surgical specialists in breast cancer from the University of Texas M.D. Anderson Cancer Center, have compiled a series of reviews and articles from an international group of experts in breast cancer from Cambridge, England, to Palo Alto, California, and points in between, although the majority of the authors are colleagues from the M.D. Anderson Cancer Center. One weakness of this book is also a strength: the variety of authors causes heterogeneity in style, scientific opinion, and scholarly approach.

The book covers screening, breast self-examination, and breast-cancer prevention. Nipple discharge, gynecomastia, and breast pain are given separate chapters. There is attention to minimally invasive techniques for breast biopsy, the dissection of sentinel lymph nodes, and breast cancer in the elderly and during pregnancy. Aspects of reconstructive surgery and systemic therapy for early-stage, locally advanced, and metastatic breast cancer are also discussed. Most authors use an evidence-based approach even when discussing the more controversial topics related to breast care. Many sections include data from landmark clinical trials that have shaped current approaches to the management of breast cancer. The investigators who actually conducted these important clinical experiments have written many of the relevant chapters. Most, but not all, chapters are carefully referenced, and most include references as recent as 1998. Well-planned illustrations, tables, and photographs enhance the readability of the text. A CD-ROM version is included with the book, providing another way to use the material.

This book succeeds in its mission of guiding clinicians through the vast amount of literature on breast cancer and breast disease. It will help doctors and patients as they struggle with a rapidly changing field. As the editors state in the preface, "it is not intended to be a comprehensive review, but rather a unique collection of expert opinions from nationally acclaimed authorities in the field." Both primary care practitioners and other physicians whose practices are devoted more exclusively to the prevention and treatment of breast cancer will value the ideas, opinions, and information imparted in Advanced Therapy of Breast Disease.

Lipids and Vascular Disease: Current Issues

Edited by D. John Betteridge. 262 pp., illustrated. London, Martin Dunitz, 2000. $120. ISBN 1-85317-627-3

The basic sciences, epidemiology, and clinical trials have continued to expand the field of lipid research and preventive cardiology. The goal of Lipids and Vascular Disease is to explore areas of current interest and controversy in this fast-moving field. Most of the book's 18 chapters were written by experts in Europe. In general, the book has been well edited and has a rather uniform format for a multiauthored book. The figures are nicely presented in a standard fashion. The chapters are well referenced, with up-to-date citations.

Two chapters constitute an excellent introduction to new areas of investigation and current controversies, but they are not the initial chapters in the book. Faergeman, in chapter 4, provides an introduction to lipoprotein metabolism and then discusses monogenic and polygenic disorders and gene-environment interactions. Law, in chapter 14, provides an overview of cholesterol lowering on a population basis. Law appropriately points out the contribution of cohort studies in estimating the long-term effects of lipid-lowering drugs, a contribution that the usual clinical trial, with a study period of five to seven years, cannot make.

Several chapters bring together information from large and dispersed areas of research. Postprandial hyperlipidemia probably accounts for coronary risk, in addition to the risk attributed to elevated lipid levels in the fasting state. Foger and Patsch summarize the epidemiologic and clinical-trial data that support this contention. I appreciated the thorough discussion of the peroxisome-proliferator-activated receptor (PPAR) system. Fibric acid derivatives have been used clinically for many years, but their mechanism of action has been unclear. Staels discusses the ability of fibrates to increase hepatic fatty-acid metabolism, to induce the production of lipoprotein lipase, to reduce the production of apolipoprotein C-III, and to increase the production of high-density lipoprotein (HDL) cholesterol -- all of which involve the PPAR system. Davignon and Dufour review the expanding data base on the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins). Although the consistency of data demonstrating their efficacy in reducing coronary events is almost unprecedented, clinicians should also be aware of new evidence that pleiotropic actions of statins may have benefits in the treatment of other disorders, such as cancer, inflammatory diseases, transplant rejection, renal failure, and osteoporosis.

In possibly the most interesting chapter, Koch and Beisiegel discuss the role of lipoproteins in the central nervous system. The brain is one of the most lipid-rich organs, and recent epidemiologic studies of apolipoprotein E polymorphisms suggest a role for lipoproteins in senile dementia and Alzheimer's disease. This chapter contains data from research on lipoproteins, enzymes, and receptors in the cerebrospinal fluid and brain. The reader is left convinced that this new field merits attention from both lipid researchers and neurologists.

The controversy over HDL cholesterol as a target for therapy merits discussion. Unfortunately, the chapter by Mackness and Mackness is largely limited to a discussion of the basic-science mechanisms through which HDL cholesterol prevents atherosclerosis through reverse cholesterol transport and the prevention of oxidation. The considerable epidemiologic evidence in support of raising the HDL cholesterol level is mentioned only briefly, and recent clinical trials, such as the Veterans Affairs Cooperative Studies Program High-Density Lipoprotein Cholesterol Intervention Trial, are not discussed at all.

The molecular discussion should have been extended to the chapter on familial hypercholesterolemia. This chapter is clinical in its orientation, in contrast to the preceding chapters on molecular mechanisms. Familial hypercholesterolemia is the virtual paradigm for molecular medicine.

Three chapters deal with emerging data on risk factors other than lipids or lipoproteins. Although fibrinogen, homocysteine, and chronic infection are of great interest to cardiovascular epidemiologists, it would have been helpful if these interesting factors had been discussed in relation to hyperlipidemia.

The book contains five chapters on subgroups that are often undertreated by clinicians: patients with noncoronary vascular disease, those with hypertension, heart-transplant recipients, patients with diabetes, and women. Each chapter provides a useful update on the special needs of these subgroups.

The final chapter, by Wood, reviews the joint approach of the European Society of Cardiology, the European Atherosclerosis Society, and the European Society of Hypertension to the identification and management of global coronary risk. The main thrust of the guidelines is clearly to reduce overall coronary risk, not just low-density lipoprotein cholesterol levels. Though somewhat different from approaches in the United States, this approach is commendable for its speed and simplicity of risk assessment, reliance on a global risk score rather than on a single risk factor, and use of this global risk score to identify patients in whom lipid-lowering therapy is most likely to be cost effective.

Several other interesting and controversial topics should have been addressed in this book. The role of diet is not covered to any extent, despite the emergence of nutritional supplements with potent cholesterol-lowering effects (e.g., stanol esters) and data from recent clinical trials demonstrating the ability of diets high in certain fatty acids (e.g., linolenic acid) to prevent cardiac events. In addition, controversies over the appropriate treatment of children and elderly persons are not addressed. Finally, there is no discussion of the economics of lipid screening and management, a contentious topic, with health care payers continuing to balk at paying for lipid management even as the evidence of its efficacy mounts.

Lipids and Vascular Disease largely succeeds in identifying and discussing important areas of current lipid research. As with many multiauthored books, the depth of coverage varies from one chapter to another, and some topics that are addressed in more comprehensive textbooks are not included here. On the other hand, this book covers a number of topics in more detail than do the standard endocrinology and cardiology textbooks. I recommend the book for students and teachers in the field of lipid research and for endocrinologists and preventive cardiologists who specialize in the management of lipid disorders, but not for general internists or cardiologists, who would benefit from a broader review of this burgeoning field.

What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth from 1800 to the Present
By Donald Caton. 304 pp. New Haven, Conn., Yale University Press, 1999. $30. ISBN 0-300-07597-9

From biblical verses to Homer's "sharp sorrow of pain" to Sylvia Plath's "long, blind, doorless and windowless corridor of pain," chroniclers, poets, and novelists have recounted the suffering of women in childbirth. Physicians, midwives, and others who have helped women through labor and delivery have also witnessed their pain, and throughout history many of them tried to relieve the suffering. In the 19th century, the demonstration of the efficacy of ether in relieving the pain of surgery led physicians to start using ether, chloroform, and then other agents to relieve the agonies of childbirth.

Donald Caton is an academic physician who has devoted much of his medical practice to obstetrical anesthesia. As he points out in the introduction to What a Blessing She Had Chloroform, there are numerous histories of surgical anesthesia and of childbirth, but Caton's book is the first to explore the relation between these two topics. Moreover, he examines not only the science of obstetrical anesthesia but also the social context in which ideas about pain and its relief arose.

Early in the book, Caton notes that the introduction of ether and then other analgesic and anesthetic agents raised questions about the physiologic response to pain during surgery and childbirth, as well as about the moral aspects of pain. Both topics were taken up by medical scientists of the times, as Martin S. Pernick relates in A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America (New York: Columbia University Press, 1985), a classic study that Caton curiously does not cite until later chapters. A close reading of Pernick's book might have helped Caton avoid a substantial problem with his own book -- the judging of 19th-century science by 20th-century standards. Other medical historians have shown that 19th-century physicians did understand science and that they practiced scientific medicine, though they often did not use quantitative methods or resort to the laboratory. Instead, good medical science of this period -- especially in physiology and therapeutics -- was predicated on an understanding of each patient's unique constitution. Indeed, as Caton points out, anesthetic agents fit this model, because what produced mild pain relief in one woman might produce almost total anesthesia in another.

Caton is more successful with the thinking of the physicians who developed and then used obstetrical anesthesia. James Simpson in Great Britain and Walter Channing in the United States are his heroes. Facing substantial criticism from colleagues, these two physicians developed and used a number of agents, including ether, to relieve pain during childbirth. Both men also urged others to use these agents, and Channing's book, A Treatise on Etherization in Childbirth (Boston: William D. Ticknor, 1848), played a large part in popularizing the use of ether to relieve pain during childbirth. Not surprisingly, Caton disagrees with feminist critics who have argued that physicians developed and used these agents to "control" women during labor. He argues that these physicians had grave concerns about the use of forceps during delivery in women with deformed pelvises or those who became exhausted during a long and difficult labor. Indeed, as Caton points out, many women themselves called for obstetrical anesthesia because they were frightened of the extreme pain they might suffer. However, Caton paints too extreme a picture of feminist scholarship on this matter. For example, he cites Judith Walzer Leavitt as one of the feminist critics, but she is actually sympathetic to the physicians who used anesthesia. It was Leavitt, in fact, who pointed out that women were the first to campaign for twilight sleep.

Caton's last chapter nicely brings together the physician's view of pain as a biologic process and the philosophical or theological view of suffering as a psychological or even moral process. Caton is clearly most comfortable with the biologic explanation of pain. But he has also listened to his patients' descriptions of pain in a moral context, and he speculates that women's willingness to use analgesia or anesthesia may in part be due to lack of the social structures -- families or religious communities -- that previously sustained women in pain.

The New England Journal of Medicine -- January 11, 2001 -- Vol. 344, No. 2
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Adonis Complex: The Secret Crisis of Male Body Obsession
By Harrison G. Pope, Jr., Katharine A. Phillips, and Roberto Olivardia. 286 pp., illustrated. New York, Free Press, 2000. $25. ISBN 0-684-86910-1

This interesting and provocative book describes a form of obsession in which otherwise healthy men become absorbed by compulsive exercising, eating disorders, body-image distortion, and ultimately, abuse of anabolic steroids. In a manner analogous to the course of anorexia nervosa, the social norm of male "fitness" turns, in these sad men, into an insatiable obsession with growing "bigger" and more muscular. When exercise and dieting rituals, no matter how fanatical, fail, recourse to drugs, mostly anabolic steroids, appears to be an easy transition. Body-obsessed men find that drugs are readily available from underground suppliers who gravitate to gyms like moths to the light. Gripped by unshakable fat phobias as well as dietary and drug-related rituals, these pathetic men lose touch with reality and become isolated, socially dysfunctional, and sometimes even dangerous.

The authors, two psychiatrists and a psychologist, describe vividly a wide repertoire of strange forms of behavior, extending well beyond the merely eccentric, undertaken by men who are driven to grow bigger muscles, to reshape their disappointing bodies. This book comprises a welter of personal stories written in a style best described as relentless montage. It includes more than 185 vignettes, two thirds of which quote verbatim from pseudonymous men, exhibiting a potent mixture of narcissistic drug abuse and self-abuse. This cavalcade of anecdotes makes for a vivid and personalized narrative, but the scientific analysis is, by contrast, very limited. The narcissistic self-absorption of these men seems to be a conflation of Veblen's conspicuous leisure and conspicuous consumption in which the vigor and stoicism of the warrior metamorphoses into a hollow emulation, a comic-book satire consisting of somatic sculpting in mock-heroic posture. Although 200 slightly different anecdotes are hardly more persuasive than 1 anecdote repeated 200 times, the slight differences curiously give the narrative an illusion of multidimensionality.

The strength of this book is its eclectic but effective historical review of the changing fashions in the male physique, charting the progressive distortion of male body images. The art of deception in the media and marketing is well highlighted by a judicious compilation of images. Although the underlying message rests on a wafer-thin surface of credibility, the marshalling of a variety of sources of evidence provides an uneven but ultimately persuasive survey of trends over recent decades. Whether the male physique is depicted in action toys, professional wrestling and weightlifting champions, beefcake magazines, or advertising, there is a remarkable consistency in the patterns of distortion. There has been a progressive rise in the muscularity in these depictions to pathologic and unattainable proportions increasingly at variance with reality. Few will be able to resist the book's conjunction of systematic distortion of the body image with the parade of body-obsessed men undertaking extreme rituals of dieting, purging, and drug abuse to meet delusional and self-destructive ideals. The linkage of such ritualistic obsessionality with youth suicide seems tantalizing but surprisingly little considered by the authors.

The magnitude of male somatic obsessionality is dealt with less well by the authors. With justification, discoverers of "secret crises," like the chroniclers of vast hidden conspiracies, are more likely to be considered deluded or exaggeration-prone than prescient. Disregarding the oft-repeated clarion calls about a secret crisis, this book does not clarify the frequency of such extreme somatic obsession. Although the only reasonably reliable estimates come from systematic surveys of high school students as a captive population susceptible to valid sampling, the prreviewence of anabolic-steroid abuse is modest compared with abuse of most other licit and illicit social drugs. Accurate estimates of the prreviewence in the adult population are unavailable, but common sense suggests that such abuse is restricted to distinct subpopulations.

Disappointingly, this book contributes little to our understanding of the origins of this disorder. Is it a new condition or a new manifestation of an old condition? By highlighting the media and advertising, the book encourages the belief that these disorders are driven, if not caused, by propaganda. The authors offer no argument against the alternative possibility that this is merely a variant of obsessive-compulsive disorder that expresses new features due to a novel social framework. To be fair, these issues remain largely unresolved in the similar disorder in girls and women, which has been well defined for much longer. Although it does not resolve the significance of men's obsessions with the body, this book does have the virtue of bringing the question to public attention.

The book's approach to therapy is not enlightening. The authors' approach of cognitive behavioral therapy and medication with selective serotonin-reuptake inhibitors is hardly surprising, but it would not be feasible in the sort of large-scale epidemic they claim is under way. Among the least convincing aspects of this book are the self-help questionnaire and the body-image checklists for self-diagnosis. This populist approach, although de rigeur for do-it-yourself health care books, lacks validation even for use in individual counseling or diagnosis by experts, let alone self-diagnosis by the "worried well" or for use by concerned friends and relatives.

Perhaps the boldest and most important claim the authors make is to have discovered not only a "natural limit" to muscular development without steroids but also a simple formula to detect anabolic-steroid abuse. The hubris of this unproven assertion recalls the equally naive claim of the original Frisch hypothesis that puberty occurred at a threshold body weight, which was inconsistent with the continuing existence of the African Pygmy population. Disseminating to the general public such an unsubstantiated claim masquerading as proven science risks encouraging the misuse of science, undermining its credibility, and misleading the public.

Among the book's weaknesses are its scholarship. Curiously, the authors unhesitatingly question received medical wisdom but seem to lack similar courage when it comes to street folklore about anabolic steroids, much of which they tacitly accept. A prime example is their lack of rigorous analysis of an "entity" called "roid rage." This memorably alliterative epithet, a street description serving mostly as an excuse for bad behavior, is too journalistically good not to be true. Disappointingly, given their backgrounds in psychological medicine, the authors do not question whether this "entity" is really due to drug abuse or is an epiphenomenon of disturbed behavior by men who abuse steroids in the hope of improving their self-image. If ever there was a semiotic argument for the power of naming things, it is the ability of felicitously named entities such as "anabolic steroid" or "roid rage" to outgrow their foundations and outlive their usefulness.

The book contains well-referenced footnotes but no specific bibliography, making it hard to examine its scientific background. The perfunctory and uncritical analyses of published studies presumably also reflect the book's targeting of a popular rather than a professional market -- an impression strengthened by the publisher's description of the book as a "frank and explosive look... for millions who suffer in silence." It would be a pity if this targeting deterred physicians who work with young men from becoming familiar with the book. At the least, it can preemptively forearm physicians whose patients come armed with reams of information from the Internet. For physicians interested in the intersection between media propaganda and public health in modern society, this book is interesting and provocative; for some, it is essential reading. Even those dismissive of its subjective methodology will find its description of a group of men strangely hobbled by this culture of the body beautiful sad, and even moving.

This book's scientific and scholarly weaknesses are also its journalistic strengths. It will form a useful part of the backdrop for doctors in their efforts to deal with the ever-changing facets of drug abuse. This intriguing but flawed book leaves room for a more critical and scholarly appraisal of the modern epidemic of male somatic obsession and its medical dimension of anabolic-steroid abuse. For the expert, however, this book represents more specimen than evidence. Despite its repetitiousness, it is a book that anyone with an interest in the way changing fashions affect health-related forms of behavior cannot afford to ignore.

How Scientists Explain Disease

Why do scientists acquire new beliefs, sometimes abandoning old ones? For anyone who has practised medicine long enough towonder how and why some theories become fashionable and othersfail to thrive, this book will make an interesting read. PaulThagard finds both the traditional view of science as logic andthe postmodern view of science as power inadequate for understandinghow sciencedevelops.

He starts his exploration by considering various explanatory models before proposing his own. I found his integrated cognitive-socialapproach intuitively satisfying and the examples he uses are inkeeping with my personal experience of changes in medical tenetsover the past 30 years. Having struggled with some tracts on postmodernisttheory, I found the book an easy read, light on sociologicaljargon.

Anyone who remembers reading Warren and Marshall's original description of Helicobacter pylori in the Lancet in 1983 and thesubsequent resistance to the reclassification of peptic ulcerdisease as a bacterial disease will enjoy the use of this episodein medical history to illustrate Thagard's explanation of howscientists change their minds. Those who assume that only logiccan change scientific belief will find little to please them.Personally, I think the chapter on the role played by social processesin this underplays the influence of the pharmaceutical industry.It is interesting to speculate how much more quickly the treatmentof peptic ulcers would have changed had the therapy been underpatent to a drugmanufacturer.

Non-medical readers will find much to inform them but should be aware that Thagard underestimates the role of the drug companies,particularly their role in the dissemination of new knowledgeand the development of consensus. Like the pedlars of yesteryear,today's drug representatives play a key role in spreadingideas.

There is the obligatory chapter on the internet. For most scientists the dubious quality of many websites is probably irrelevant,as most are well able to judge this for themselves. The illustrationsThagard uses are a valuable way of demonstrating to those whothink we spend all our time gossiping, trading online, or downloadingpornography that the internet is now as critical as a freezeror centrifuge to the conduct of research. This section would makeuseful reading for hospital boards reluctant to invest in informationtechnology.

Doctors who remember a little history of medicine, a little philosophy, and a little sociology should enjoy this book. Thosewith greater knowledge will find a scholarly work that advancesthe theory of how medical knowledgegrows.

Strong Imagination: Madness, Creativity and Human Nature

What are brains for? Why does madness exist? Why is human culture obsessed with creativity? These striking questions punctuatethis thought provoking book, as it explores the relation betweenmadness andcreativity.

The first half elegantly surveys affective illness and schizophrenia, with a fresh explanation of the biological, psychological,and social aspects of causation, and a helpful pr�cis of the historyof psychiatry (including the mistakes of the "antipsychiatry"movement). It rounds off with a convincing exploration of thecurrent genetic understanding of major mental illness, includingNettle's proposal that the personality trait of "psychoticism"be considered an inherent dimension of human personality, servingto heighten creativity. He divides psychoticism into two axes,"thymotypy," enhancing mood, and "schizotypy," enhancing divergenceof thought. If an individual's genetic loading is pathological,cognitive enhancement is at risk of overdrive and the creativeadvantage of psychoticism becomes expressed aspsychosis.

In the second half of the book, Nettle considers the whole purpose of creativity. Steering us into evolutionary psychology,he explains Geoffrey Miller's "sexual selection theory." Thisstates that creativity, in itself useless for survival, is a demonstrationthat one can survive and do frivolous things. It is the humanequivalent of the peacock's resplendent tail and advertises thatthe possessor of such genes (predominantly male) will dominatecomplex social organisations, inherent in human societies of allcultures.

Nettle's conclusion (the genetic-creativity argument) is that the human trait of psychoticism is the foundation of this creativeelement. Because of limited genetic loading, individuals displayingpsychoticism are more creative than their psychotic relatives.Madness is not conducive to creativity, because it involves disorganisationand self-destructiveness. It is the price paid by humanity forimmense creativity in rare individuals. In consequence, the authorcounsels vigorous treatment for psychosis and prophylaxis forthose at risk of it. For those with artistic pretensions, he adviseson how to stay sane while nurturing creativeflow.

This fascinating, lucid book is surprisingly short, in view of the breadth and depth of information covered. I accept thatdissection of psychosis points the way to increased understandingof human creativity, but what about other psychopathologies, suchas autistic spectrum disorder or obsessive states? Such disorders,though non-psychotic, fundamentally influence the subject's worldview. Has anyone explored their contribution to creativity? Ifthey do not contribute, and if Nettle, and Miller, are right,why are these traits still present in the humanpopulation?

The Hidden Structure: A Scientific Biography of Camillo Golgi

By Paolo Mazzarello. Translated and edited by Henry A. Buchtel and Aldo Badiani. 407 pp., illustrated. New York, Oxford University Press, 2000. $90. ISBN 0-19-852444-7

Great conceptual advances in science are often based on great technical advances. Either type of discovery can bring scientific fame. In 1896 Riva-Rocci devised the mercury sphygmomanometer for measuring blood pressure, but it took several decades for hypertension as a cause of disease to be unmasked. Conversely, Watson and Crick in 1953 discovered the structure of DNA but not the technique of x-ray crystallography that limited the number of possibilities for their model. There are countless other examples, but it is rare for a scientist to develop both a new instrument and new ideas. Camillo Golgi (1843-1925) did his utmost to be more than the inventor of a revolutionary staining technique for nerve tissue. The "reazione nera," or black reaction, which he discovered in 1873 after systematic experiments, consisted of immersing specimens in silver nitrate after fixation with potassium dichromate. It allowed visualization of nerve cells and their ramifications in unprecedented detail. In The Hidden Structure, the excitement of this discovery is conveyed to the reader mainly through words, because the histologic illustrations are sparse. Once Golgi's technique was used in other countries (he published almost exclusively in Italian), it stirred a flurry of new hypotheses about the anatomical organization and eventually the function of the nervous system.

Golgi was less successful in staking his claims with regard to these wider implications. His theory that nerve-cell processes formed a giant anastomotic network was initially attractive, because it fit with the emerging notions about electricity in the nervous system. But with the ascendancy of the cell theory in the second half of the 19th century, fewer and fewer scientists were prepared to make an exception for the nervous system. The doctrine of separate nerve cells, first proposed by His (in 1886) and Forel (in 1887), was anathema to Golgi until the end of his life. The ultimate insults were the term "neuron" (coined by Waldeyer in 1891) and the successful campaigning for the individual nerve cell by Ramon y Cajal. The Spaniard made a rather sudden appearance on the international stage (he too published only in his own language) and swiftly convinced the scientific community with his superb preparations, made with modified Golgi stains. He later added the concept of "dynamic polarization" (i.e., one-way traffic in nerve cells). Cajal and Golgi would never get on well together. Irony dictated that in 1906 they were to share the Nobel Prize for Medicine. Sadly enough, Golgi chose to use his official lecture for another desperate attack on the neuron doctrine.

Though in his main theme of research Golgi's work exemplified a mixture of success and error, he was undoubtedly a great scientist in many other respects. That Mazzarello's book makes this abundantly clear is its greatest merit. The book follows Golgi from the cradle to the grave, in 24 chronologically arranged chapters. It describes his lifelong attachment to the University of Pavia, which was interrupted only by a stint as the director of a psychiatric hospital in the country. It was there, in his spare time and in the kitchen of his private apartment, that he discovered the black reaction. His name is also linked with the discovery of several microscopic cellular structures (tendon organ, muscle spindle) and subcellular structures (the Golgi apparatus). What will be new to most readers outside Italy are his contributions to general medicine with regard to intestinal-worm infections, Bright's disease of the kidney, and especially malaria. Golgi and his pupils not only accepted and defended Laveran's theory of a parasitic origin for malaria, but they also provided many new pieces of evidence and wholeheartedly threw their weight into a prolonged and complicated battle with proponents of a "bacillus malariae."

The book has some weak points, in addition to the elaboration of histologic details without corresponding illustrations. The style does not always run smoothly, and in places it is too encyclopedic. Also, Golgi does not really come to life as a human being, apart from his stubborn defense of "reticularism"; however, he was probably reserved in his private life, leaving few emotional traces for his biographers.

Where the book does succeed is in depicting a man who, until his last moments, was totally dedicated to medicine and to his university, at which he served as rector for a long period late in his life. Inevitably, the reader is given many a glimpse of the intricacies of Italian politics. Only one year before his death, when he was 80 years old and had received all imaginable honors, Golgi had to endure the transfer of Pavia's medical school to Milan, an event he had tried to avoid for decades. All in all, the book is a good read, especially for aficionados of histology and neuroscience.

J. van Gijn, M.D.
University Medical Center Utrecht
3584 CX Utrecht, the Netherlands

Dear Mr. Darwin: Letters on the Evolution of Life and Human Nature

By Gabriel Dover. 268 pp., illustrated. Berkeley, University of California Press, 2000. $27.50. ISBN 0-520-22790-5

What would happen if a modern biologist could get in touch with Charles Darwin and enter into a lively and stimulating discussion about recent developments in evolutionary theory? Here, we have the answer. Molecular biologist Gabriel Dover uses imaginary correspondence as a literary device for explaining how our ideas about evolution have evolved since Darwin's day.

Dover argues that evolution involves more than just natural selection and cites such phenomena of sampling error as genetic drift. The basic idea behind sampling error is easily recalled. Gene frequencies inevitably fluctuate at random. Some alleles within a population may happen not to be present in any of the zygotes that ultimately become the next generation of adult organisms. This is more apt to happen when the alleles are rare and in small populations. So pure accident may result in the elimination or fixation of an allele. The result is change in gene frequencies, but not adaptation.

According to Darwin's theory of natural selection, adaptation results when one organism has properties that allow it to out-reproduce another of the same species. Dover does not mention another of Darwin's mechanisms -- correlated variability, or pleiotropy. Variation sometimes involves traits that always go together, so that they both increase in frequency even if only one of them is selectively advantageous. Dover's additional mechanisms are something different. Because of the way in which chromosomes behave in the course of reproduction, the genome is constantly being reorganized. Sexual reproduction generates change, and Dover sees in it a cause of evolution (a "molecular drive") that interacts with selection and sampling error.

Although Dover explains all this very well, his real goal is to rebut the metaphysics of Richard Dawkins, an Oxford behaviorist who studied chickens before branching out and writing popular books. Dover laments the influence of Dawkins's reasoning on persons who are not equipped to see through it, especially textbook writers and social scientists. Let me clarify what Dover is complaining about. Dawkins decided to call genes, and other things of which copies are made, "replicators." The problem with that term is that in ordinary English, the suffix "-or" refers to the doer of the action. Thus, a replicator should be that which does the replication, not that which is replicated. (Likewise, a photocopier is not the copy that is produced by the machine.) Dawkins's term is apt to dupe the unwary into thinking that a passive participant is an active agent. This is what Dover has to grapple with: the metaphysics of agency. He makes it abundantly clear that genes are not replicators, in the sense of things that carry out replication. Rather, they are replicated by the cells that contain them. More important, he argues that organisms are active agents in evolution by virtue of their roles in restructuring the genome in producing compatibility among genes, chromosomes, and other components of organisms and species.

This suggests an important role for sex. Dover maintains that molecular drive produces compatibility within reproductive populations. The compatibility within species, together with the lack of it between them, is fundamental to the modern "biological species concept." The point that species are not just abstractions but, rather, higher-level units that play an important part in evolution is very much in line with Dover's antireductionist metaphysics. However true it may be that species and other populations are not likely to have adaptations over and above those of their component organisms, there is no legitimate reason to extrapolate and treat species and organisms as mere epiphenomena of molecules.

Species are important because they are historical units -- things that evolve and give rise to the branches of the phylogenetic tree. Dover is off the mark when he suggests that biology is history, pure and simple, and that we seek in vain for its laws of nature. Rather, biologists have been seeking laws of nature in the wrong place. Although it is true that there are no laws of nature for organisms and species, this is because organisms and species are concrete, particular things, or "individuals" in the broad, metaphysical sense. All laws of nature are about kinds, or things in general, and not about instances of such kinds. In evolutionary biology, laws apply to kinds of populations, such as large populations and small populations. For example, as the effective population size goes down, the frequency with which alleles are fixed by sampling error goes up. This is a perfectly legitimate law of nature: it is necessarily true of everything to which it applies, irrespective of time and place. However, it is a statistical law, since it does not predict which particular version of a gene will be eliminated from the population. The fact that so much of the lawfulness (such as it is) of biology must be conceptualized in such statistical terms gives scant comfort to those who would have us treat human behavior in Laplacian, deterministic style.

One might wonder whether debunking the metaphysical pretensions of one's colleagues is perhaps beneath the dignity of a good scientist like Dover. Isn't it enough to joke about selfish chromosomal deletions and then get on with one's research? The trouble is that selfish genes are becoming part of popular culture. The medical community should brace itself for an onslaught of belief systems, alternative therapies, and nostrums -- all justified on the basis of what purports to be legitimate science.

Michael T. Ghiselin, Ph.D.
California Academy of Sciences
San Francisco, CA 94118

By Kevin Davies. 310 pp. New York, Free Press, 2001. $25. ISBN 0-7432-0479-4

An article featured in the January 17, 2001, business section of the New York Times, "When Gene Sequencing Becomes a Fact of Life" by Andrew Pollack, reported the development of a new way to sequence the genes of the human immunodeficiency virus. This genetic test, its owners claim, will "help doctors choose which of the 15 or so available drugs will work best against a particular patient's infection." Although the value of the test is unsettled, the announcement underscores the way in which molecular genetics is going to change clinical medicine. Physicians who doubt that gene-based medicine will soon influence their day-to-day practice should consider the billions of dollars that pharmaceutical companies are spending to find genes that may lead to novel treatments for common diseases and hence enormous profits. Using gene sequences for making recombinant pharmaceuticals such as insulin and erythropoietin is now old hat (though still very useful). Soon to come are designer drugs tailored to the genetic peculiarities of a patient with hypertension, coronary artery disease, or depression.

Apart from clinical applications of pharmacogenomics, there are the patients who seek from their physicians explanations of genetic risks. The woman whose sister had breast cancer at the age of 39, the man whose father died of a myocardial infarction at the age of 50, and the son of a woman with Alzheimer's disease want to know about their own susceptibility to these diseases. Their awareness of molecular genetics comes from television programs and newspapers, and they read books like Kevin Davies's Cracking the Genome. One indication of the public interest in DNA is the fact that an Internet search of Amazon.com for books on the human genome turned up a total of 105 matches.

Cracking the Genome, like its protagonist, DNA, consists of two intertwined strands. One of them recounts the highlights of the history of molecular genetics, beginning with the isolation of a viscous liquid from the nuclei of pus cells by Johann Friedrich Miescher in 1869 and reaching a pinnacle in 1953, when James Watson and Francis Crick described the double helical structure of DNA. That historic moment launched a dazzling and often daring scientific journey that, by the end of 2000, reached the shore of the human genome. There were many brilliant explorers, and Davies spices their stories with revealing personal anecdotes. My favorite is the revelation that Bert Vogelstein, whose landmark multistep model of the origin of colon cancer was published in the Journal, heads a rock group called Wildtype. This book will surely satisfy readers seeking a breezy, personalized, and digestible account of polymorphisms, mutations, DNA sequencing, expressed sequence tags, and DNA microarrays.

The second strand of Cracking the Genome describes the political issues surrounding molecular genetics and the battle over the commercialization of the information contained in the double helix. The leading characters are Francis Collins, the head of the government-sponsored Human Genome Project, and Craig Venter, the maverick molecular biologist who broke away from the National Institutes of Health to sequence the human genome in his own way. Venter ultimately became the director of Celera Genomics, which he calls an "information company." The political debate concerns the best method for sequencing all the genes in the human genome, and the battle is over the legitimacy of patenting the sequences of these genes. Collins and his colleagues opted for a methodical, nucleotide-by-nucleotide approach, whereas Venter chose a shotgun method in which the sequences of millions of short fragments of DNA are aligned into a plausible thread of translatable genes by a supercomputer. It was the repeated refusal of the National Institutes of Health to fund this bold scheme that led Venter to quit his government job and strike out on his own.

One anecdote can summarize the battle over commercializing genomic information. When these projects began, the number of human genes was unknown; guesses ranged from 60,000 to 100,000. According to Davies, Venter's hunch was on the low side, which led the late Wallace Steinberg (Venter's financial backer) to complain, "What the hell do you think you're doing, saying that there are only 60,000 genes? I just sold 100,000 genes to SmithKline-Beecham!"

That question brings us to another: Can human genes be patented? Donna MacLean, a waitress and poet, crystallized the problem by applying for a patent on "Myself," claiming that she had invented herself and thereby met all the criteria for a patent. According to Davies, the patent office has not yet made a decision about her application. Although genes are being patented, an accord between the Human Genome Project and Celera will make most of Celera's sequences available to university researchers. Unlike academic investigators, however, Celera will not deposit its sequences in publicly available data bases, but will retain them in its own data base.

Last year, Collins and Venter agreed to a cease-fire, and on June 26, 2000, after more than a decade of intense rivalry, they announced the completion of a rough draft of the human genome. Whether this truce will satisfy all concerned and evolve into lasting peace is unclear, but what does seem certain is that this draft of the human genome is only the beginning. Even though it is barely intelligible, the draft has already pointed medicine in a direction from which there is no return. Cracking the Genome, like many other popular books about science, tends toward hyperbole, but it tells a story that will fascinate all readers.

Abraham Lincoln's DNA and Other Adventures in Genetics

By Philip R. Reilly. 339 pp., illustrated. Cold Spring Harbor, N.Y., Cold Spring Harbor Laboratory Press, 2000. $25. ISBN 0-87969-580-3

The 21st century has begun with an overwhelming outpouring of advances in molecular biology and genetics, and the medical profession has only started to wrestle with the many social and moral questions posed by the startling progress in these fields. Indeed, as Philip Reilly suggests in this straightforward and readable collection of intertwined essays, society as a whole must confront these questions. For laypeople and professionals alike who yearn for a better understanding of genetically engineered crops, DNA fingerprinting, cloning, or gene therapy, here is a valuable addition to a small but critical literature that will frame our public discourse as we decide how to use the burgeoning knowledge of the genome.

Like Matt Ridley's approach in his book Genome: The Autobiography of a Species in 23 Chapters (New York, HarperCollins, 1999; reviewed in the June 8, 2000, issue of the Journal), Reilly has assembled an enjoyable series of vignettes that are understandable to the novice but contain lessons for the professional geneticist. The early chapters explain the fundamental tools of the modern genetic detective, such as the polymerase chain reaction, mutation analysis, and the difference between mendelian and nonmendelian inheritance. The lessons are delivered in the course of fascinating historical tales (including an especially enjoyable chapter on Henri de Toulouse-Lautrec) with a hint of Lewis Thomas-like awe and fascination with the power of genetic analysis. We can diagnose diseases that afflicted Abraham Lincoln by analyzing DNA recovered from the shaft of a single hair. Evidence capable of identifying the perpetrator of a crime is invariably contained in tiny molecules of DNA shed from the skin or deposited by the touch of a finger. Reilly is trained in both genetics and law, and these advances are marvels that offer unprecedented investigative powers both for the scientist and for the police detective. At the same time, we are faced with disquieting challenges to our privacy. Do these scientific capabilities mean that the banking of DNA samples from every citizen is inevitable? You will be convinced by Reilly's arguments that we are moving rapidly in that direction unless we educate ourselves and choose to object.

In summarizing and simplifying the most complex of recent genetic advances, Reilly addresses the most basic and controversial issues in the field. Is nature or environment the more important determinant of personality, talent, and behavior? Is our mental and physical health determined by our genes? Is there a gene for sexual preference? Should we provide potential parents with the ability to screen fetuses for what they consider to be "favorable" genes, such as those promoting height, strength, or good looks? These questions and many more are framed in fair and provocative presentations using examples that are generally derived from the author's experiences in the laboratory and the courtroom. The many details related to recent events and discoveries lend a timeliness to the discussion. In most cases, we are left without answers but gain important insights and knowledge with which to consider issues. I found myself wanting to know more about the expert opinion of the author, especially regarding the most critical questions, or at least to learn how he thinks we should attempt to resolve these pressing issues. Not until one of the very last chapters do we receive guidance in the opinion that "on balance, it seems the wiser course... to forbid human cloning for any reason." However, we are immediately warned that forbidding it will not prevent it, and we are directed that "the only morally permissible response is to welcome [cloned individuals] into the human family."

Here and elsewhere in the book, a certain inevitability pervades the author's predictions -- a hint of determinism that seems to diminish our ability to keep tight hold of the reins and to choose the course we steer. "The use of germ-line gene therapy... is as inevitable as it is welcome." "Designer foods will become a reality." "One prediction does seem certain. Women in large numbers will continue to use genetic (and other) tests to avoid the birth of children with serious disorders." These bold statements are intended to provoke the reader to take an active role in the discussions of public policy and professional ethics that will determine the veracity of Reilly's predictions. They evoke a natural impulse (genetically encoded?) to resist the fates. This may be the most powerful and successful aspect of Reilly's collection: he conveys up-to-the-minute data concerning modern genetics while prodding the reader to become engaged in the task of integrating these discoveries into the moral framework of our society.

The New England Journal of Medicine -- November 9, 2000 -- Vol. 343, No. 19
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Engineering the Human Germline: An Exploration of the Science and Ethics of Altering the Genes We Pass to Our Children
Edited by Gregory Stock and John Campbell. 169 pp. New York, Oxford University Press, 2000. $29.95. ISBN 0-19-513302-1

Let's dispense with the suspense. This is a short, readable, thought-provoking book that discusses in nontechnical terms the future of humankind in the age of genetic engineering and should be read by anyone who wishes to participate in a public discourse that will shape the future. The central topic is the technology of genetically altering germ-line cells. Altering germ-line cells, which produce ova and spermatozoa, is considerably different from altering somatic cells. Germ-line changes will affect every cell in the body and will be passed on to future generations, whereas somatic-cell changes affect only specific cells within a given organ system and are not passed on.

It is interesting to see the shift in opinion within the scientific community, which previously discounted germ-line therapy, eugenics, and cloning as unachievable and morally suspect. With familiarity, increased understanding, and discussion, many now see these forms of technology as inevitable, and most of the contributors to this book are willing to consider them and some even to defend them.

Germ-line engineering, by providing a means for humans to control and direct the evolution of their species, is another blow to the fading credibility of supernatural explanations of human nature and purpose. Having established humans as inconsequential animals destined to exist only a brief time on a speck of a planet in a huge cosmos, science has left us with the ultimate truism that for humankind, man is the measure of all things.

The book is based on a 1998 symposium and is supplemented with short essays by 17 authors who represent a broad spectrum of expertise and opinion. The organization allows the reader to reach a relatively painless understanding of the technical and societal issues involved. The short-essay format does not allow detailed analysis of the issues or defense of the opinions expressed and may leave the reader wanting more.

The book is divided into three parts. Part 1 consists of reviews of the current state of germ-line engineering. The attempt is to be realistic and practical. Topics covered in this section include the introduction of genes into an existing chromosome and the introduction of an artificial extra chromosome into the gamete. The discussion covers numerous issues, including the need to understand gene regulation and interaction, reversibility, and prevention of generational transmission. The need to increase the interaction between genetics and information technology is emphasized. The consensus is that the technical issues can ultimately be resolved and that the only question is how long that process will take. Whereas Campbell and Stock predict applications in the next two decades, Anderson is more cautious and prefers to envision the development of somatic-gene therapy before a venture into the germ line. The problems with somatic-gene therapy include methods for introducing a fully functional gene into a cell that needs it and for keeping it functional over time. Capecchi suggests that germ-line therapy might be easier to bring to practical application since it avoids these problems. If past experience is any guide, its development may take longer than estimated. We have known the genetic sequence of the sickle cell gene for 20 years and the sequence of the cystic fibrosis gene for more than 10, yet there are no somatic-gene therapies available. These forms of technology, however, will be real and practical within the lifetimes of our children or grandchildren.

In the discussions of this technology, therefore, it is assumed that the procedure is "no more risky in humans than natural conception," and the discussants proceed to analyze what kinds of limits should be imposed on its use. However, it is clear that a few discussants are concerned not with physical risks, but with risks to society and its moral structure. They raise the usual objections to hubris and "playing God" and raise antireductionist objections as well. Most of the participants, however, set aside these objections and are concerned with the question of use.

The initial discussions are in terms of therapeutic or health-related applications, such as ways to introduce resistance to human immunodeficiency virus infection or prevent cancer. Capecchi uses the example of eliminating Huntington's disease. However, the issue of enhancement (i.e., the use of germ-line alteration to enhance desirable natural characteristics) is soon raised. This will be a clear demand as the technology is developed.

Each essayist is asked whether he or she would use an artificial chromosome to extend the life of his or her child. This is an unfortunate choice of question, since it involves the confounding "quality of life" issue. A better choice would have been a question about an intelligence-enhancing gene, which focuses on the use of this technology.

McGee argues that given safety, human germ-line modification is no different from many other efforts of parents to modify their offspring. The issues of increasing the existing inequities in society, the moral status of contingent persons and embryos, and unreasonable expectations of parents are discussed in this context. McGee finds nothing wrong, in principle, with enhancements. As with technology in general, scientific ignorance within society is the greatest threat to the intelligent and ethical application of germ-line modification. Until this problem is rectified, it will be necessary to regulate and control this new and powerful technology. The possibility of international and national regulations is addressed in the last two essays. Humans will develop this technology using their own intelligence; that same intelligence is the only means available to direct and control its use rationally for the development of a new, healthier, happier, and kinder humankind. The species that invented gods is the only one that can emulate them.

The New England Journal of Medicine -- November 23, 2000 -- Vol. 343, No. 21
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Genetics and Public Health in the 21st Century: Using Genetic Information to Improve Health and Prevent Disease
(Oxford Monographs on Medical Genetics. No. 40.) Edited by Muin J. Khoury, Wylie Burke, and Elizabeth J. Thomson. 639 pp. New York, Oxford University Press, 2000. $65. ISBN 0-19-512830-

Now that the first draft of the human-genome sequence has been substantially completed, attention is shifting to, among other things, proteomics, pharmacogenomics, the genetics of complex traits, and public health genetics. Although the first three areas of inquiry are new, the use of genetics to improve the health of the population -- current or future -- is not.

Public health was the asserted justification for state laws enacted before World War II that criminalized marriage or sexual relations between "genetically unfit" persons and authorized the involuntary sterilization of people with mental impairments as well as those who were merely deemed immoral. As recently as the 1970s, thousands of women were sterilized without their consent by the Indian Health Service. During the same period, the federal government sponsored a sickle cell-screening program before first obtaining community support or educating people at risk and the public about the difference between sickle cell disease and sickle cell trait. The result was needless anxiety, stigmatization, and discrimination.

New efforts to use genetics to improve public health are complicated by this history of abuses and the public's justifiable concern about avoiding any future recurrence. Against this challenging backdrop, Genetics and Public Health in the 21st Century: Using Genetic Information to Improve Health and Prevent Disease, an important and timely new book, highlights some of the most promising scientific approaches and daunting social issues facing public health genetics.

The book's 31 chapters delve into diverse topics, including genetic epidemiology and medical surveillance, screening of newborns, access to genetic services, genetic strategies in the prevention and treatment of various disorders, informed consent to genetic testing, ethical and legal responses to social risks created by genetic information, and professional and consumer education about genetics.

One cannot imagine a more distinguished group of editors and authors. The editors are the director of the Office of Genetics and Disease Prevention at the Centers for Disease Control and Prevention (Muin Khoury), a professor of medicine at the University of Washington and member of the Secretary's Advisory Committee on Genetic Testing (Wylie Burke), and the program director of the Ethical, Legal, and Social Implications Program of the National Human Genome Research Institute of the National Institutes of Health (Elizabeth Thomson). They have gathered a first-rate collection of thoughtful analyses of a range of important topics.

If there is a major substantive shortcoming of the book, it is that some of the chapters fail to confront the fundamental differences between medical genetics and public health genetics. Several of the chapters deal with traditional issues of the practice of medical genetics, such as when to use genetic testing and how to counsel patients, without carefully assessing whether or how public health is implicated. Indeed, neither this book nor any other source has made a persuasive case for the large-scale introduction of genetics into public health practice. If genetics is to have a more limited role in public health, then what are the contours of that role? What are the respective roles of the federal, state, and local governments; health care providers; and members of the public in using "advances in genetics and molecular biotechnology to improve public health and prevent disease" -- the editors' definition of public health genetics?

The introduction of genetic factors into traditional areas of public health -- occupational and environmental health, infectious disease, immunization, sanitation, toxicology, food safety, and nutrition -- is undoubtedly appropriate, but it still needs to be done with care. Surveillance systems for genetic disorders and genetic cofactors in cancer are important areas for research. Using assessments of genetic risk to identify changes that must be made in a person's lifestyle is a promising strategy for health promotion. The question of when to use genetically based interventions on a population basis to improve individual health, such as genetic screening for late-onset disorders, is more difficult to answer. Furthermore, even if genetic screening is appropriate on a population-wide basis in the clinical setting, genetic screening should not necessarily be considered within the purview of public health in the absence of further justification.

There is a need for greater clarity in the definition of public health genetics. To many health professionals, public officials, and members of the public, the term "public health" connotes more than the mere application of health measures on a population-wide basis. Public health implies that government has an affirmative role to protect the public's health, as well as the legal authority to impose mandatory measures to protect the public, and that the health benefits to the population clearly outweigh individual risks -- for example, with respect to immunization and screening of newborns.

In one of the book's most thoughtful chapters, "Access to Genetic Services in the United States: A Challenge to Genetics in Public Health," Jane S. Lin-Fu and Michele Lloyd Puryear observe the incongruity between the directiveness of public health and the nondirectiveness of genetic counseling. They also recognize that the traditional emphasis of public health on primary prevention is nearly impossible to implement in the context of genetics without raising the specter of eugenics.

Public health genetics is likely to operate under a cloud of suspicion until there is a delineation of its proper scope and until a scientifically and socially compelling rationale is developed for public health strategies involving direct intervention. In the meantime, this book should be read by anyone interested in understanding the potential risks and benefits of the new public health genetics.

The New England Journal of Medicine -- January 4, 2001 -- Vol. 344, No. 1
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Life at the Extremes: The Science of Survival
By Frances Ashcroft. 326 pp., illustrated. Berkeley, University of California Press, 2000. $27.50. ISBN 0-520-22234-2

Frances Ashcroft was "galvanized" to write this intriguing book when a friend suggested she submit an entry for the Wellcome Trust prize, awarded every two years to the British life scientist who writes the best book for nonscientists. Ashcroft, professor of physiology at Oxford and fellow of the Royal Society, has long believed that the general public is deeply interested in science if it is simply but accurately described, so she applied. She did not win the prize, but this fact should not detract from the appeal of her delightful book to scientists and the public alike.

Ashcroft describes how survival (primarily but not exclusively of humans) is possible in the most inhospitable environments on earth, and she speculates about survival in outer space. Each chapter is an account of survival in an extreme environment -- the low pressure of high altitudes, the high pressure in the ocean depths and deep in the earth, polar cold, desert heat, the vacuum of space -- and the limits of speed generated by human or animal muscles. Finally, there is a fascinating grab bag of descriptions of life in acid, salty, oxygen-free, and locked-in-stone conditions.

The richness and variety of Ashcroft's subjects are extraordinary. Here are only a few of the many remarkable tales in this book. Full-term babies are born with a layer of brown fat, which metabolizes rapidly to generate heat during the first few weeks of life. Caribou have fat in their feet that remains soft in subzero temperatures. Plant and animal life abounds 4.8 km (3 mi) down in the black depths of the ocean, right next to huge volcanic vents that spew superheated water and sulfurous fumes.

While holding his or her breath, a diver can descend 133 m (439 ft) in the ocean and remain underwater for six minutes, but elephant seals can swim 750 m (2475 ft) below the surface and stay there for two hours. Fully acclimatized humans can stand on the summit of Mount Everest for hours breathing only ambient air, but humans can live only a short time if they are taken directly from sea level to the summit. Without oxygen, the human brain will die within six minutes, but hibernating mammals and many cold-blooded animals survive for months or years with little or no oxygen, and many bacteria are killed by even a trace of it.

Half of our muscles are called slow-twitch, but endurance athletes can increase this proportion to 90 percent through training; all of us have tiny fast-twitch muscles that can close our eyelids instantly. A red fox can run 72 km (45 mi) per hour, whereas a champion sprinter can run 35 km (22 mi) per hour and a cheetah can reach a speed of 113 km (70 mi) per hour in three seconds from a standing start.

Ashcroft inserts lovely bits about ancient history and glimpses of contemporary primitive societies, and she pays tribute to recent scientists, such as the secretary of the Royal Society who emerged unhurt after 15 minutes in a room where the 105�C temperature cooked an egg and overcooked a good steak.

Regrettably, most of her heroes and citations are British, and she overlooks many excellent contributions from other countries. The Korean War, for example, resulted in far more injuries from cold, and taught us more, than the battle for the Falklands. Bert, Haldane, and Barcroft were not the only ones to explore altitude illnesses; scores from other countries have contributed to a better understanding of hypoxia. A few pioneers, such as Scheele (who studied oxygen), Priestley (who identified photosynthesis), and Berti (who made discoveries that led to the invention of the barometer), have been omitted.

The book is a delicious meal, each chapter a tasty dish well suited to be sampled alone and all seasoned with wit and incredible anecdotes. Because there were too many references to be cited in a book for nontechnical readers, a comprehensive reference list for each chapter is available online from the publishers. There is a good index and a brief list of works for further reading.

We need more books like this to show us why even esoteric research can be important. Scientists with the curiosity that should be inherent in researchers and nonscientists alike will find new ideas and insights here. Every thoughtful reader will finish the book with greater awe and reverence for the complexity and beauty of the mystery we call life.

Book Review
It Ain't Necessarily So: How Media Make and Unmake the Scientific Picture of Reality

By David Murray, Joel Schwartz, S. Robert Lichter
Rowman & Littlefield
Copyright 2001
249 pages
ISBN: 0-7425-1095-6
$24.95 hardcover

At a time when the nation is gripped by the fear of bioterrorism and seeks definitive answers from the federal government, a new book that examines the media's less-than-rigorous reporting on scientific findings and its influence on policy-making and public opinion is especially timely.

David Murray, director of the Statistical Assessment Service in Washington, D.C., Joel Schwartz, senior adjunct fellow at the Hudson Institute, an Indianapolis-based think tank, and S. Robert Lichter, president of the Center for Media and Public Affairs in Washington, D.C., draw a troubling picture of the gullibility of media coverage of studies in the natural and social sciences. They look at the agenda-driven mission of advocacy groups that sponsor these works, and the dependence of politicians on research-supported "solutions," and offer up a wealth of examples from print and television coverage to illustrate this dilemma.

Their insights into the way scientific studies are formulated, conducted, and reported by the press illustrate how biased or misleading -- or even grossly inaccurate -- some news reports can be. Since consumers of this information can be subject to unwitting manipulation, the authors assert, they must become more skeptical about how to better assess research findings, determine their value, and communicate that knowledge.

Extensively referenced and well written, It Ain't Necessarily So is divided into 3 sections. The first describes the media's troubling tendency to ignore findings that suggest a positive trend, such as the declining number of AIDS diagnoses in the mid-1990s, or to slant the findings in a more negative, but attention-getting, manner. The authors also skewer the media's tendency to elevate preliminary but compelling research findings, such as a nonpeer-reviewed study on the effects of day care on the mother-infant relationship.

The second section, examining the ambiguity of measuring scientific and social phenomena, could serve as an introductory (though more entertaining) course in statistics. Witty commentary, vivid examples, and sharp insight make what could be a tedious exercise in dissecting research methodology an entertaining and instructive guide. In 5 chapters, the authors examine the perils of "tomato statistics," or cases where news reports draw attention to what appears to be a high number of incidents such as date rape or domestic assault but in fact are fueled by faulty research assumptions and definitions.

Readers also learn the vulnerabilities of research findings that rely on proxy instead of direct measurement; the tendency of data to be used to support only 1 conclusion, not several plausible conclusions; and the tendency of the media to exaggerate health and environmental risks. Examples used to illustrate this section, such as misleading statistics about AIDS among women and a rise in mortality from infectious diseases, may serve as a helpful model to the physician or healthcare professional asked by patients to explain the significance of the latest health news report.

While the book is replete with examples of incomplete reporting and biased research, the authors frequently point out the steps that readers can take to become better consumers of scientific information. In some cases, such as reporting on the incidence rates and risk of breast cancer, reporting has grown more sophisticated, the authors state. A widespread perception that 1 in 8 women will develop breast cancer has been refined in recent years by the media to reflect the fact that lifetime risk is not the same as the risk a woman faces at any one point in her life. "Activist contentions have repeatedly been questioned, and alternative interpretations of the statistics have been readily offered," the authors state. "In this notable instance, the print media have often excelled at explaining the realities of risk" (123).

The ongoing debate over to what extent research is influenced by industry sponsorship will make the final section of particular interest to many readers.

In one example, the authors relate the uproar that ensued in 1996 following publication of a study concluding that women who had abortions faced a slightly increased risk of breast cancer than women who did not. Instead of closely examining the study results or questioning its methodology, the Philadelphia Inquirer focused on the coauthor's personal views, which included speaking out in Christian media outlets and serving as an expert witness for antiabortion groups in Philadelphia federal court.

"All that may be true," the authors point out, but it is unclear why it is relevant. "Should only pro-choice researchers be allowed to study the medical effects of abortion?" (153). The Inquirer also failed to point out that one of the study's coauthors was pro-choice, and that the study was published in a peer-reviewed journal.

A second example showed reporting by the print media, but not network television, capable of more discriminating coverage. A 1996 study published in the Journal of the American Medical Association concluded that women with breast implants face a small increased risk of developing connective tissue disease. The lion's share of the $18.3 million study came from the National Institutes of Health ($17 million); the remaining $1.3 million came from Dow Corning, the company that manufactured silicone breast implants until they were banned in the United States in 1992. Dow did not learn of the study results until shortly before they were published.

In covering the JAMA study's findings, articles published in the Boston Globe, Chicago Tribune, and The New York Times mentioned Dow's financial contribution to the research without suggesting that it tainted the validity of the results. Articles included quotes by the leading researcher who underscored the importance of the "arm's length" relationship between Dow's participation and the study's findings. However, a report on CBS Evening News highlighted Dow's funding without stating the amount, and declared that future studies from Harvard and the NIH "will try to assess the real risk" of breast implants and connective tissue disease.

In its concluding chapter, the authors acknowledge that their effort to bring a more rigorous examination to the proliferation of scientific studies by a harried press and results-driven advocacy organizations "may seem like the labors of Sisyphus." That may be true, but the information provided in It Ain't Necessarily So gives readers the necessary tools to begin an ascent.

Cathy Tokarski is site editor of Medscape's Money&Medicine and Managed Care sites. She can be reached at ctokarski@medscapeinc.com.

PC, M.D.: How Political Correctness Is Corrupting Medicine

By Sally Satel. 285 pp. New York, Basic Books, 2000. $27. ISBN 0-465-07182-1

In PC, M.D., Satel deplores the "political correctness" (the PC of her title) advocated by some physicians, academics in the fields of nursing and public health, psychologists, social workers, and health lawyers. She defines political correctness as the assumption that the health problems of the poor, members of minority groups, women, and persons with mental illness are mainly a result of their oppression by dominant groups in society. "Indoctrinologists" for political correctness in the health professions have what the author calls a "social empowerment agenda" that "will divert resources from strategies that really work" and is already "making some people sick, or sicker than they need to be."

Satel devotes a chapter to each of seven examples of the effects of this social empowerment agenda. These examples are urging by an "academic elite" that the theory and practice of public health "encompass the quest for social justice"; the participation of former psychiatric patients ("consumer-survivors" of a "medical model" of care) in the delivery of mental health services; the preoccupation of some academic nurses with "fad therapies" and its contribution to the "dumbing down of nursing education"; false claims by leaders of the "modern women's health movement" that women are "not getting sufficient attention from medical research"; a misguided "lawyer-mounted campaign" for the "freedom" of "crack" cocaine-addicted women in South Carolina to use cocaine during pregnancy; simplistic analysis by officials of federal agencies and professional associations of the causes of disparities in access to care and health status between members of minority groups and whites of European descent; and the "strange new world" of "psychotherapy for victims," especially victims of actual or imagined abuse and discrimination.

This book will be controversial. Satel's arguments and rhetoric blend analysis and anger. She can report engagingly on what she has witnessed and read. But she also dispenses harsh and inadequately documented opinions about issues and individual persons. Satel is sympathetic to many of the issues that she accuses "indoctrinologists" of taking to extremes. Thus, she acknowledges that health status has multiple determinants, that members of minority groups have historically had less access to health care and worse health status than other Americans, and that many persons with mental illness and addiction to narcotic drugs have not retained their civil rights. Her complaint is that political-correctness extremists support policies on the basis of ideology rather than evidence. Their strident advocacy increases the difficulty of gaining support for interventions that are both more moderate and more effective.

Satel exaggerates the influence of these advocates. She elevates the status of "PC medicine" by calling it the "fourth era" of American public health, following the "sanitation, biological and lifestyle eras." PC medicine is, however, an insurgency rather than the defining theme of an era. For example, the academics in the field of public health who embrace the extreme version of the "social production of health" that dismays Satel have had little discernible influence on public health practitioners. Similarly, nurses who embrace New Age rhetoric and alternative therapies embarrass many nursing leaders.

Satel overstates her criticism of politically correct professionals in her own field of mental health. Health care providers, managed-care organizations, and public officials in each state make most policy for the care of patients with mental illness; "consumer-survivors" and their sympathizers have a limited role. The courts and the media are increasingly skeptical of persons who, during therapy, recover memories of sexual and physical abuse.

Moreover, Satel is too often an unreliable guide to the issues she discusses. Sometimes she oversimplifies complicated matters. For instance, she claims that public health is a "clinical enterprise" and ignores its other core functions. Similarly, her discussions of harm reduction as an approach to treating substance abusers and of community mental health fail to take into account the history and complexity of these concepts.

She also makes dubious accusations. For example, Satel associates Harvey V. Fineberg and William H. Foege with the extremists among public health advocates because they have expressed opinions that she supports elsewhere in the book. Similarly, she assigns the National Institute of Drug Abuse sole responsibility for defining addiction as a "chronic and relapsing brain disease" and reduces the distinguished history of the Bazelon Center for Mental Health Law to the inaccurate epithet "consumer-survivor advocacy group."

In addition, Satel omits pertinent information that would weaken her case. Describing the success of politically correct nursing in the United Kingdom, for example, she claims that "by 1995 all the traditional nursing schools had closed," that the new schools diverted students' attention to social science and "race and gender awareness," and that "patient care suffered" as a result. She neglects to add, however, that nursing education in Britain, which had been vocational since the 19th century, has recently been integrated into higher education, and that the effect on care of offering degrees in nursing is a controversial issue.

Finally, Satel invents data. For instance, "California has approved legislation requiring their public medical schools to increase the number of training slots for primary care physicians and decrease slots for specialists." Not so: in 1993 and 1994, the California legislature twice passed and Governor Pete Wilson twice vetoed bills to achieve this purpose.

Participants in the health sector have been debating for years the issues that Satel addresses. This book, like Satel's newspaper op-ed articles on similar themes, could make more people aware of these debates. If that happens, it will be regrettable that her publisher did not conduct a rigorous review of the manuscript.

The New England Journal of Medicine -- December 7, 2000 -- Vol. 343, No. 23
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Is the Fetus a Person? A Comparison of Policies across the Fifty States
By Jean Reith Schroedel. 223 pp. Ithaca, N.Y., Cornell University Press, 2000. $29.95. ISBN 0-8014-3707-5

It is said that politics is perception, and Jean Reith Schroedel, a professor in the Department of Politics and Policy at Claremont Graduate University, has set out to explore the war of perception in the ongoing struggle over abortion and women's rights. Her provocative and well-researched book tests the rhetoric of the prolife movement, which focuses on the protection of the most vulnerable among us, and the rhetoric of the prochoice movement, which focuses on the protection of women's equality and autonomy. By examining the degree to which antiabortion forces also support other measures to enhance the well-being of fetuses and infants, Schroedel concludes that their motivations are better explained by a resistance to female autonomy. This perception is widely shared within the women's movement, but until now it has not had the benefit of systematic empirical research to support the claim. Although the methods are certainly imperfect and the conclusions still subject to challenge, Schroedel's research nonetheless provides crucially important evidence in support of the claim.

Schroedel compares three phenomena: antiabortion statutes, statutes that criminalize drug use by pregnant women, and those that criminalize third-party fetal killings. Her hypothesis is that states with policies that strongly discourage abortion ought to have policies that are equally strong in their condemnation and criminal treatment of third parties who cause fetal death (usually by domestic battering of pregnant women), if the underlying justification of the antiabortion policies is indeed to protect the fetus's right to life. In contrast, if third-party killings are largely ignored, whereas prenatal drug exposure renders pregnant women subject to prosecution or involuntary commitment, then the antiabortion policy is probably focused more on moral approbation of women's behavior than on the protection of the rights of the fetus. After devoting several chapters to a history of attitudes toward fetal life, legal treatment of abortion, and third-party fetal killing and prenatal drug exposure, Schroedel moves on to a state-by-state correlation of policies.

The author presents her key findings by testing three propositions. The first, and more important, assertion is that if the premise of antiabortion statutes is a concern for fetal rights, then states with antiabortion legislation should consistently treat the fetus as a person in other settings. A review of legislation in these states suggests that they do not. The states with strong antiabortion statutes criminalize third-party fetal killings only a little less than two thirds of the time, and the states with weak antiabortion statutes do so about a third of the time; in contrast, these two groups of states enact punitive measures against pregnant drug users 80 and 64 percent of the time, respectively. Thus, the treatment of the fetus as a person with moral and legal rights is inconsistent in states with strong antiabortion policies. These states are more likely to treat the fetus as a person when the threat to the fetus comes from the pregnant woman herself rather than from a third party, such as an abusive husband. This observation leads to the author's next proposition: the states with strong antiabortion statutes tend to be those in which women have a relatively low socioeconomic status. Her analysis supports this correlation.

Together, these two observations, along with Schroedel's evidence that antiabortion states often fail to have a variety of other policies that could promote the well-being of fetuses and infants, provide strong circumstantial evidence that the perceptions of the women's movement are correct: antiabortion politics is strongly motivated, whether consciously or unconsciously, by disapproval of women's choices and foibles rather than solely -- or even predominantly -- by concern for fetal life. In this respect, Schroedel's book joins other noteworthy works that have used long conversations with members of the antiabortion movement as a basis for deconstructing the motivations that underlie the passionate and well-organized opposition to abortion.

Schroedel is appropriately modest in her claims for this approach. She acknowledges, without extensive exploration, the reality that policy making is not driven entirely by ideology. Instead, coalitions form and reform around specific events, making some bills easier to pass than others. Indeed, as someone who teaches and writes about congressional-executive relations, Schroedel is undoubtedly aware that compromise is a more potent force than consensus in American politics, leading to piecemeal approaches to policy issues. It would be interesting to use her methods in a country with a parliamentary system, in which more comprehensive and ideologically coherent approaches are possible because the executive and legislative branches share an ideological vision and party discipline makes it easier to pass sweeping programs of reform.

It would also be interesting to pose the author's question in a somewhat more explicit fashion. The title of her book, Is the Fetus a Person?, presupposes that personhood entitles the fetus to certain rights. Schroedel sets out to determine whether those rights are enforced in a sex-neutral way and concludes that they are not. But as philosopher Judith Jarvis Thomson has persuasively argued, granting the fetus personhood does not necessarily entitle it to a right to life that precludes a right to abortion. Instead, it instigates a discussion about the degree to which one person is obligated to make sacrifices for another. If a pregnancy is unexpected and unwanted, is a woman obligated to sacrifice her own psychological and bodily interests in order to permit the fetus to develop to term? If so, then to what degree are parents, fathers and mothers, obligated to make similar sacrifices for their children who have already been born? Must they donate blood or organs in order to allow their children to live? In fact, parents are not obligated to make such sacrifices, even if they are the only people with the necessary, life-saving tissue types and even if the donation would pose a minimal risk.

Many scholars have noted that there appears to be a higher degree of sacrifice forced on pregnant women than on the fathers and mothers of children already born, even when such children were expected, wanted, and deliberately conceived. This difference in notions of parental duty, many argue, is evidence that the underlying motivation is not so much concern about the well-being of the fetus or child as it is disapproval of pregnant women's choices. If the states imposed a higher duty on parents to sacrifice themselves for their children, a similar degree of sacrifice by pregnant women for their still nonsentient fetuses might be in order.

Schroedel's book develops important evidence for the claim that this battle will not be won or lost by our regard for fetal life, but rather by our regard for women's equality and the obligations of all people, men and women, to make sacrifices for others.

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