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The excitement aroused by the World Cup soccer tournament in Germany in 2006 may have increased that country's birthrate as much as 15 percent nine months later. But the intensely emotional matches have now also been correlated with a spike in the number of cardiac emergencies.

A study published Thursday in the New England Journal of Medicine examined the number of cardiac emergencies in the greater Munich area in the summer of 2006. It compared that number with the numbers in similar periods in 2003 and 2005, and for several weeks before and after the 2006 World Cup.

On days when the German team played, the incidence of cardiac emergencies was 2.66 times higher than during the comparison periods. For men, the incidence was 3.26 times higher; for women, it was 1.82 times higher. People with a history of heart disease were particularly affected.

The study's authors say emotional stress was the main trigger, but they add that sleep deprivation, excessive consumption of junk food and alcohol, and smoking might also be contributing factors. They suggest that spectators with heart problems should take preventive measures, such as consulting their doctors about increased medication dosages during intense sports events.

So should Americans be worried about this weekend's Super Bowl? Study author Gerhard Steinbeck says:

It's reasonable to think that something quite similar might happen.

Though if the Vegas odds-makers have it right, the greater danger on Sunday may turn out to be irate New York Giants fans.

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In previous posts, I've lamented the lack of proper health care (particularly mental health) for veterans returning from Iraq in Afghanistan, lauding both the Washington Post for its "Walter Reed and Beyond" series, and the New York Times for its "War Torn" series. The Post chose to tackle the story of vets from the beds of one hospital, whereas the NYT chose to report on veterans who had been charged with killing after returning home.

Now the NYT is under attack for its approach to the story. It is accused of more or less painting veterans as murderers and sensationalizing the plight of those suffering from post-traumatic stress disorder (PTSD). Lt. Col. Bob Bateman, normally a staunch defender of journalists, says that the NYT is playing a dangerous game with statistics, overstating the 121 cases that the newspaper uncovered as a "quiet phenomenon," when there is a population of 700,000 returning veterans from Iraq and Afghanistan. Moreover, of those 121 cases, 22 were DUIs, two were speeding accidents, and five cases resulted in exonerations of the accused killers. Hardly a trend. Bateman parses more numbers and says one could make an equally faulty argument: that veterans of active combat in Iraq and Afghanistan are, in fact, less likely to commit homicide than the population at large. (With the likely reasoning being that military training teaches young men and women to become more responsible citizens.) Bateman accuses the Times of "sloppy thinking... that does not help anyone." 

After much outcry, Clark Hoyt, the NYT public editor, basically agrees with the newspaper's critics in his Sunday column:

[T]he questionable statistics muddy the message. A handful of killings caused by the stresses of war would be too many and cause for action. Sometimes, trying to turn such stories into data — with implications of statistical proof and that old journalistic convention, the trend — harms rather than helps."

Both Bateman and Hoyt acknowledge that PTSD is a serious problem. But, Bateman concludes, "fear-mongering and drawing specious conclusions from incomplete data is no help."

Indeed, it's unfortunate that the the NYT's "creative" use of statistics opened the story up to valid criticism such as Bateman's. In effect, it undermines the point that most people will draw from its series: that seeing combat has very real effects on the mental health of veterans, and that there simply needs to be more effort put into their care. Witness the State of the Union address on Monday. President Bush got the most sustained applause from both sides of Congress when he mentioned honoring veterans. A new study released today finds that PTSD, depression, and stress (but not brain injuries, as previously thought) are drivers behind symptoms afflicting returning vets. The stigma needs to be removed. The real health problems need to be addressed. And there needs to be no more sensationalizing about what it all means.

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Last month I blogged about the case of Lt. Elizabeth Whiteside, an Army reservist facing court martial because she tried to commit suicide while serving in Iraq. Her story was part of the Washington Post's outstanding series, "Walter Reed and Beyond," about the lives of vets returning from Iraq and Afghanistan.

Now, the New York Times is doing its part to cover the care of vets, this time from a different angle. The Times' series, "War Torn," is about veterans who have been charged with killings after returning home. The first part of the series discussed the trend in general, noting that there have been 121 cases of such tragic incidents and touching on some of those cases. The second part of the series appeared on the front page of Sunday's paper. It tells the tragic tale of the killing of 22-year-old Nicole Marie Speirs by 21-year-old Marine Lance Cpl. Walter Rollo Smith, the father of their infant twins, who was suffering from post-traumatic stress disorder (PTSD) from his war experiences in Iraq.

Speirs's parents view the situation as a fatal incident of domestic violence. They worry that people are using her death to make a statement against the war. They hold Smith responsible for his actions. He doesn't disagree:

I can't completely, honestly say that, yes, PTSD was the sole cause of what I did. I don't want to use it as a crutch. I'd feel like I was copping out of something I claim responsibility for. But I know for a fact that before I went to Iraq, there's no way I would have taken somebody else's life.”

Reading his account, it's hard not to wonder if Speirs's death could indeed have been prevented, if only Smith hadn't fallen through the cracks. A formerly squeaky clean Mormon, Smith returned to Utah smoking, drinking, doubting God, and distraught over having killed civilians in Iraq. The Marines sent him to Quantico for a marksmanship course, and while on the firing range, he began to hallucinate about his experiences in Iraq. He had what can only be described as a breakdown. The Marines diagnosed him with PTSD, then discharged him, leaving him to seek treatment from veterans' hospitals.

But it's hard for someone who's having mental difficulties to have the wherewithal to manage his or her own treatment. After Smith's discharge, he intermittently sought help. He attended a group therapy session at a VA hospital, but never returned because none of the other attendees had similar war experiences to his. For awhile he took medication for anxiety, but stopped taking the pills when they didn't work. He attempted suicide. He once called the cops and asked for help because he was having homicidal thoughts. But ultimately, he was left to deal with his mental health on his own. And so one day he disconnected, and drowned the mother of his children.

Read the entire story to learn more of the compelling details. But the bottom line is that this is a senseless tragedy. A young man with no history of violence, not even old enough to buy a beer, was sent into a war zone to fight for his country. And when he returned, troubled, he didn't get the care that he needed. Now, a young mother is dead, and he's in prison. There are no winners here.

PLoS Medicine

How do you provide healthcare to citizens in a country where nearly 75 percent of the population lives in the country, and more than 75 percent of the country's doctors live in cities? India's answer: telemedicine.

The Indian government has been investing in the technology to make healthcare accessible and affordable for the country's rural population, according to The Lancet. Telemedicine works like a regular medical consultation—except the doctor is on a computer screen peering through a webcam, and the patient's vitals are monitored by traditional equipment such as stethoscopes hooked up to computers (a more precise explanation can be found here and here). Sometimes a general physician is present, but the specialist reading and interpreting the information is located remotely.

The country's first telemedicine center was established in the state of Andhra Pradesh in 2000, and since then many analysts have come to believe that telemedicine "could be the future for health care in India." Today, there are about 500 telemedicine centers across the country, linked to about 50 specialist hospitals. So far the centers have provided "teleconsultations" to an estimated 150,000 patients—a drop in the ocean in a country of more than 1 billion. According to anecdotal accounts, however, initial skepticism about "impersonal" health consultations is waning and patients who have been treated through telemedicine appear satisfied with the care. Meanwhile, public-private partnerships are continuing to expand the size and the scope of telemedicine facilities.

Telemedicine, like the use of cellphones for health, could be a revolutionary step in medical provision for the poor. Rural residents won't need to travel as great a distance in order to access sophisticated medical treatment, and doctors won't need to move to rural areas. As of now, telemedicine consultations cost around $22—still beyond the reach of most Indians. But the government is promising to provide the consultations free of charge for the poor, though it's not clear if this is entirely feasible since many clinics are operated privately.

But as revolutionary as it might be, the growth of long-distance medicine raises some questions about accountability. What happens if a patient is misdiagnosed, or sent away with a clean bill of health when there is actually an underlying problem? Can anyone fairly be held responsible? Nonetheless, it does seem like the benefits at the moment outweigh the risks. As one surgeon and hospital director argues:

In terms of disease management, there is [a] 99% possibility that the person who is unwell does not require [an] operation. If you don't operate you don't need to touch the patient. And if you don't need to touch the patient, you don't need to be there.

Come to think of it, there's no reason to think Indian specialists and doctors couldn't start treating patients in this manner who hail from anywhere in the world, including the United States. Indeed, Indian doctors are already providing diagnostic interpretation of radiological images, including X-rays, CTs and MRIs, for American patients from hospitals in places as far away as Bangalore.

Last month, Christine noted the increase in "inverted sex tourism": wealthy foreign women heading to poor countries (for instance, Kenya) to purchase sex from younger and poorer men. But a BBC report on Kolkata in India reveals that it's not just rich foreign women who prey on male prostitutes. Indian women of means are also getting into the act:

[Male gigolos] offer some insight into the changing sexual mores of a growing number of Indian women who are ready to spend money on buying sex in a traditionally conservative society.

It is hardly a easy job to do - in the absence of male brothels, gigolos like Samrat cruise after dusk for prospective clients, mainly upper or middle-class and rich women who usually drive in their cars with dark tinted windows.

"It is not all fun and games as people think. Just as female sex workers face violence and get cheated, we face such situations from time to time too," says the son of a bank worker, who joined the sex trade after a short stint as an employee with a multi-national pharmaceutical firm in the capital, Delhi.

"I have often not been paid by clients, and when I have protested, they have threatened me with telling the police that I tried to rape them. And there are clients who love to stub out burning cigarettes on our bodies. These days I have begun to charge for a cigarette burn - 500 rupees ($11) per stub," he says.

As with female sex workers, technology such as mobile phones and the Internet has helped facilitate business. The men usually receive upwards of 1,000 rupees ($25) an hour from their clients, and when work from female clients slows, many of these workers sell sex to other men. Thankfully, the "gigolos," who constitute one of the highest risk groups for HIV/AIDS contraction, are beginning to bond together to speak out for HIV prevention. Whether that will be enough to curb the spread of the virus, of course, remains to be seen.

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The United States acknowledges and accepts that it has a weight problem. Obesity has become a serious national issue, with a quarter of the U.S. population considered obese. Health professionals have even spoken out against stigmatizing obese people. It's surprising, then, that obese people—white women specifically—are discriminated against where it arguably hurts the most: in their paychecks.

According to a recent study by David Lempert of the U.S. Bureau of Labor Statistics, there is a "statistically significant continual increase in the wage penalty for overweight and obese white women followed throughout two decades." And the trend has increased, even as more Americans have become obese. One way to look at it, the author of the study writes, is that "the increasing rarity of thinness has led to its rising premium."

Moreover, as overweight white women age, their wages suffer correspondingly more over time as they get passed over for promotions and raises. It's an alarming finding in a country that is supposedly all about non-discrimination in the workplace.

(Hat tip: New Economist) 

BRENDAN SMIALOWSKI/AFP/Getty Images

If you missed the front-page story in the Washington Post on Sunday about 1st Lt. Elizabeth Whiteside, read it now, pronto. I haven't been this outraged since the last time I read an entry in the newspaper's outstanding ongoing investigative series, "Walter Reed and Beyond," which is about the lives of soldiers returning from Iraq and Afghanistan.

This time, reporters Dana Priest and Anne Hull tell the tale of the 25-year-old Army reservist, a valedictorian of her high school who had earned nothing but accolades during her seven-year career in the military. She once worked as an officer, but faces a court martial because of an attempted suicide when she was serving in Iraq. If tried and convicted, she could face life in prison.  

The short version of the story is this: Whiteside, who was nicknamed the "Trauma Mama" by the medics she supervised in Iraq, worked at the detainee prison where Saddam Hussein was held. While there, she and another female experienced tensions with a male superior officer. She ate only one meal a day and slept in shifts. There's no doubt the atmosphere was stressful. Whiteside began to have panic attacks. Then, when Saddam Hussein was taken from the prison to be executed, violent riots broke out inside the prison. Whiteside ushered doctors to safety, conducted triage, and performed exemplary service. The next day, she experienced what she calls a "psychotic break." In clear distress, she requested to see a mental health nurse. When the nurse checked in on her later in the day, Whiteside waved her gun and eventually shot herself in the stomach.

After being sent to Walter Reed, where ironically she had once worked as an officer, the Army's own psychiatrists diagnosed her with severe major depressive disorder and a personality disorder. Then, a new team stepped in: the Warrior Transition Brigade. Made up of officers with combat experience and whose ostensible aim was to help patient recovery, the team drew up criminal charges against Whiteside. They said she was using her mental illness as an excuse. Whiteside offered to resign, but would have to forfeit the benefits that she's earned in her military career. Her alternative is to face these charges, with the prospect of life in prison.

Her treatment by the Army right now is a total travesty. Combat is hard enough for someone without a predisposition to mental illness. And mental-health issues are hard enough to deal with in civilian life under ideal conditions, never mind in a war zone. Mental illness is a serious medical problem, just as serious as any physical medical condition, and Whiteside ought to be treated as any other wounded soldier. It would be a complete shame if this case is allowed to continue. Kudos to the Washington Post for bringing attention to this important issue.

Worldmapper is a cool Web site that resizes countries on world maps based on a variety of health and other statistics. It recently added 118 maps to its collection. Below is a new map in which countries are puffed up or shriveled down based on the absolute number of people murdered there in 2002. Colombia, Nigeria, and the Philippines are huge, while Australia looks like a deflated balloon (which makes sense since a relatively small number of Aussies are living on such a large piece of land).

Many people may fear getting murdered, but being on the roads is actually more dangerous in many parts of the world. Murder caused 1.0 percent of deaths worldwide in 2002, but road accidents—the subject of the map below—caused 2.1 percent of deaths that year. In India, riding in a motor vehicle can be a near-death experience, and China doesn't look like a very safe place for road travel either.

Americans have many stereotypes about British people, but one misconception that has become particularly widespread in recent years is that Brits have bad teeth. Not so, as this map of "Decayed, missing or filled teeth at age 12 (DMFT-12 index)" in European Union countries shows. It's Eastern Europeans who need to brush and visit the dentist more often.

You can check out the British public health study from which this map is taken here. And you may be surprised to learn that the United Kingdom scores better than the United States on the DMFT Index: Brits best American 12-year-olds by a score of 1.1 to 1.4 (lower is better), according to the World Health Organization.

Whether it's suspicious spinach, suicidal snack foods, or, most recently, fatal fish, this has been the summer of food scares. Not even your pet is safe. Fido's Kibbles are just as deadly as the salad you're about to eat for lunch.

But is our food supply as deadly as news reports suggest, or have food attacks simply replaced shark attacks as cable news' filler of choice on slow news days? I'm not trying to minimize the seriousness of food-borne illness here. As stats (pdf) from the Center for Science in the Public Interest show, it's a real threat, particularly to developing nations. Contaminated food contributes to 1.5 billion cases of diarrhea in kids each year, resulting in more than 3 million unnecessary deaths.

In the United States, food-borne diseases result in 76 million illnesses and 5,000 deaths annually. These numbers sound large—until you put them in perspective. Influenza and pneumonia, for instance, together kill more than 61,000 Americans a year. But unless that flu is of the bird variety, we don't hear much about it. Food threats make for good news copy because they almost always emanate from the developing world.Wealthy nations have become so far removed from their food supplies that it's easy to shock people with stories of sketchy Chinese catfish farmers and uncouth Thai salmon brokers.

STEPHEN SHAVER/AFP/Getty Images

But the real dangers inherent in our global food chain are far more quiet, and potentially more deadly, than headline-grabbing cases of E. coli. Consider obesity. Not that long ago, people everywhere ate with the seasons and with tastes that were dictated by regional conditions. But as it has become possible to eat anything, anywhere, at any time, the world has grown fatter. "Who cares?," you might say—it's nice to have fresh strawberries in the dead of winter.

Well, chew on this:

Global increases in the incidence and prevalence of obesity are grounded in the globalization of Western post-industrial food systems," writes Cornell University's Jeffrey Sobal. "Global corporations are establishing industrialized agro-food systems in almost all nations that will provide constant 24 hours a day/ 7 days a week/365 days a year consumer access to virtually unlimited volumes of relatively inexpensive calorifically dense foods to all people in all places at all times.... Global food systems and global vehicles, appliances, and mass media are the underlying causes of increases in global obesity."

Apparently, a flat world is a fat world.

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Anyone who has lived in a big city knows what it's like when those inconsiderate neighbors decide to crank up their stereo at two in the morning. Or when rush hour traffic fills your apartment with jarring sounds of honking and cursing. But what we shrug off as the price of living in a cosmopolitan town may be deadlier than we thought.

A new study of European cities by the WHO has found that the emotional distress caused by noise pollution is responsible for three out of every 100 deaths typically blamed on heart disease. This could translate to as many as 210,000 deaths in Europe each year due to lack of peace and quiet. The unwanted raucous increases levels of stress hormones, even while we sleep, which can then lead to heart failure, strokes, high blood pressure, and immune problems if present in the bloodstream for extended periods of time. 

EU regulators have already sprung into action: By the end of this year, cities with populations exceeding 250,000 will be required by law to produce digitized noise maps marking the noise hotspots (which would really come in handy while apartment hunting). Over on this side of the Atlantic, residents of the "city that never sleeps" might finally be getting some beauty rest thanks to Major Bloomberg's recent hardening of the city's noise pollution codes. Under the new rules, music polluters in New York City will be slapped with heavier fines and cars whose alarms go off for more than three minutes at night will be towed.

The WHO study looked only at European cities, so I shudder to think what researchers would find in Cairo, Mumbai, or Beijing. But perhaps those cities can work on clearing the air first before they start going after horn-happy drivers. The air pollution in those place will probably kill you before the noise does.

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Simon Romero reports on the latest developments in the Bolívaran Revolution:

Moved by claims that it will help the metabolism and productivity of his fellow citizens, President Hugo Chávez said clocks would be moved forward by half an hour at the start of 2008. He announced the change on his Sunday television program, accompanied by his highest-ranking science adviser, Héctor Navarro, the minister of science and technology. "This is about the metabolic effect, where the human brain is conditioned by sunlight," Mr. Navarro said in comments reported by Venezuela’s official news agency. Mr. Chávez said he was "certain" that the time change, which would be accompanied by a move to a six-hour workday, would be accepted.

(Thanks to KH for sending this in.) 

REUTERS

In keeping with Passport's tradition of updating our readers about toilets in China, we have the latest news: There will be no more food stalls attached to public toilets in Beijing. The Beijing Municipal Commission has decided that "It is not proper to sell soft drinks or snacks right at the toilets," which up till now had been permitted. The city government is also planning to publish a toilet guide and offer telephone and Internet services containing information to help toilet users.

What's the motivation for these efforts? The 2008 Beijing Olympics, of course. China is making a huge effort to crack down on poor public hygiene and improve social etiquette. Earlier this year, China initiated an effort to curb public spitting, cursing and littering, and promote orderly queues. Even poorly-translated English signs in China are getting the boot. But for all the cosmetic changes, it seems that some things aren't changing so quickly: press freedoms and protection for human rights.