4.7 Silicone nightmare

The Dow Corning corporation was considered one of the most ethical and progressive corporations in the world with a code of conduct that was cited as a model in case studies by business schools. In the 1977 version of this code, the company agreed that, "Dow Corning accepts as our responsibility a recognition, evaluation and sensitivity to social needs. We will meet this responsibility by utilizing our technological and management skills to develop products and services that will further the development of society." The Dow Corning code focused primarily on conduct in the global marketplace, covering issues like refusing any kind of payment or bribe, avoiding political contributions and respecting the rights of employees.

Here was a company that, on paper at least, was committed to making the world a better place. But one of its products, a silicone breast implant, became the focus of an ethical controversy that would force the company into bankruptcy and make it a pariah.

The Dow Corning Corporation was created in 1943 by The Dow Chemical Corporation and Corning, Incorporated as a jointly-owned business centered non-silicone technology. Dow Corning’s first triumph was a sealant used to protect the ignitions in Allied fighter planes from failing at high altitudes during the Second World War. When the war was over, Dow Corning explored non-defense applications of silicone, eventually creating more than 5,000 silicone products. Dow Corning continued to emphasize research and expansion throughout the 1950's and 1960's.

During this time, the company ordered a substantial amount of testing on silicones' effects, both on organisms and the environment. Typically, silicone was found to be chemically inert, failing to cause harmful reactions in rats, monkeys, or even human embryonic cells. With such characteristics, silicone seemed the perfect candidate for use in medical applications, for instance, in synthetic coverings for burn patients and in a coating on needles to ease insertion.

To encourage research in this area, Dow Corning opened the Center for Aid to Medical Research (CAMR) as a source of silicone for in-house and independent medical researchers. Thus, in the early 1960,'s Dow Corning supplied Texas plastic surgeons Frank Gerow and Thomas Cronin with silicone for their medical implant device research. Gerow and Cronin, using Dow Corning silicone, invented the first silicone breast implant as a device to aid women who had undergone mastectomies. At that time, the Food and Drug Administration had no regulations governing implantable devices. Companies like Dow Corning had to determine the safety of devices on their own. The surgeons conducted clinical trials of the implant prior to product introduction in 1964. In the next several years, the implant grew popular for cosmetic surgery as well as reconstructive, and Dow Corning cornered both markets.

Through their Center for Aid to Medical Research, CAMR, Dow Corning also invented many other important medical devices. For example, first introduced in the late 1950’s, Dow Corning created the hydrocephalic shunt, a silicone valve implanted in a child’s head to relieve the effects of hydrocephalus, "an excess of cerebrospinal fluid in the cranial cavity causing enlargement of the skull and mental retardation". In 1952, Doctors F. E. Nulsen and E. B. Spitz originally developed the technique of treating hydrocephalus by inserting a valve into the skull, diverting the excess water from the ventricle to the jugular vein. Later, they used a shunt valve developed by a Dow Corning employee, with encouraging results.

4.7.1 Development of the First Breast Implant

The original Cronin implant was developed for use by mastectomy patients to replace ones made of sponge, which tended to harden and appear less natural over time. This new mammary prosthesis was a breast-shaped silicone sac filled with silicone gel. The sac was in elastomer form, and the gel was high-density. The elastomer had a much more tightly woven atomic pattern, which kept the gel inside the sac. The gel was firm, yet pliable, so that it successfully simulated natural breast tissue. With over 10 years of research already completed on it, silicone was a natural candidate for use in breast reconstruction. In addition, it had already been utilized in other medical applications, such as the hydrocephalic shunt and life-saving pace-maker. These cases could provide information on the long-term effects of silicone on the host.

1962 marked the first implanting of a mammary prototype. For the next two years, selected surgeons used the implants in clinical trials to obtain information on their performance, both long and short term, before Dow Corning took the Cronin implant fully to market in 1964. Additional support for the implants was found in the hydrocephalic shunt’s performance , since it used the same elastomer. By 1962, about four-thousand shunts had been placed in children’s brains without any apparent ill effects.

Also, in 1962, the National Institute of Health funded the Battelle Memorial Institute to conduct research on the stability of silicone implants in animals, among them, SilasticÆ, which was used in breast implants. In particular, the study concentrated on the polymers' tensile strength and elongation, along with the reaction of the implant site to the polymers. (Tensile strength is a measure of the polymer’s pliancy.) The studies used mongrel dogs as test sites, implanting samples of all five materials in each. The plastics were recovered after six, eleven, and seventeen month intervals. Their tensile strength was recorded before implantation and after each removal, to track any loss, along with any elongation due to implantation. After 17 months, SilasticÆ showed little decrease in tensile strength and slight elongation. At the same time as the introduction of the Cronin implant in 1964, Dow Corning contracted Food and Drug Research Laboratories, an independent research company, to complete more long-term testing on the implants, which had already been followed for two years in the clinical studies and seventeen months in the Battelle study. Results encouraged the continued use of silicone in medical implants, especially in mammary prostheses.

Although implants were first targeted at mastectomy patients, even Cronin and Gerow would have been able to foresee a market for breast enhancement as well. Thus, other manufacturers developed similar implants, in response to a market which grew as women opted for cosmetic breast procedure. However, Dow Corning, where the implant originated, remained the industry leader.

4.7.2 A "New and Improved" Implant?

In 1968, Dow Corning started updating the breast implant, a process that would take approximately seven years. First, they developed a seamless envelope, which provided a smoother finish and a more natural appearance. Now came the tough part. Doctors were requesting a softer, more natural gel formulation, so the breast implant product team went to work. Research scientist Jack Roberts worked on the new gel formulation.

By the first half of 1971, he had found one, and sent it for preliminary toxicity testing. Dow Corning employed a standard, widely used chemical test involving human embryonic cells. The experimental gel was introduced to some embryonic cells, to investigate if any of them changed. Although the cells rarely reacted adversely, they did so when introduced to this gel. However, such a reaction did not necessarily indicate that the gel was unsuitable for medical use. Dow Corning had two options: complete a large, expensive battery of tests to determine if this gel was suitable for implantation, or substitute a similar polymer into the original test.

Dow Corning chose the second option, since Roberts already had a gel similar to the first. Although Roberts' second gel overcame the embryonic cell hurdle, it also had to undergo a penetration test to measure its stiffness. For example, the gelatin we eat is a fairly stiff gel. Roberts and associates allowed a weighted probe to descend for a span of time into the gel. The farther into the gel the probe made it, the softer the gel. After tracking this characteristic in the second attempt gel, Roberts found that this gel was growing softer over time. This tendency was undesirable for an implant gel, since softer consistency could cause more diffusion. Also, if the implant ruptured, more gel would migrate from the area of implantation. Thus, this gel, too, was rejected.

By June of 1974. Roberts had joined another product team, and Kim Anderson had joined the mammary prosthesis team in his place. She was a chemist by training and had been with Dow Corning since February of 1970. Taking over where Roberts left off, Anderson sought to understand the objectives of her mission clearly. As the team members explained to her, they had been trying to develop a more responsive implant gel, one that more closely simulated the behavior of actual breast tissue. Originally, breast implants had been designed for women with mastectomies. Now they were being used increasingly for cosmetic reasons. Dow Corning's competitors were marketing new gels, softer and more responsive, partly in response to this increased need.

An important restriction given to Anderson was to include only ingredients in her gel formulations that had previously been safety-tested, and/or had successful medical implant histories. This meant the new gel would be a conservative design, which should ensure a safer implant for the customer. By January of 1975, Anderson and the Implant Development team (PMG) had created a product with a more responsive gel that passed the embryonic cell reaction and weighted probe tests.

Dow Corning geared up to engineer a major effect on the breast implant market with this new, improved product, creating a special Mammary Task Force to complete the final development of this new product for marketing by June of 1975. However, Dow Corning knew that two more questions had to be answered before the new gel could go to market:

1. Can we manufacture the product?

2. Can it suitable for long-term human use?

While Anderson had been working on the new gel formulation, she had simultaneously addressed a manufacturing issue. Presently, the gel was divided into Parts A and B for production, with the ratio of ingredients needed A to B at 100:1. This incongruent ratio would not allow for true simultaneous production in Dow Corning’s batch processing. (Since a batch of A required 100 times the number of ingredients as B, it took much more time.) In order to improve efficiency, DCC asked Kim Anderson to divide the batch ingredients for production more equitably. Her work ended in the masterbatching of the gel, with the ratio of ingredients needed A:B a much more equitable 3:1, allowing for improved efficiency in production. The new gel formula could essentially drop into this new process, and the question of whether Dow Corning could manufacture the new formulation was easily answered in the affirmative.

Anderson and the development team moved on to the second question, concerning the safety of the product. In addition to Anderson, other scientists on the task force included a biocompatability expert along with Anderson's laboratory manager. Chemists and biologists disagreed on the second question. In the chemists’ opinion, no additional testing of the new gel was needed, since it utilized only components which had been previously tested and used in medical implant devices. In contrast, the biologists argued that, since the softer, more responsive gel was made from a novel combination of familiar ingredients, it needed further testing. The biologists recommended to management a two to four week study of the worst case scenario, the insertion of silicone gel without any elastomer envelope. This kind of study simulated a situation where there was total leakage, with silicone flowing freely throughout the body; no human being would ever experience this. The studies would be performed in monkeys, rats and rabbits. In the interest of safety, Dow Corning delayed production until the biologists, tests had been performed.

In March/April 1975, the results of a Dow Corning two-week study on the effect of silicone gels injected subcutaneously into rats and monkeys were delivered. The current Cronin gel acted as the control gel, and the scientists at Dow Corning tried out three new gels, including the New Production gel, the one they tentatively planned on producing; an experimental High-fluid gel; and a Low-cross linker gel. Specifically, Dow Corning wanted to investigate any tissue reaction, tendency to systemic migration, or differences in general response to the gels among the rats and the monkeys.

One iteration of the study produced an increase in the silicon in the axillary lymph node of the rats, but this result could not be replicated. No "grossly observable" tissue reaction in the monkeys was seen. However, in at least one monkey, gel moved from its original implant site. Another monkey was injected with the same formulation at multiple sites, and the gel migration result was replicated. Although this was an experimental gel and not the one tentatively scheduled for production, Dow Corning was concerned, and narrowed the acceptability criteria to rule out this gel and others with similar formulations.

In addition, Dow Corning also contracted out the requested rabbit study to Biometric, an independent research laboratory in New Jersey. The experiment involved the four gels previously discussed, as well as 28 rabbits, certain of whom were to be sacrificed after 7, 14, 21, and 90 days to reveal what, if any, effects the injected silicone gels had on them. At the end of the first twenty-one days, the only negative effect was a moderately acute inflammatory reacton at the implantation sites. This reaction was less in the twenty-one day rabbits than those sacrificed after seven and fourteen, so the inflammation appeared to decline over time. Overall, the test results had proved positive. Eager to get its implants out, Dow Corning asked Biometric if the test could be shortened by 10 days without incidence, and Biometric answered in the affirmative. After 80 days,

The majority of implant sites were entirely free of any reaction at all. These histopathologic changes observed during the 80 day course of this study were, in our opinion, due to the trauma of implantation and not due to the test gels.

Thus, the extra studies were complete and could be added to the collection of independent and in-house research on silicone already available. Anderson knew that the product team had been working for upwards of four years on this project, and it seemed like the new gel’s time had come.

4.7.3 Enter the ethicist

John Swanson was the one permanent member of Dow Corning’s Business Conduct Committee and therefore played an important role in shaping and maintaining the company’s award-winning ethical policy. His wife Colleen decided to get the new Silastic breast implants in 1974. Almost immediately afterwards, she started to have a variety of symptoms--migraines, lower back pains, rashes and fatigue that plagued her for years. In the late 1990s, her daughter told Colleen about a television program in which another woman with similar symptoms blamed them on Dow Corning implants.

Now Swanson was caught in an ethical dilemma. At work, he listened to his colleagues complain about lawsuits like the Stern case, in which the plaintiff was awarded 1.5 million dollars in damage on the grounds that Silastic implants had caused her auto-immune disorders. They also expressed concern about the Food and Drug Administration’s new role in regulating medical devices. The FDA was asking all breast implant manufacturers to prove their devices safe and effective, or face a moratorium on further sales. At home, Swanson heard Colleen’s accusations that the company he worked for her had hidden the true risk of her implants. She wanted them out--right away.

John Swanson was in a position to see the breast implant problem from both the standpoint of a woman who felt the implants were destroying her body and from the perspective of the company that had created them and saw them as a safe product, given the scientific evidence. Here was the classic hero’s call to an inward journey, in which he would have to exercise moral imagination to decide whether his wife was right, or the company he had worked for--or whether it was possible to reconcile these two opposing views in any way.

For Dow Corning, this was a great opportunity, too. The managers and employees believed they were virtuous. The breast implant was created in response to a surgeon’s need, and the company followed an expanding market. Of course they wanted to make a profit, but they also felt they were providing a service, particularly to those women who had mastectomies.

Therefore, the company felt blind-sided by the controversy surrounding its new breast implants, and were not prepared for the wave of public outrage. Dow Corning’s ethical practices had been the toast of business schoolsfor over a decade. Dow Corning’s Code of Conduct included the following statement:

We are committed to providing products and services that meet the requirements of our customers. We will provide information and support necessary to effectively use our products.

We will continually strive to assure that our products and services are safe, efficacious and accurately represented for their intended uses. We will fully represent the use and characteristics of our raw materials, intermediates and productsincluding toxicity and other potential hazards to our employees, suppliers, transporters and customers.

Dow Corning’s policy committed the company to total honesty and integrity, and this policy was reinforced by the Business Conduct Committee, on which John Swanson served. When I first met with Barie Carmichael, Vice-President and Executive Director for Corporate Communications at Dow Corning, to discuss doing a case, she seemed surprised that I saw ethical issues in the scientific testing the company had conducted. If the science said the product was safe, that was the end of the story. But she was coming to realize that, "We were naive. This is a company in the middle of a cornfield in Michigan. We were not publicly traded and didn’t have to answer to public stockholders. And we were naive about politics and did not fully appreciate how Washington, D.C. worked, or how politics could affect the company. Not only that, but most of management saw the implant issue as a scientific one, not one of communications".

But science, as John Burnham and others have shown, is not held in universal esteem by the public and in some quarters, is even seen as a tool used by the powerful to oppress groups that are underrepresented in the scientific community like women. The case of Lise Meitner and dozens of others show how hard it has been for women to break into what for years has been a primarily male fraternity. Is it any wonder many women felt suspicious about Dow Corning’s scientific claims--especially when other scientific experts appeared to disagree?

According to Carmichael, Dow Corning was not surprised that some women were skeptical of the science. What surprised the company was that these individual reports of suffering seemed to carry more weight than scientific studies. Dow Corning did not value emotional ways of knowing as much as scientific ones. They also did not pay much attention to anecdotal reports of problems with the implants, preferring scientific data. Dow Corning was learning the importance of case-based reasoning the hard way. Real cases of human pain are more salient to the public than mountains of scientific evidence.

In 1991, a jury awarded Marian Hopkins $7.3 million in damages against Dow Corning on the grounds that her implants contributed to connective tissue disorder even though she had been diagnosed before having implants. In April of 1992, the "Food and Drug Administration announced that breast implants filled with silicone gel would be available only through controlled clinical studies and that women who need such implants for breast reconstruction would be assured of access to these studies" (Kessler, 1992, p. 1713). This decision was interpreted by many women as meaning the FDA thought breast implants were not safe, when in fact the agency really intended to keep the product off the market until more testing could be done. The Hopkins suit and the FDA moratorium led to a wave of lawsuits that forced the company into bankruptcy. Colleen Swanson’s was one of them.

Here we go back to the issues we discussed at the beginning of Chapter 2, where we talked about science and truth. A relativist might argue that scientific truths are always the product of social negotiations. A sociologist with a more realist bent would amend this statement to say not solely the product of social negotiations, but negotiations can and should play an important role in what counts as truth--especially when this truth has important policy implications.

The scientists at Dow Corning were realists; they felt that they had the data and were astonished that anyone else could have failed to see it as they did. They did not realize that in order to establish a scientific fact, it is not sufficient to let the data speak for itself; one has to build a network of allies, and as the network grows, the scientific knowledge is transformed . As we will see below, studies of rats and monkeys were gradually supplanted, in terms of importance, by human epidemiological studies.

Irwin & Winn argue that, in general, "science...misunderstands both the public and itself" Even within science, the process of creating consensus can take years, as in the controversy over continental drift. Indeed, in some areas of research, a single experiment may involve a large network of collaborators and funding sources and take as much as twenty years to complete .

One of the characteristics of scientific development that most plagues historians is the enormous diversity of viewpoints that can continue to persist long after it appears that a consensus has been reached. The difficulty arises not only because consensus is never total, but also because of the fact that consensus always means the consensus of a particular community. Scientists make up many communities, and these communities vary by subject, by methodology, by place, and by degree of influence. Science itself it s polyphonic chorus. The voices in that chorus are never equal, but what one hears as a dominant motif depends very much on where one stands. At times, some motifs appear dominant from any standpoint. But there are always corners from which one can hear minor motifs continuing to sound (Keller, 1983, p. 174).

One of the minor motifs’ was Barbara McClintock’s work on gene transposition in corn, which was not integrated into the dominant consensus, or paradigm, for almost thirty years (see 2.2). The cold fusion case is also instructive (see 3.1). Initially, other scientists claimed to get a cold fusion effect, though the effect itself was a moving target: was it mainly temperature? did it include neutrons and increased tritium levels? did it require heavy water? Eventually, most of the scientific community concluded that there was no validity to claims for the existence of cold fusion, but Pons and Fleischmann continue to work in this area and receive funding from industrial sources. This minor motif may lead to a new discovery, but as of this writing, it looks like a consensus over cold fusion has been achieved in the space of a few years.

Similar time-frames and complex networks can be required for epidemiological studies on health issues (Angell, 1996). One example is the controversy over whether silicone breast implants cause cancer, which began in the early 1980s and peaked in 1988. By 1993, animal, epidemiological and clinical studies showed no carcinogenic link and a consensus was achieved. It took about a decade for a consensus to emerge in this area, helped by the fact that the controversy shifted to other conditions, like autoimmune disorders. In their obligation to prove safety, Dow Corning and other implant manufacturers were confronted with a moving target; one problem like cancer would get settled as another like autoimmune disorders arose.

Irwin & Winn argue that the boundary between science and the public is uncertain and often re-negotiated during controversies. Cases like the Swansons, might have helped Dow Corning anticipate where the controversy was shifting and develop strategies for further testing. According to Keith McKennon, who became CEO of Dow Corning in February of 1992, Swanson raised the possibility of a meeting between McKennon and Colleen. McKennon thought it was a good idea; this was an opportunity to meet directly with someone who was having a problem with silicone breast implants.

On March 19th, McKennon took Dow Corning out of the breast implant business. He also provided $10 million in funding for more research, provided up to $1200 a piece in financial aid for women whose doctors recommended that their implants be removed and tried whenever possible to talk to women. But Colleen remained suspicious of McKennon’s motives and did not want to meet with him.

John Swanson and McKennon eventually had a second meeting, at McKennon’s request. McKennon had finally heard about Colleen’s lawsuit, filed three months earlier, and he was angry. He would have liked to have talked with her. According to Swanson, McKennon asked what Colleen wanted,a zillion dollars? & and offered to discuss a resolution. McKennon says he might have asked whether Colleen really wanted lots of money or whether there was another way to resolve the conflict. Swanson had moved into the legal, adversarial mode, in which you cannot afford to trust the other party, whereas McKennon was still searching for a more cooperative solution.

Colleen did eventually settle her lawsuit with the company, and John retired in 1993 with full benefits, to work as an ethics consultant and criticize his former employer. The conversation that never took place between Colleen Swanson and Keith McKennon might have represented a missed opportunity for Dow Corning to get a better understanding of the reasons why an intelligent woman who had every reason to be loyal to the company thought one of its products was causing her major health problems, and why she did not trust the company’s efforts to deal with the problem.

Richard Hazleton, who took over the job of CEO and Chairman of Dow Corning in June of 1993, had Swanson in mind when he asked,

How do you respond ethically to someone who is questioning your ethics? For instance, the major contributor to a book that has just been published about the breast implant controversy is an ex-employee who actually played an administrative role in the Dow Corning ethics program. He and his wife firmly believe that her current illness is due to her implants. That belief has led him to question the ethics of decisions and actions, some of which he was involved in, and some of which he wasn’t.

On the other hand, there are ethical questions around this individual’s actions. For instance, what were his responsibilities to act on his convictions while he was still employed at Dow Corning rather than two years after he retired? What were his obligations, while still an employee, to investigate his concerns regarding the company’s conduct and find out whether the accusations were true rather than waiting to raise them in a book for which he will be compensated?

Did John Swanson do enough to help the company he loved cope with its growing Frankenstein monster? Consider Gioia and the Pinto case, discussed in 4.3 above. Gioia played his role of Ford’s recall coordinator according to the schema and scripts he had learned; he was never able to step out of them and imagine how the problem would have looked to someone outside the organization. In Swanson’s case, the reverse seems to have happened. Understandably, he started looking at the problem from the perspective of his wife Colleen, adopting an outsider’s schema. He would have been well-positioned to try to see the problem from an inside view, as well--to try to understand why the company believed this was a safe and effective product, despite the experiences of women like Colleen. I do not mean to place too much burden on John Swanson, a decent person trying to do his best in a difficult situation. He knew he had a conflict-of-interest on the breast implant problem and tried to walk a tightrope that would allow him to do his job while offering his wife the support she deserved (see Byrne, 1993, for more details).

I think most of the people at Dow Corning were decent, also. Virtue is a necessary but not sufficient condition for moral action. Swanson might have been able to help his company understand why so many reasonable people saw their product as a monster. McKennon and Hazleton, in turn, might have helped Swanson see that, scientifically speaking, there was no monster. What some customers and outsiders saw as a monster other customers and company insiders saw as technological progress. Virtue needs to be complemented by moral imagination, by the ability to switch between perspectives and ultimately transcend them to arrive at another point of view. Could Keith McKennon and Colleen Swanson have worked jointly to create a compensation program that would have addressed the needs of dissatisfied customers without admitting that sicilone implants could cause disease? Dow Corning is moving towards such a policy now (see footnote below).

In the wake of the FDA’s moratorium and the wave of litigation, McKennon had to decide whether to take Dow Corning out of the implant market which was still only a small percentage of the company’s overall business. At first glance, this looks like an ethical no-brainer until one considers patients with mastectomies who relied on Dow Corning to supply a product for which they felt a genuine need. As one women said after her mastectomy,

You just didn’t feel like you’re all there, you know, you just, it, my clothes didn’t fit. It was just that, you know, I looked so sunken in, you know you could tell that I didn’t have anything. I came home from the hospital and my husband said, "Let’s see what you look like," and I said "No." I said, "I cannot believe what I look like, what a person looks like, what a woman looks like without breast tissue. And I just could not wait till the day came that I could have something done" .

After getting her silicone implants, another mastectomy patient described her feeling as follows:

So I just wanted to, sort of, to look like I did before I started this, and I’m very happy with the result. And I just think it’s, sort of a self-esteem...thing for a woman, you know, it makes you feel like a whole person?

A 1991 study suggested that about 90% of the mastectomy patients were satisfied with their implants and about 95% of the augmentation patients were satisfied with theirs . Even so, in March of 1992, McKennon announced that Dow Corning would leave implant business and would fund a $10 million research program to determine the effects of silicone in the human body. McKennon also announced a fund for women who were unable to afford the removal of implants.

Dow Corning pulled the product, sold the medical devices part of their business and declared Chapter 11 in May of 1995, after an effort to settle the huge number of lawsuits (almost 20,000) failed. Was this just desserts for a company that had produced a faulty product, or a victory of superstition over science?

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WHERE THERE'S SMOKE THERE'S FIRE ~ On The Net

The following websites have the "Where There's Smoke There's Fire"

documents:

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OTHER SILICONE RELATED RESOURCES ARE AVAILABLE THROUGH THE SILICONE WEBRING

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THOUGHT FOR THE DAY

Sent to us by Uneeda. . .Thank you Uneeda

Subject: THE WORLD AS A VILLAGE

"If we could shrink the earth's population to a village of precisely 100 people, with all the existing human ratios remaining the same, it would look something like the following.

There would be:

57 Asians

21 Europeans

14 from the Western Hemisphere, both north and south 8 Africans

52 would be female

48 would be male

70 would be non-white

30 would be white

70 would be non-Christian

30 would be Christian

6 people would possess 59% of the entire world's wealth and all 6 would be from the United States.

80 would live in substandard housing

70 would be unable to read

50 would suffer from malnutrition

1 would be near death; 1 would be near birth

1 (yes, only 1) would have a college education

1 would own a computer

When one considers our world from such a compressed perspective, the need for both acceptance, understanding and education becomes glaringly apparent.

Phillip M Harter, MD, FACEP

Stanford University, School of Medicine