William C. Roberts, MD

I spoke at a meeting of about 350 attendees in Bangkok, Thailand, on May 11, 2002, and had an opportunity to speak to several Thai physicians about their country and about medicine in it. Although I had been to Bangkok once previously, that visit was brief (<24 hours), and my memory of that visit is hazy. This time I stayed at the Royal Orchid Sheraton Hotel and Towers, one of Thailand's magnificent hotels, which provided a magnificent view of the Chao Phraya River (“river of the king”). The river is incredibly busy, with large barges, dining boats, and boat taxis of various sorts.

Thailand is a country of about 60 million people, and has the shape of an elephant's head seen in profile when facing west. It is surrounded by Cambodia and Laos on the east, Myanmar (Burma) on the west, and Malaysia on the south. Thailand is roughly 180,000 square miles, about the size of the Utah and Colorado together.

Bangkok with its >10 million population is both an ancient and a modern city. Canals (klongs) that extend more or less at right angles from the river allow some to call Bangkok the “Venice of the East.” It is both the financial capital and the political capital of Thailand, the center of one of the fastest growing economies in the world. Bangkok has some of the worst air and water pollution on earth; the automobile traffic is staggering. Shopping is a major industry, and there are giant outdoor markets, glittering shopping malls, modern buildings, the Grand Palace, and numerous Buddhist temples. Bangkok may have the greatest concentration of luxury hotels of any city in the world, and as the capital of sumptuous Thai cuisine, some of the best dining options anywhere.

The Thai people are descendants of people from the Bronze Age who retreated from Africa on their way to China but stayed in the land that later became Thailand (1). Later, many people from Laos, Cambodia, Myanmar, and southern China migrated into what became Thailand, such that at least 75% of the population are a hodgepodge from waves of immigrants over the past 10 or so centuries. The Thais are a warm and welcoming people. They appear to delight in having foreigners in their country, particularly those who take an interest in their heritage and especially those who eat their spicy foods and appreciate their customs. The Thai people appear to have an incredible sense of humor. A light spirit and a hearty chuckle go a long way in Thailand. Thais greet each other with a graceful bow called a wai, with hands pressed together; the higher they are held, the greater the show of respect. Thais have no use for those prone to temper, aggravation, or frustration. Anger and confrontational behavior are greeted with blank stares, and the Thais not only think these outbursts are rude, but that they are an indication of a lesser-developed human being. They simply are not equipped to handle such “in your face” situations, and they avoid them. They have a phrase called “Mai pen rai,” which means “never mind,” for situations that one cannot control, such as a traffic jam or a delayed flight. In these frustrating situations, they much prefer a little humor and definitely no confrontational solution. The old phrase “catching flies with honey” appears to hold true in Thailand.

The Thais hold 2 things sacred: their religion and their royal family. Their religion, of course, is Buddhism, and that is followed by >90% of the population. The Buddha was a great Indian sage who lived in the sixth century bc. He was born Siddhartha Gautama, a prince sheltered from the outside world. When he finally left the palace walls, he encountered an old man, a sick man, a corpse, and a wandering monk. He concluded that all is suffering and resolved to search for relief from this suffering. Sensing that the pleasures of the physical world were impermanent and shallow, he shed his noble life and went into the forest to live as a solitary ascetic. But, nearing starvation, he soon realized that this was not the path to happiness, so he turned instead to meditation. One night, while meditating under a Bodhi (fig) tree, he gained an intuitive insight into reality and a supernatural knowledge of the nature of the universe. The Dhamma is “the Bible” of Buddhism. It contains about 18,400 chapters and is now on 2 CD-ROMs. The highlights of his life include his temptation by Mara, the god of death, who sent demons to try to frighten him and who sent his beautiful daughter to try to seduce him with voluptuous dancing; his protection by serpent king Mucalinda from raging floods that followed a 7-day storm; and his death and cremation. After his death, 2 schools arose. The oldest and probably the closest to the original is Theravada, which prevails in Sri Lanka, Myanmar, Thailand, and Cambodia. The other school is Mahayana, which is practiced in China, Korea, and Japan.

The basic document is the Pali canon, which was recorded in writing in the first century. The doctrine is essentially an ethical and psychological system in which no deity plays a role. It is a religion without a god and is mystical in the sense that it strives for the oneness of the universe. It has no pope, no earthly authority, and no priests. It requires that individuals work out their own salvation, as commanded by the Buddha himself, to “look within, thou art the Buddha” and, in his final words, to “work out your own salvation with diligence.” The open pagoda design of the temples reflects the openness and accessibility to all of the teachings that admit to no caste, no gender, and no race superiority. It is tolerant and seeks no converts.

The Buddhists enter the temple and prostate themselves before the Buddha, placing their hands together in a gesture of worship; light incense; and make offerings of food and flowers. At the death of Buddha, his disciples, distraught at the prospect of losing their great and beloved teacher, asked how they might remember him. Buddha granted them permission to make pilgrimages to the great events of his career and to gather his bodily relics and place them in stupas, or mounds, to remind them of his life and teachings and to bring joy and contentment to their hearts. Stupas were built, and the events of his life were followed by making representations of Buddha himself. Buddha images were first produced about the beginning of the Christian era and have been reproduced by artists and artisans ever since. The images are honored in the same way that any great teacher is honored and revered in the Eastern tradition. They are not idols of worship but images that in their physical form radiate spirituality and convey the essence of Buddhist teachings. Flowers and fruits are offered by those who would pay their respects, and worshipers bow 3 times before the image—once for the Buddha himself, once for the Sangha (the order of monks), and once for the Dhamma.

Buddhism has only one aim: to abolish suffering. It proposes to do so by the purely human means of ridding oneself of the causes of suffering, which are desire, malice, and delusion. All Buddhists are expected to eliminate craving and ill will by exercising self-restraint and showing kindness to all creatures. Only monks can participate directly in the struggle against delusion, which involves years of concentrated learning and discipline.

Another aspect of Buddhism includes the law of karma, whereby every action has effects, and the energy of past action, good or evil, continues and is “reborn.” As a consequence tam bun (merit making) is taken very seriously. Merit can be gained by entering the monkhood, and most Thai men do so for a few days or a few months, helping in the construction of a monastery or a stupa, contributing to education, giving alms, or performing any act of kindness. When the monks go daily with their bowls from house to house, they are not begging but giving people an opportunity to make merit. Similarly, the people selling caged birds, which people purchase and free, allow people to gain merit by freeing the birds. When making merit, it is the motive that is important—the intention of the mind at the time of the action determines the karmic outcome, not the action itself.

Virtually all Thais have Buddha statues in their homes, usually multiple statutes and sometimes one in each room. Buddha statues cannot be taken by a foreigner out of Thailand.

Spirit houses, from dainty to elaborate shrines, sit atop a post in every yard to house spirits or spirits of former dwellers. Each day, the household will place offerings of flowers, drinks, and food to care for the spirits and keep them happy. The spirit house is erected shortly after a new occupant enters a home. I saw several of these spirit houses during my relatively brief walks in the vicinity of the hotel. Each municipality has a city shrine, which is simply a larger spirit house. These are well tended, draped with colorful garlands, and offerings from residents. Thais rarely neglect their shrines, their ancestors, or the spirit world—a tradition that is as alive today as it has been for centuries.

If one is born in Thailand, the chances are overwhelming that the person's religion will be Buddhism. If one is born in Malaysia, Indonesia, Saudi Arabia, or 54 other such countries, the chances are overwhelming that the person's religion will be Islam. If one is born in India, the chances are that one will be a Hindu. If one is born in Europe or in North or South America, the chances are that one will be a member of the Christian faith or the Jewish faith.

Thailand has approximately 9000 physicians, about half of whom are general practitioners; the other half are specialists. Of the 60 million people, 20 million have some type of insurance, a third of which is paid by the employee, a third by the employer, and a third by the government. The other 40 million have no insurance, and about a year or so ago, the government capitated every hospital and paid each hospital approximately $30 US per year per patient in that hospital's community. Not only does the hospital bill have to come from the $30, but the physician's bill for caring for the patient also comes from that $30. Each time a capitated patient goes to the hospital, that patient has to pay $1, a small fee to help prevent overutilization of the system.

Thailand has 12 medical schools: 11 are owned by the federal government and 1 is private; all 12 are connected to a university. The medical schools in Thailand produce about 1200 new physicians each year, which means each medical school averages 100 students per class. The cost to go to medical school is small, about $250 US per year, and the federal government subsidizes those student fees. After 6 years in medical school, the graduates are awarded a medical degree, but they are not allowed to practice until they have a seventh year, which is a rotating internship, and fulfill a 3-year tour in a government hospital, usually located in a small town and underserved portion of the country. After those 3 years, the physicians are free to go wherever they wish. In Bangkok, there is 1 physician per 900 people; in some rural areas, there is only 1 physician per 30,000 people.

Most physicians are paid a salary by the hospital to which they are connected. Most physicians work in the hospital from 8 am until about 4 pm, and then most go to their private office, where they see private patients from approximately 5 to 8 pm. The private practice pays them much more than does their hospital salary. Most physicians also work on Saturday mornings.

The lay public in Thailand appear to trust their physicians completely because physicians there do not have malpractice insurance. The chance of being sued by a patient is remote.

Because medical practice is better in Thailand than in many surrounding Asian countries, in earlier years non-Thai physicians migrated to Thailand to practice medicine. Then the Thai Medical Council required that any non-Thai physicians had to speak the Thai language, and the examination for the foreign physician was switched from English to Thai. Since the Thai language is very difficult to learn, now few foreign physicians migrate to Thailand.

The income per physician in Thailand apparently is quite variable. Some general practitioners make a lot of money and others make little; likewise, some specialists make a lot of money and others do not. It has to do with the particular physician.

Students desirous of going to medical school take the medical school examination immediately after finishing high school at age 18 or 19. Those making the highest grades have their choice of the best medical schools; those making good, but not the highest grades, go to the less prestigious medical schools. Whether or not one gets into medical school, however, is entirely dependent on one's examination results. Generally, the best students in high school are the ones that go into the medicine.

Barbara Kingsolver, in her recent book Small Wonder (2), tells the true story of a lost child who was saved in an inconceivable way. A wife and husband, nomads of the Lori tribe near Kayhan, while walking home from their morning's work, were suddenly stopped cold by the sight of their teenaged baby-sitter running toward them to tell them that their baby had disappeared. She had already looked everywhere; the little boy had strong enough legs to wander off while her attention was turned to another. The parents looked in their yurt, in the village, and in the rocky outskirts, but it grew dark and then cold, and he was nowhere. Early the next morning, larger parties were organized to comb the stony hills. They ventured closer to the caves and oak woods of the mountainside. Another nightfall, another day, and some began to give up, but not the mother or father. The father gathered several men willing to go the 5 km into the caves. But the baby was only 16 months old. He took his first steps in June, and it was now only October. The mother could not believe he could walk that far, but they still went. Their feet scraped the rocky soil; then the path became softer under the live oaks. (Lori people used to make bread from the acorns of these oaks. Their animals feed on the acorns. These trees sustain every life in these mountains—the wild pigs, the bears.) At the mouth of the next cave they entered, they heard a voice. It was that of a child crying. Cautiously, they entered. They smelled bear and heard crying. Moving closer, they saw the animal, a thick-furred quiescent she-bear lying against the cave's wall. Then they saw the child. The bear was curled around him, protecting him from these intruders into her cave.

The author, Barbara Kingsolver, never learned what happened to the bear, but the child was rescued and was healthy. The baby was with the bear in her den! The child was alive, unscarred, and perfectly well after 3 days—and well fed, smelling of milk. The bear had nursed the child.

The January/February 2002 issue of World Watch (3) produced the following comparisons:

• Number of people in Washington, DC, who were murdered by anthrax poisoning between September 11 and November 9, 2001 = 2. Number of people murdered by other means in the same city during the same period = 53.
• Number of US residents who died of anthrax between October 1 and November 1, 2001 = 4. Approximate number of US residents who died during the same month as a result of having smoked cigarettes = 33,000.
• Number of US residents who would die of anthrax in 2002 if the October 2001 rate continued = 48. Number of children in Afghanistan that the United Nations estimates died in the winter 2001–2002 from pneumonia and diarrhea = 100,000.
• Probability that someone who flies once a month will die in a commercial airplane crash in 2002 in the USA if terrorists hijack and crash 1 plane every month = 1 in 540,000. Probability of dying of a heart attack in the USA in the same year = 1 in 400.
• Odds of a US resident being killed by terrorists in a shopping mall in 2002 if the person spends 2 hours a week in malls and if terrorists destroy 1 mall and everyone in it each week = 1 in 1.5 million. Odds of the average US resident being killed in that year by cancer = 1 in 600.

A television program called Affluenza appeared on Public Broadcasting System (PBS) stations on September 15, 1997, and the show produced unexpected vigorous responses by viewers. It was followed by Escape from Affluenza, which provided a look at treating the “disease” affluenza. Since then, both television programs have been widely shown throughout the USA and abroad. After the television broadcast, Thomas Naylor, an economist, and David Wann, an environmental scientist, suggested to John de Graaf, the producer of the 2 PBS programs, that they collaborate in producing a book on the topic. The book Affluenza, which concerns the all-consuming epidemic of overconsumption, appeared in 2001 (4). The authors define affluenza as “a painful, contagious, socially transmitted condition of overload, debt, anxiety, and waste resulting from the dogged pursuit of more.”

Shopping fever: Since World War II, Americans have been on a spending binge unprecedented in history and fueled to a frenzy by the booming economy of recent years. We now spend nearly $6 trillion a year, >$21,000 per person, most of it on consumer goods, which account for two thirds of the recent growth in US economy. We spend more on shoes, jewelry, and watches ($80 billion) than on higher education ($65 billion). In 1986, America still had more high schools than shopping centers. By 2000, we had more than twice as many shopping centers as high schools. Shopping centers have supplanted churches as symbols of cultural values. Indeed, 70% of Americans visit malls each week, more than attend houses of worship. The megamalls are now the equivalent of gothic cathedrals. Forty-six acres of prime American farmland are “lost to development” every hour. Americans now spend 6 hours a week shopping and only 40 minutes a week playing with our kids. Shopping malls have become the centers of many communities. Both children and adults view shopping centers now as the natural destination to fill bored lives.

Big malls sell much more per square foot than do their smaller counterparts. Seeing so much leads to impulse buying, the key to mall profitability. Only one quarter of mall shoppers actually come with a specific product in mind. The Mall of America in Bloomington, Minnesota, has 4.2 million square feet of shopping space and spreads over an area the size of 78 football fields. It employs 10,000 people and attracts 40 million visits a year.

But one doesn't have to go to the mall to shop anymore. A whole lot of shopping can be done right from the couch. Some 40 billion mail-order catalogs flooded US homes in 2000, about 150 for every American. And there are home shopping channels and cyber shopping, a new affluenza carrier online. The Internet has, indeed, been embraced as a shopping center. Twenty-five percent of Americans now spend at least 5 hours a week online, and much of that time is spent shopping. Most Internet sites now sell something. In 1999, consumers spent $10 billion online, 3 times what was spent in 1998. Soon, Internet shopping will eclipse catalog sales.

Bankruptcies: The average American now possesses at least 5 credit cards, for a nationwide total of >1 billion. According to The Guinness Book of World Records, one American now possesses 1262 credit cards! The credit card companies encourage customers to carry as much debt as possible. Less than a third of Americans avoid interest by paying off their credit card balances each month. The average American household carried just over $7500 in credit card debt in 2000. Even college students averaged $2500. Total American credit card indebtedness tripled in the 1990s.

Bankruptcies are another affluenza symptom. Each year >1 million Americans declare bankruptcy, that's 1 in every 70 Americans, more than graduate from college. That's been the case for the past 6 years. On average, the debt load for such bankruptcy filers is 22 months of income. In 1980, US household debt was 65% of disposable income; in 2001, the 2 figures were virtually equal.

The more incomes rise in the USA, the less money is saved. Obviously, it should be the other way around. In 1996, Americans were saving just under 4% of their incomes, half the German rate and only a quarter of the Japanese rate. By 2001, the national saving average hovers near zero, and in some months, it falls below that line. In contrast, impoverished Chinese, Indian, and Pakistani workers save a quarter of their incomes. Paychecks don't last long in contemporary America. Sixty percent of US families can only sustain their lifestyles for about a month if they lose their jobs.

Swollen expectations: The average size of new homes is now more than double what it was in the 1950s, while families are smaller. In the late 1940s, 750 square feet was the average-size house built; in the 1950s, it had increased to 950 square feet; by the 1960s, to 1100 square feet; and by the 1970s, to 1350 square feet. Now it's 2300 square feet. The 2-car garage became a common feature in the 1970s, and by the late 1980s, 3-car garages were not uncommon. That's 600 to 900 square feet of garage space alone, as much square footage as an entire family used in the early 1950s. A master bedroom in the 1950s averaged about 130 square feet; today, 300 square feet. In recent years homes have become symbols of conspicuous consumption. In many communities, existing homes (and perfectly functional ones) are bulldozed and replaced with megahouses of ≥10,000 square feet, called “starter castles” or “monster homes.”

Automobiles present a similar story. In 1960, <5% of new cars had air conditioning; now 90% do. Much of what we take for granted as standard automobile features weren't even available in luxury models in the 1960s. And big is back. Fuel efficiency has been forgotten, with gas-guzzling 4-wheel-drive wagons called sport utility vehicles (SUVs; some call them suburban assault vehicles). In the late 1990s, half of all new vehicles sold were SUVs and light trucks, both of which are exempted from federal fuel-efficiency standards. Until recently, the 18-foot-long Chevy Suburban set the standard for gigantism. Now Ford has introduced the Excursion, a 7000-lb titan and a foot longer. General Motors now has the Hummer (cost, $93,000).

Consider luxuries: In the 1950s, TV dinners appeared, and they might include turkey, peas, and mashed potatoes in a throwaway tray for 65 cents. Then Chinese, Mexican, and Thai food appeared. Any fruit and vegetable is now available in all seasons. When it's winter in the USA, it's summer in New Zealand after all. Eating out used to be a special occasion. Now we spend more money on restaurant food than on food we cook ourselves.

Items previously deemed luxuries as recently as 1970 are now considered necessities: dishwashers, clothes dryers, central heating, air conditioning, color and cable television, microwave ovens, VCRs, CD players, cell phones, compact discs, leaf blowers, and personal computers. And there always seems to be a better model.

Take travel. We drive twice as much per capita as we did 50 years ago and fly 25 times as much as in 1950, when middle-income Americans seldom ventured >100 miles from home. Now many of us spend long weekends in Mexico or Europe.

TV shows display a very inflated standard of living relative to the American public's true standard of living. People on television tend to be upper middle class or rich, and people who watch a lot of television have highly inflated views of what the average American has. In the years just after World War II, the superrich sought to conceal their profligacy, but now most flaunt it. Now, >20 million Americans own big-screened TVs that cost at least $2000 each.

Chronic congestion: There are now >30,000 self-storage facilities in the USA, offering over a billion square feet of relief for overstuffed homes. The storage industry has expanded 40-fold since the 1960s, from virtually nothing to $12 billion annually, making it larger than the US music industry. Two million Americans compulsively save everything from bottle caps to fast food wrappers to utility bills. Their houses become landfills.

The USA now has more cars (203 million) than registered drivers. Cars on highways with 65-mile speed limits can go no faster than 20 miles an hour or less at rush hour, speeds that waste $60 billion a year in lost time and fuel. Although we continue to build more roads, every 10% increase in the highway network results in a 5% increase in the amount of congestion. Building new roads may just make things worse.

Between 1988 and 1998, air travel increased by 35%, and more and more stuff is carried on the planes. Even space is packed with stuff. More than 7 million pounds of spaceship pieces are hurtling around the planet at 22,000 miles an hour. At that speed, a piece of space debris the size of a small marble has the kinetic energy of a 400-lb boulder dropped from 100 feet.

America's 102 million households currently contain and consume more stuff than all other households throughout history put together. As Ellen Goodman writes, “Normal is getting dressed in clothes that you buy for work, driving through traffic in a car that you are still paying for, in order to get to the job that you need so you can pay for the clothes, car and the house that you leave empty all day in order to afford to live in.”

The stress of excess: Affluenza is a major disease. Acute stress is now the norm. Most of us have little room in our lives for rest, relaxation, and reflection. Some headaches, back pain, hyperacidity, cardiac palpitations, unexplained aches and pains, some depression, anxiety, sleeplessness, irritability, anger, driving too fast, drinking too much, and abusing others may all be a part of affluenza. Possession overload is the kind of problem in which one has so many things that life is taken up maintaining and caring for things rather than people. We go to the mall and shop, and that good feeling is short lived. Certainly there is an addictive quality to consumerism. All these things do not fill the emptiness or the hollowness in many of us. Time is in short supply. We have technology, but no additional time. The computers, fax machines, cell phones, e-mail, robots, express mail, freeways, jetliners, microwaves, fast food, 1-hour photos, digital cameras, instant this, and instant that have produced less free time than we had 30 years ago. The cell phones might give extra working time while driving, but they are as likely to cause an accident as someone who is legally intoxicated. As the volume of consumption goods increases, requirements for the care and maintenance of these goods also tends to increase: we get bigger houses to clean, a car to wash, a boat to put up for the winter, and a television set to repair, and we have to make more decisions on spending. And shopping itself is a very time-consum-ing activity. Americans now spend nearly 7 times as much time shopping as they do playing with their kids. The average supermarket now contains 30,000 items, 2.5 times as many as it did 20 years ago. One may have to choose between 100 types of cereal, simply too many choices.

Americans are working more now than they did a generation ago. Full-time American workers are now toiling 160 hours—1 full month—more on average than they did in 1969. In 1999, the USA passed Japan as the modern industrial country with the longest working hours. Nearly half of American workers say they feel “used up” by the end of the workday, and nearly 70% say they would like to slow down and live a more relaxed life. The speed of American production, driven by an insatiable desire for more, virtually guarantees no time to care.

The USA has more than doubled its productivity since World War II. Although our consumption has doubled, the working hours have not fallen at all but have risen. More than half of all Americans get too little sleep—an average of 1 hour too little each night. We average 20% less sleep than we did in 1900. Our time urgency or hurry sickness leads to fast walking, fast eating, doing 2 or more things at the same time, expiratory sighing, etc.

Family convulsions: American couples now find just 12 minutes a day to talk to each other. The pressure to keep up with the Joneses leads many families into debt and simmering conflicts over money matters, which frequently result in divorce: the American divorce rate is double what it was in the 1950s, and arguments about money are precipitating factors in most divorce cases. In addition to the family conflicts brought on by overspending, rampant consumerism or affluenza weakens marriages. In the use-it-once-and-throw-it-away, planned obsolescence world of American consumer culture, it should not be surprising that attitudes formed in relation to products eventually get transferred to people. Family life simply strains under the stress of excess. As both parents work full time and more to meet swelling expectations of the good life, then rush to maintain the frenetic lifestyles those expectations demand, nerves are frayed and tempers boil. The degeneration of family life leaves some partners spending more time at the office just to avoid the friction and turmoil back home. It's a vicious cycle. The longer hours we work, the more stressful our home lives become, and the greater the tensions at home, the more we try to escape into work. But the cycle frequently starts not with work but with affluenza: we work more because we want more. As a culture, at least, we have chosen money over time.

There is another means by which affluenza pulls families apart. People live in houses with one another but are not connected with one another. Each has his own toy to play with. Dad is on the Internet. Mom is upstairs watching a movie on the VCR. The kids are downstairs playing video games. Everybody is connected to something outside the home, even though they are physically within the home. Thus, the market in a real sense is hostile to the family. There is an inherent tension between market values and family values.

Dilated pupils: For the first time in human history, children get most of their information from entities whose goal is to sell them something rather than from family, school, or religion. The average 12-year-old in the USA spends 48 hours a week exposed to commercial messages. The same child spends only about 90 minutes per week in significant conversation with his or her parents. Children under 7 are especially vulnerable to marketing messages. They are unable to distinguish commercial motives from benign or benevolent motives. There is a fundamental collision of values between children's needs and advertising. As a consequence, childhood affluenza is reaching epidemic proportions. Ninety percent of food ads on Saturday morning children's programs still hawk high-calorie, sugary, or salt-laden items. Combine that with the time children spend in front of the tube, and it's not surprising that children today are far more likely to be obese than they were in the early days of television. Obesity rates among American children doubled in the 1980s alone. Today's children are exposed to far more TV advertising than their parents were—up to 200 commercials a day! Marketers openly refer to parents as “gatekeepers” whose efforts to protect their children from commercial pressures must be circumvented so that those children can be “captured, owned, and branded.”

Companies selling beauty products are targeting younger and younger girls. By age 13, 26% of American girls wear perfume every day.

As funding for education tightens, school boards all across America have turned to corporations for financial help. In exchange for cash, companies are allowed to advertise their products on school rooftops, hallways, reader boards, book covers, uniforms, and buses. The hallways of some high schools contain a string of mini-billboards that inform students that “M&Ms are better than straight A's.” In nearly half a million classrooms, 8.1 million children watch Channel 1, a 12-minute daily news program that includes 2 minutes of commercials. Viewing is mandatory for students because advertisers, who pay as much as $200,000 for a single 30-second spot on Channel 1, are told they can count on a captive audience. Ninety-three percent of teenage girls cited shopping as their favorite activity; <5% listed “helping others.”

Community chills: Community life is deteriorating. Citizens have mutated to consumers in the past 60 years. Voter turnout, newspaper readership, and membership in choral societies have dropped precipitously. We have changed from a nation of joiners to a nation of loners. Although more Americans are volunteering, they volunteer for shorter installments, so that the total time volunteered has actually diminished in recent years. Another symptom civic degeneration is the disappearance of traditional civic leaders of community organizations. Bank presidents and business owners with long-standing ties to the community are bounced from positions of community leadership when the US banks, Wal-Marts, Office Maxes, and Home Depots come to town and put them out of business. The “chaining of America” means the loss of the personal touch of the community store.

And the neighborhoods are not as safe as in the past. Crime and violence fear now shares top ranking with development/ sprawl/traffic/roads. Both are problems that many Americans feel are out of control. Taxpayers pick up the tab for cost per prisoner that is now comparable to sending a student to Harvard University. More than 3 million children are reportedly abused every year—47 cases for every 1000 children. What will be the impact on marriage, child rearing, education, and employment from all that abuse? Youth suicide rate among youth aged 15 to 24 in 1950 was 4.5 out of 100,000; by 1970, suicides had almost doubled, and by 1996, the rate was 12 out of 100,000. Each suicide resonates far beyond an individual's family, causing serious depression among the victim's friends, schoolmates, and neigh-bors—not to mention the loss potential of the youth. When affluenza affects our communities, we begin to choose things over people, a choice that disconnects us from community life and causes even more consumption, and more disconnection.

An ache for meaning: The more Americans fill their lives with things, the more they tell psychiatrists, pastors, friends, and family members that they feel “empty” inside. The more toys our kids have to play with, the more they complain of boredom. There may be a spiritual vacuum at the heart of American society, “a tumor of the soul” as Lee Atwater once expressed. As Americans increasingly fall victim to affluenza, feelings of depression, anxiety, and lower self-esteem are likely to become even prevalent. Preoccupation with wealth can lead to loneliness, estrangement, and isolation. A survey of Duke University students found that most wanted money, power, and things—very big things, including vacation homes, expensive foreign automobiles, yachts, and even airplanes. Alcohol abuse—and particularly binge drinking—is an increasing problem on American campuses. Alcohol-related deaths, injuries, and poisoning are common. Students now spend about $6 billion a year on booze, more than they spend on all other beverages and their books combined. It takes a lot of alcohol to fill an empty soul.

Mass production, which makes the universal consumer lifestyle possible, drives large numbers of people out of more varied occupations, such as artisans and small farmers, and agglomerates them in factories, where the division of labor reduces the scope of their activities to a few repetitive motions. Their work offers neither variety nor control. Failure to repress individual personality in or after working hours is costly; in the end, the production of standardized things by persons also demands the production of standardized persons. De-individualization, the result of material progress itself, cannot help but strip life of both meaning and inherent interest. The worker/consumer is vaguely dissatisfied, restless, and bored, and these feelings are reinforced and enhanced by advertising, which deliberately attempts to exploit them by offering new products as a way out. The products and the media distract us from the soul's cry for truly meaningful activities.

Social scars: A titanic gulf now separates rich and poor in America. Among 22 leading industrialized nations, the USA is dead last in income equality. As the superrich increased their share of national income during the 1980s, they also became stingier. They gave a far smaller share of their incomes to charity than was previously the case. In spite of America's image as a cornucopia of plenty, 10 million Americans go hungry each day, 40% of them children, and the majority are members of working families. Twenty-one million other Americans keep hunger from the door by turning frequently to emergency feeding programs such as food banks and soup kitchens. On any given night at least 750,000 Americans are without shelter, and nearly 2 million experience homelessness during the course of the year. In contrast, 9 million Americans own second homes. The top 20% of American households now earn nearly as much as the bottom 80% (49% vs 51% of national income), a record-high rate of inequality. By 1999, 92% of all financial wealth (stocks, bonds, and commercial real estate) in America was owned by the top 20% of families, and 83% of stock was owned by the top 10%. At one point, before a drop in Microsoft's stock prices halved his net worth, Bill Gates held assets worth about 90 billion, nearly as much as the bottom half of the American population and greater than the gross national products of 119 of the world's 156 nations. Bill is now estimated to be worth only a paltry $40 billion. By contrast, 40% of all Americans own no assets at all! Average total chief executive officer compensation has increased by 542% since 1990, when it averaged only $2 million a year. They now earn >400 times what their average workers make, up from 40 times as much in 1980.

Affluenza affects Americans across all income barriers, but its impacts are more destructive for the poor, who are often the original victims of the environmental consequences of cost-cutting production strategies. They live disproportionately in areas where environmental contaminants and patterns of pollution are most severe. At the same time, vastly inflated wage scales paid to winners in the new information economy lead to competitive bidding on housing stock that drives the cost of shelter beyond the reach of even average earners. Finally, the poor are taunted by television programs and commercials that flash before them images of consumption standards that are considered typical of the average American, but which they have no possibility of achieving—except perhaps by robbing a bank or winning the lottery. In our poorest communities, the sense of deprivation is intense.

The social scars left by affluenza are now being replicated throughout the entire world as more and more cultures copy the American lifestyle. Every day, television exposes millions of people in the developing world to the Western consumer lifestyle (without showing them its warts), and they are eager to be in-cluded. As affluenza, the disease of unbridled consumerism, spreads throughout the world, the gap between rich and poor grows ever wider, and the social scars that still remain somewhat hidden in the USA fester as open sores elsewhere. One fifth of the world's people—a billion human beings—live in abject poverty, slowly dying of hunger and disease. Millions of others desperately need more material goods. Yet, were they to begin consuming as we do, the result would be an environmental catastrophe. The USA must begin to set another example for the world and quickly.

Resource exhaustion: Lili Tomlin said, “We buy a wastebasket and take it home in a plastic bag. Then we take the wastebasket out of the bag, and put the bag in the wastebasket.” The more we buy, the faster natural species disappear. Each of the megahomes now being built requires an acre's worth of trees and the equivalent of a house-sized hole to provide minerals for concrete, steel, and other construction materials. Our demand for buildings, fuel, and consumer products sends huge draglines, combines, chain saws, bulldozers, and oil rigs into pristine wilderness. Americans spend more for trash bags than 90 of the world's 156 countries spend for everything! In an average lifetime, each American consumes a reservoir of water (43 million gallons, including personal, industrial, and agricultural uses) and a small tanker full of oil (2500 barrels, each 44 gallons). Although slightly <5% of the world's population lives in the USA, Americans account for 25% of the global-warming greenhouse gas emissions. Each of our average 4-wheeled motorized vehicles generated 700 lbs of air pollution in its manufacture and 4 tons of carbon. Each will burn at least 450 gallons of gasoline every year, requiring >35 gas station fill-ups. We spend 3 full days every year vacuuming, polishing, and cleaning the windows of our vehicle and waiting for it at the auto shop. When we divide the miles driven by the time spent to buy and maintain the car, we go about 5 miles an hour.

In the USA each year, we burn 155 billion gallons of gasoline, spend $60 billion to ensure the Middle Eastern oil supply, have 40,000 fatal car crashes and 6000 pedestrian deaths, and kill 50 million animals, including at least a quarter million pets: cats, dogs, and horses. Since the automobile was first sold in 1905, in the USA alone, 250 million people have been maimed or injured and more killed than in all the wars in America's history! The noise and pollution produced by these vehicles inhibit sleep and contribute to the striking increase in asthma, emphysema, and bronchial infections. We spend >$200 billion annually in taxes for road construction and maintenance, snow plowing, subsidized parking, and public health expenditures because of our motorized vehicles.

It's bad enough that resource supplies, along with recreational and aesthetic opportunities, are wearing thin as the affluenzaencouraged plundering of the planet continues. But even more distressing is the fact that life on earth becomes far less diverse as habitats disappear. The loss of key species from an ecosystem is like pulling out the wrong melon from a supermarket display. You create an avalanche of melons thunking to the floor because each melon was supported by another. Hundreds of “melon avalanches” occur every day during resource extractions. Far from being just a rainforest phenomenon, habitat destruction and its accompanying extinction are happening right under our noses.

Freshwater species, from snails to fish to amphibians, are dying out 5 times faster than are terrestrial species—as fast as rainforest species, which are generally considered to be the most imperiled on earth. Half of America's wetlands are gone, as are 99% of all tallgrass prairies. As these systems are being destroyed for development, agriculture, and other uses, 935 species in the USA (356 animals, 579 plants) are fighting for their lives.

A quarter of the world's plants are threatened with extinction by the year 2010. Nearly 40% of US amphibians are endangered. About 75% of all bird species are declining; 11% are threatened with extinction. Almost all species of cats and bears are declining in numbers. One third of North American freshwater fish are rare or endangered. About 100 invertebrate species are lost each day due to deforestation. About 25% of mammals are threatened with extinction. Over 40% of reptiles species are threatened, 20% with extinction.

Industrial diarrhea: The products that cause industrial diarrhea are innocent enough on the surface: plastic packaging, toys, cars, and computer circuit boards. But when we track hazardous chemicals to their sources and endpoints, we slosh through muck every step of the way. Cigarettes kill >430,000 Americans annually, wiping out 5 million years of potential life each year. Radiation from nuclear power destroys DNA and can cause cancer. Two of every 5 Americans will contract cancer at some point in their lives, including increasing percentages of children. That tiny particle of dioxin transmitted to a fetus at the wrong time could permanently disrupt the unborn child's reproductive system. Between 1940 and 1995, the production of synthetic chemicals increased 600 times. We now produce 1600 pounds of chemicals a year per capita.

Dissatisfaction guaranteed: Psychologist David Myer said, “More than ever we have big houses and broken homes, high incomes and low morale, secured rights and diminished civility. We excel at making a living but often fail at making a life. We celebrate our prosperity but yearn for purpose. We cherish our freedoms but long for connection. In an age of plenty we feel spiritual hunger.” Material wealth does not create happiness. We keep looking outside ourselves for satisfaction that can only come from within. In the human species, happiness comes from achieving intrinsic goals like giving and receiving love. Extrinsic goals like monetary wealth, fame, and appearance are surrogate goals often pursued as people try to fill themselves up with “outsidein” rewards. Psychologist Richard Ryan believes that while people are born with intrinsic curiosity, self-motivation, and playfulness, too often these qualities are squelched by deadlines, regulations, threats, directives, pressured evaluation, and imposed goals that come from external sources of control rather than self-motivated choices and goals.

The road not taken: Nineteenth-century Americans had more respect for thrift than for spendthrifts, and the word “consumption” meant something different then. Samuel Johnson defined “to consume” to mean “to exhaust, to pillage, to lay waste, to destroy.” Tuberculosis was called “consumption.” Until the 20th century, to be a consumer was considered a bad thing. But it was the factory system that made possible a tremendous efficiency in the time required to produce products. What do to with all that time? One side suggested that we make more stuff; the other believed we should work less. Luxury or simplicity. Money or time. Thus, we elected the road of money rather the road of time.

An emerging epidemic: During World War II, Americans accepted rationing and material deprivation. Wasteful consumption was out. Citizens gathered scrap metal to contribute to the war effort. Most grew some of their own food in “victory gardens.” Driving was limited to save fuel. Despite the sacrifices, what many older Americans remember most about that time was the sense of community, of sharing for the common good and uniting to defeat a common enemy.

But shortly after World War II ended, pent-up economic demand in the form of personal savings, coupled with low-inter-est government loans and mushrooming private credit led to a consumer boom unparalleled in history and it has continued to this day. The immediate postwar period produced a huge change in the kinds of attitudes that Americans have had about consumption. Discreetly conspicuous waste got another boost from what marketers called “planned obsolescence”: products were either made to last only a short time so that they would have to be replaced frequently (adding to sales) or they were continually upgraded, more commonly in style rather than in quality. The annual model change by the automobile companies took off after World War II. Families were encouraged to buy a new car every year. Consumer loans began in the late 1940s, which also, of course, helped spiral consumption. During the 1950s and 1960s, the rush to suburbia continued. The nationwide freeway system began under President Eisenhower, and by 1970, Americans were spending 4 times as much time shopping as were Europeans. The malls encouraged Sunday shopping, then as rare in the USA as it still is in Europe. The economic boom was the result of multiple factors, including pent-up demand, government loans, expanded credit, suburbanization, longer shopping hours, and mallification. As a result, affluenza found its way into most American homes by the 1950s.

Healthy again: We don't need to be millionaires to eat well, sleep soundly, or get to know our neighbors. Without a doubt, we do need to consume less because we are running out of affordable resources, as well as tolerable places to dump our waste. We need to go beyond consuming less to wanting less and needing less. Most diseases cost a great deal to treat. Affluenza is one disease that we can cure by spending less money, not more money.

William Clifford Roberts, MD