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+{"text":"\n\nCopyright \u00a9 2012, 2009 by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.\n\nISBN: 978-0-07-177053-8  \nMHID: 0-07-177053-4\n\nThe material in this eBook also appears in the print version of this title: ISBN: 978-007-177052-1, MHID: 0-07-177052-6.\n\nAll trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. 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However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confi rm the information contained herein with other sources. For example, and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. 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Your right to use the work may be terminated if you fail to comply with these terms.\n\nTHE WORK IS PROVIDED \"AS IS.\" McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and\/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.\n\n## **Contents**\n\nPreface\n\n**1. Introduction: The Paradox of Excess and Deprivation**\n\n**2. Paying for Health Care**\n\n**3. Access to Health Care**\n\n**4. Reimbursing Health Care Providers**\n\n**5. How Health Care Is Organized\u2014I: Primary, Secondary, and Tertiary Care**\n\n**6. How Health Care Is Organized\u2014II: Health Delivery Systems**\n\n**7. The Health Care Workforce and the Education of Health Professionals**\n\n**8. Painful Versus Painless Cost Control**\n\n**9. Mechanisms for Controlling Costs**\n\n**10. Quality of Health Care**\n\n**11. Prevention of Illness**\n\n**12. Long-Term Care**\n\n**13. Medical Ethics and Rationing of Health Care**\n\n**14. Health Care in Four Nations**\n\n**15. Health Care Reform and National Health Insurance**\n\n**16. Conflict and Change in America's Health Care System**\n\n**17. Conclusion: Tensions and Challenges**\n\n**18. Questions and Discussion Topics**\n\nIndex\n\n## **Preface**\n\n_Understanding Health Policy: A Clinical Approach_ is a book about health policy as well as about individual patients and caregivers and how they interact with each other and with the overall health system. We, the authors, are practicing primary care physicians\u2014one in a public hospital and clinic and the other, for many years, in a private practice. We are also analysts of our nation's health care system. In one sense, these two sides of our lives seem quite separate. When treating a patient's illness, it seems that health expenditures as a percentage of gross domestic product or variations in surgical rates between one city and another seem remote if not irrelevant\u2014but they are neither remote nor irrelevant. Health policy affects the patients we see on a daily basis. Managed care referral patterns determine to which specialist we can send a patient, the coverage gaps for outpatient medications in the Medicare benefit package affects how we prescribe medications for our elderly patients, and differences in access to care between families on Medicaid and those with private coverage influences which patients ended up seeing one of us (in the private sector) and which the other (in a public setting). In _Understanding Health Policy_ , we hope to bridge the gap separating the microworld of individual patient visits and the macrouniverse of health policy.\n\n### **THE AUDIENCE**\n\nThe book is primarily written for health science students\u2014medical, nursing, nurse practitioner, physician assistant, pharmacy, social work, public health, and others\u2014who will benefit from understanding the complex environment in which they will work. Physicians feature prominently in the text, but in the actual world of clinical medicine, patients' encounters with other health care givers are an essential part of their health care experience. Physicians would be unable to function without the many other members of the health care team. Patients seldom appreciate the contributions made to their well-being by public health personnel, research scientists, educators, and many other health-related professionals. We hope that the many nonphysician members of the clinical care, public health, and health science education teams as well as students aspiring to join these teams will find the book useful. Nothing can be accomplished without the combined efforts of everyone working in the health care field.\n\n### **THE GOAL OF THE BOOK**\n\n_Understanding Health Policy_ attempts to explain how the health care system works. We focus on basic principles of health policy in hopes that the reader will come away with a clearer, more systematic way of thinking about health care in the United States, its problems, and the alternatives for managing these problems. Most of the principles also apply to understanding health care systems in other nations.\n\nGiven the public's concerns about health care in the United States, the book concentrates on the failures of the system. We spend less time on the successful features because they need less attention. Only by recognizing the difficulties of the system can we begin to fix its problems. The goal of this book, then, is to help all of us understand the health care system so that we can better work in the system and change what needs to be changed.\n\n### **CLINICAL VIGNETTES**\n\nIn our attempt to unify the overlapping spheres of health policy and health care encounters by individuals, we use clinical vignettes as a central feature of the book. These short descriptions of patients, physicians, and other care-givers interacting with the health care system are based on our own experiences as physicians, the experiences of colleagues, or cases reported in the medical literature or popular press. Most of the people and institutions presented in the vignettes have been given fictitious names to protect privacy. Some names used are emblematic of the occupations, health problems, or attitudes portrayed in the vignettes; most do not have special significance.\n\n### **OUR OPINIONS**\n\nIn exploring the many controversial issues of health policy, our own opinions as authors inevitably color and shade the words we use and the conclusions we reach. We present several of our most fundamental values and perspectives here.\n\n### **THE RIGHT TO HEALTH CARE**\n\nWe believe that health care should be a right enjoyed equally by everyone. Certain things in life are considered essential. No one gets excited if someone is turned away from a movie or concert because he or she cannot afford a ticket. But sick people who are turned away from a medical practice can make headlines, and rightly so. A simple statement of the right to health care reads something like this: All people should have equal access to a reasonable level of appropriate health services, regardless of ability to pay.\n\nIn 2009, the United States entered into a fierce debate over whether health care should be a right. The debate focused on President Barack Obama's campaign to enact universal health insurance. Following a year of public ferment, Congress passed the Affordable Care Act, which goes a long way toward guaranteeing health care as a right. Yet, at the time of writing this edition of _Understanding Health Policy,_ the controversy continues with challenges to implementation of the Affordable Care Act.\n\n### **THE IMPERATIVE TO CONTAIN COSTS**\n\nWe believe that limits must be placed on the costs of health care. Cost controls can be imposed in a manner that does relatively little harm to the health of the public. The rapidly rising costs of health care are in part created by scientific advances that spawn new, expensive technologies. Some of these technologies truly improve health care, some are of little value or harmful, and others are of benefit to some patients but are inappropriately used for patients whom they do not benefit. Eliminating medical services that produce no benefit is one path to \"painless\" cost control (see Chapter 8).\n\nReduction in the rapidly rising cost of administering the health care system is another route to painless cost containment. Administrative excess wastes money that could be spent for useful purposes, either within or outside the health care sector. While large bureaucracies do have the advantage of creating jobs, the nation and the health care system have a great need for more socially rewarding and productive jobs (eg, home health aides, drug rehabilitation counselors, childcare workers, and many more) that could be financed from funds currently used for needless administrative tasks.\n\nThere is a growing consensus that health care cost increases are bad for the economy. Employers complain that the high cost of health insurance for employees reduces international competitiveness. If government health expenditures continue their rapid rise, other publicly financed programs essential to the nation's economy (eg, education and transportation) will be curtailed and the unsustainable government budget deficits will strain the future of the nation's well-being.\n\nRising costs are harmful to everyone because they make health services and health insurance unaffordable. Many companies are shifting more health care costs onto their employees. As government health budgets balloon, cutbacks are inevitable, generally hurting the elderly and the poor. Individuals with no health insurance or inadequate coverage have a far harder time paying for care as costs go up. As a general rule, when costs go up, access goes down.\n\nFor these reasons, we believe that health care costs should be contained, using strategies that do the least harm to the health of the population.\n\n### **THE NEED FOR POPULATION-BASED MEDICINE**\n\nMost physicians, nurses, and other health professionals are trained to provide clinical care to individuals. Yet clinical care is not the only determinant of health status; standard of living and public health measures have an even greater influence on the health of a population (see Chapter 3). Health care, then, should have another dimension: concern for the population as a whole. Individual physicians may be first-rate in caring for their patients' heart attacks, but may not worry enough about the prevalence of hypertension, smoking, elevated cholesterol levels, uncontrolled diabetes, and lack of exercise in their city, in their neighborhood, or among the group of patients enrolled in their practices. For years, clinical medicine has divorced itself from the public health community, which does concern itself with the health of the population. We believe that health caregivers should be trained to add a population orientation to their current role of caring for individuals.\n\n### **ACKNOWLEDGMENTS**\n\nWe could not have written this book by ourselves. The circumstances encountered by hundreds of our patients and dozens of our colleagues provided the insights we needed to understand and describe the health care system. Any inaccuracies in the book are entirely our responsibility. Our warmest thanks go to our families, who have provided both encouragement and patience.\n\nEarlier versions of Chapters 2, , , , , and  were published serially as articles in the _Journal of the American Medical Association_ (1994;272:634\u2013639, 1994;272:971\u2013977, 1994;272:1458\u20131464, 1995;273:160\u2013167, 1995;274:85\u201390, and 1996;276:1025\u20131031) and are published here with permission (copyright, 1994, 1995, and 1996, American Medical Association).\n\n### **CONCLUSION**\n\nThis is a book about health policy. As such, we will cite technical studies and will make cross-national generalizations. We will take matters of profound personal meaning\u2014sickness, health, providing of care to individuals in need\u2014and discuss them using the detached language of \"inputs and outcomes,\" \"providers and consumers,\" and \"cost-effectiveness analysis.\" As practicing physicians, however, we are daily reminded of the human realities of health policy. _Understanding Health Policy: A Clinical Approach_ is fundamentally about the people we care for: the uninsured janitor enduring the pain of a gallbladder attack because surgery might leave him in financial ruin, or the retired university professor who sustains a stroke and whose life savings are disappearing in nursing home bills uncovered by her Medicare or private insurance plans.\n\nAlmost every person, whether a mother on public assistance, a working father, a well-to-do physician, or a millionaire insurance executive, will someday become ill, and all of us will die. Everyone stands to benefit from a system in which health care for all people is accessible, affordable, appropriate in its use of resources, and of high quality.\n\n_Thomas Bodenheimer  \nKevin Grumbach  \nSan Francisco, California  \nFebruary, 2012_\n\n## **1 Introduction: The Paradox of Excess and Deprivation**\n\n_Louise Brown was an accountant with a 25-year history of diabetes. Her physician taught her to monitor her glucose at home, and her dietician helped her follow a diabetic diet. Her diabetes was brought under good control. Diabetic retinopathy was discovered at yearly eye examinations, and periodic laser treatments of her retina prevented loss of vision. Ms. Brown lived to the age of 88, a success story of the US health care system._\n\n_Angela Martini grew up in an inner-city housing project, never had a chance for a good education, became pregnant as a teenager, and has been on public assistance while caring for her four children. Her Medicaid coverage allows her to see her family physician for yearly physical examinations. A breast examination located a suspicious lesion, which was found to be cancer on biopsy. She was referred to a surgical breast specialist, underwent a mastectomy, was treated with a hormonal medication, and has been healthy for the past 15 years._\n\nFor people with private or public insurance who have access to health care services, the melding of high-quality primary and preventive care with appropriate specialty treatment can produce the best medical care in the world. The United States is blessed with thousands of well-trained physicians, nurses, pharmacists, and other health caregivers who compassionately provide up-to-date medical attention to patients who seek their assistance. This is the face of the health care system in which we can take pride. Success stories, however, are only part of the reality of health care in the United States.\n\n### **EXCESS AND DEPRIVATION**\n\nThe health care system in the United States has been called \"a paradox of excess and deprivation\" (Enthoven and Kronick, 1989). Some persons receive too little care because they are uninsured, inadequately insured, or have Medicaid coverage that many physicians will not accept.\n\n_James Jackson's Medicaid benefits were terminated because of state cutbacks. At age 34, he developed abdominal pain but did not seek care for 10 days because he had no insurance and feared the cost of treatment. He began to vomit, became weak, and was finally taken to an emergency room by his cousin. The physician diagnosed a perforated ulcer with peritonitis and septic shock. The illness had gone on too long; Mr. Jackson died on the operating table. Had he received prompt medical attention, his illness would likely have been cured._\n\n_Betty Yee was a 68-year-old woman with angina, high blood pressure, and diabetes. Her total bill for medications, which were only partly covered under her Medicare plan, came to $200 per month. She was unable to afford the medications, her blood pressure went out of control, and she suffered a stroke. Ms. Yee's final lonely years were spent in a nursing home; she was paralyzed on her right side and unable to speak._\n\n_Mary McCarthy became pregnant but could not find an obstetrician who would accept her Medicaid card. After 7 months, she began to experience severe headaches, went to the emergency room, and was found to have hypertension and preeclampsia. She delivered a stillborn baby._\n\nWhile some people cannot access the care they need, others receive too much care that is costly and may be harmful.\n\n_At age 66, Daniel Taylor noticed that he was getting up to urinate twice each night. It did not bother him much. His family physician sent him to a urologist, who found that his prostate was enlarged (though with no signs of cancer) and recommended surgery. Mr. Taylor did not want surgery. He had a friend with the same symptoms whose urologist had said that surgery was not needed. Since Mr. Taylor never questioned doctors, he went ahead with the procedure anyway. After the surgery he became incontinent of urine._\n\n_Consuelo Gonzalez had a minor pain in her back, which was completely relieved by over-the-counter acetaminophen. She went to the doctor just to make sure the pain was nothing serious, and it was not. The physician gave Ms. Gonzalez a stronger medicine, indomethacin, to take three times a day. The indomethacin caused a bleeding ulcer requiring a 9-day hospital stay at a cost of $27,000 to her health insurer._\n\n#### **Too Little Care**\n\nIn 2009, over 50 million people in the United States had no health insurance. Many are victims of the changing economy, which has shifted from a manufacturing economy based on highly paid full-time jobs with good fringe benefits, toward a service economy with lower-paying jobs that are often part-time and have poor or no benefits (Renner and Navarro, 1989). Three-fourths of uninsured adults are employed. Lack of insurance is not simply a problem of the poor but has also become a middle-class phenomenon, particularly for families of people who are self-employed or work in small establishments. Many people with health insurance have inadequate coverage. In 2007, 45% of adults could not get needed care because they could not afford to pay the bills (Collins et al, 2008).\n\n#### **Too Much Care**\n\nAccording to health services expert Robert Brook (1989):\n\n_...almost every study that has seriously looked for overuse has discovered it, and virtually every time at least double-digit overuse has been found. If one could extrapolate from the available literature, then perhaps one-fourth of hospital days, one-fourth of procedures, and two-fifths of medications could be done without. (Brook, 1989)_\n\nA 1998 report estimated that 20%\u201330% of patients continue to receive care that is not appropriate (Schuster et al, 1998). A 2003 study found that elderly patients in some areas of the country receive 60% more services\u2014hospital days, specialty consultations, and medical procedures\u2014than similar patients in other areas; the patients receiving fewer services had the same mortality rates, quality of care, access to care, and patient satisfaction as those receiving more services (Fisher et al, 2003a and 2003b). In 2009, health care quality expert Brent James estimated that half of all health care dollars are wasted (James, 2009).\n\n### **THE PUBLIC'S VIEW OF THE HEALTH CARE SYSTEM**\n\nHealth care in the United States encompasses a wide spectrum, ranging from the highest-quality, most compassionate treatment of those with complex illnesses, to the turning away of the very ill because of lack of an ability to pay; from well-designed protocols for prevention of illness to inappropriate high-risk surgical procedures performed on uninformed patients. While the past three decades have been witness to major upheavals in health care, one fundamental truth remains: the United States has the least universal, most costly health care system in the industrialized world (Davis et al, 2010).\n\nMany people view the high costs of care and the lack of universal access as indicators of serious failings in the health care system. In 2009, only 15% of people in the United States believed that the system was working well (Blendon et al, 2009). In 2010, 33% of Americans reported not seeing a doctor or not filling a prescription due to costs, a prevalence of access problems considerably higher than that in other developed nations (Schoen et al, 2010).\n\n### **UNDERSTANDING THE CRISIS**\n\nIn order to correct the weaknesses of the health care system while maintaining its strengths, it is necessary to understand how the system works. How is health care financed? What are the causes and consequences of incomplete access to care? How are physicians paid, and what is the effect of their mode of reimbursement on health care costs? How are health care services organized and quality of care enhanced? Is sufficient attention paid to the prevention of illness, and what are different strategies for preventing illness?\n\nHow can the problems of health care be solved? Does the health reform law enacted by Congress in 2010 provide the answer? Can costs be controlled in a manner that does not reduce access? Can access be expanded in a manner that does not increase costs? How have other nations done it\u2014or attempted to do it? How might the health care system in the United States change in the future?\n\n### **REFERENCES**\n\nBlendon RJ et al. The American public and the next phase of the health care debate. _N Engl J Med_. 2009;361:e48.\n\nBrook RH. Practice guidelines and practicing medicine. _JAMA_. 1989;262:3027.\n\nCollins SR et al. _Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families_. New York: Commonwealth Fund; 2008.\n\nDavis K et al. _Mirror, Mirror on the Wall_. New York: Commonwealth Fund; 2010.\n\nEnthoven A, Kronick R. A consumer-choice health plan for the 1990s. _N Engl J Med._ 1989;320:29.\n\nJames BC. A conversation with Brent C James, MD. Health reform debate overlooks physician\u2013patient dynamic. _Managed Care_. December 2009:18(12):31.\n\nFisher ES et al. The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care. _Ann Intern Med_. 2003a;138:273.\n\nFisher ES et al. The implications of regional variations in Medicare spending. Part 2: Health outcomes and satisfaction with care. _Ann Intern Med._ 2003b;138:288.\n\nRenner C, Navarro V. Why is our population of uninsured and underinsured persons growing? The consequences of the \"deindustrialization\" of the United States. _Int J Health Serv_. 1989;19:433.\n\nSchoen C et al. How health insurance design affects access to care and costs, by income, in eleven countries. _Health Aff (Millwood)_. 2010;29:2323.\n\nSchuster M et al. How good is the quality of health care in the United States? _Milbank Q_. 1998;76:517.\n\n## **2 Paying for Health Care**\n\nHealth care is not free. Someone must pay. But how? Does each person pay when receiving care? Do people contribute regular amounts in advance so that their care will be paid for when they need it? When a person contributes in advance, might the contribution be used for care given to someone else? If so, who should pay how much?\n\nHealth care financing in the United States evolved to its current state through a series of social interventions. Each intervention solved a problem but in turn created its own problems requiring further intervention. This chapter will discuss the historical process of the evolution of health care financing.\n\n### **MODES OF PAYING FOR HEALTH CARE**\n\nThe four basic modes of paying for health care are out-of-pocket payment, individual private insurance, employment-based group private insurance, and government financing (Table 2\u20131). These four modes can be viewed both as a historical progression and as a categorization of current health care financing.\n\n**Table 2\u20131.** Health care financing in 2009 _a_\n\n#### **Out-of-Pocket Payments**\n\n_Fred Farmer broke his leg in 1911. His son ran 4 miles to get the doctor, who came to the farm to splint the leg. Fred gave the doctor a couple of chickens to pay for the visit. His great-grandson, Ted, who is uninsured, broke his leg in 2011. He was driven to the emergency room, where the physician ordered an x-ray and called in an orthopedist who placed a cast on the leg. The cost was $1800._\n\nOne hundred years ago, people like Fred Farmer paid physicians and other health care practitioners in cash or through barter. In the first half of the twentieth century, out-of-pocket cash payment was the most common method of reimbursement. This is the simplest mode of financing\u2014direct purchase by the consumer of goods and services (Figure 2\u20131).\n\n**Figure 2\u20131.** Out-of-pocket payment is made directly from patient to provider.\n\nPeople in the United States purchase most consumer items, from DVD players to haircuts, through direct out-of-pocket payments. This is not the case with health care (Arrow, 1991; Evans, 1984), and one may ask why health care is not considered a typical consumer item.\n\n##### **Need versus Luxury**\n\nWhereas a DVD player is considered a luxury, health care is regarded as a basic human need by most people.\n\n_For 2 weeks, Marina Perez has had vaginal bleeding and has felt dizzy. She has no insurance and is terrified that medical care might eat up her $500 in savings. She scrapes together $100 to see her doctor, who finds that her blood pressure falls to 90\/50 mm Hg upon standing and that her hematocrit is 26%. The doctor calls Marina's sister Juanita to drive her to the hospital. Marina gets into the car and tells Juanita to take her home._\n\nIf health care is a basic human right, then people who are unable to afford health care must have a payment mechanism available that is not reliant on out-of-pocket payments.\n\n##### **Unpredictability of Need and Cost**\n\nWhereas the purchase of a DVD player is a matter of choice and the price is known to the buyer, the need for and cost of health care services are unpredictable. Most people do not know if or when they may become severely ill or injured or what the cost of care will be.\n\n_Jake has a headache and visits the doctor, but he does not know whether the headache will cost $100 for a physician visit plus the price of a bottle of ibuprofen, $1000 for an MRI, or $100,000 for surgery and irradiation for brain cancer._\n\nThe unpredictability of many health care needs makes it difficult to plan for these expenses. The medical costs associated with serious illness or injury usually exceed a middle-class family's savings.\n\n##### **Patients Need to Rely on Physician Recommendations**\n\nUnlike the purchaser of a DVD player, a person in need of health care may have little knowledge of what he or she is buying at the time when care is needed.\n\n_Jenny develops acute abdominal pain and goes to the hospital to purchase a remedy for her pain. The physician tells her that she has acute cholecystitis or a perforated ulcer and recommends hospitalization, an abdominal CT scan, and upper endoscopic studies. Will Jenny, lying on a gurney in the emergency room and clutching her abdomen with one hand, use her other hand to leaf through a textbook of internal medicine to determine whether she really needs these services, and should she have brought along a copy of Consumer Reports to learn where to purchase them at the cheapest price?_\n\nHealth care is the foremost example of asymmetry of information between providers and consumers (Evans, 1984). A patient with abdominal pain is in a poor position to question a physician who is ordering laboratory tests, x-rays, or surgery. When health care is elective, patients can weigh the pros and cons of different treatment options, but even so, recommendations may be filtered through the biases of the physician providing the information. Compared with the voluntary demand for DVD players (the influence of advertising notwithstanding) the demand for health services is partially involuntary and is often physician-rather than consumer-driven.\n\nFor these reasons among others, out-of-pocket payments are flawed as a dominant method of paying for health care services. Because the direct purchase of health services became increasingly difficult for consumers and was not meeting the needs of hospitals and physicians to be reliably paid, health insurance came into being.\n\n#### **Individual Private Insurance**\n\n_Bud Carpenter is self-employed. He recently purchased a health insurance policy from his insurance broker for his family. To pay the $500 monthly premium, he had to work some extra jobs on weekends, and the $2500 deductible meant he would still have to pay quite a bit of his family's medical costs out of pocket. Mr. Carpenter preferred to pay these costs rather than take the risk of spending the money saved for his children's college education on a major illness. When his son became ill with leukemia and the hospital bill reached $80,000, Mr. Carpenter appreciated the value of health insurance. Nonetheless he had to feel disgruntled when he read a newspaper story listing his insurance company among those that paid out on average less than 60 cents for health services for every dollar collected in premiums._\n\nWith private health insurance, a third party, the insurer, is added to the patient and the health care provider, who are the two basic parties of the health care transaction. While the out-of-pocket mode of payment is limited to a single financial transaction, private insurance requires two transactions\u2014a premium payment from the individual to an insurance plan (also called a health plan), and a reimbursement payment from the insurance plan to the provider (Figure 2\u20132). In nineteenth-century Europe, voluntary benefit funds were set up by guilds, industries, and mutual societies. In return for paying a monthly sum, people received assistance in case of illness. This early form of private health insurance was slow to develop in the United States. In the early twentieth century, European immigrants set up some small benevolent societies in US cities to provide sickness benefits for their members. During the same period, two commercial insurance companies, Metropolitan Life and Prudential, collected 10\u201325 cents per week from workers for life insurance policies that also paid for funerals and the expenses of a final illness. The policies were paid for by individuals on a weekly basis, so large numbers of insurance agents had to visit their clients to collect the premiums as soon after payday as possible. Because of the huge administrative costs, individual health insurance never became a dominant method of paying for health care (Starr, 1982). In 2009, individual policies provided health insurance for only 5% of the US population (see Table 2\u20131).\n\n**Figure 2\u20142.** Individual private insurance. A third party, the insurance plan (health plan), is added, dividing payment into a financing component and a reimbursement component.\n\n#### **Employment-Based Private Insurance**\n\n_Betty Lerner and her schoolteacher colleagues each paid $6 per year to Prepaid Hospital in 1929. Ms. Lerner suffered a heart attack and was hospitalized at no cost. The following year Prepaid Hospital built a new wing and raised the teachers' prepayment to $12._\n\n_Rose Riveter retired in 1961. Her health insurance premium for hospital and physician care, formerly paid by her employer, had been $25 per month. When she called the insurance company to obtain individual coverage, she was told that premiums at age 65 cost $70 per month. She could not afford the insurance and wondered what would happen if she became ill._\n\nThe development of private health insurance in the United States was impelled by the increasing effectiveness and rising costs of hospital care. Hospitals became places not only in which to die, but also in which to get well. However, many patients were unable to pay for hospital care, and this meant that hospitals were unable to attract \"customers.\"\n\nIn 1929, Baylor University Hospital agreed to provide up to 21 days of hospital care to 1500 Dallas school-teachers such as Betty Lerner if they paid the hospital $6 per person per year. As the Great Depression deepened and private hospital occupancy in 1931 fell to 62%, similar hospital-centered private insurance plans spread. These plans (anticipating health maintenance organizations [HMOs]) restricted care to a particular hospital. The American Hospital Association built on this prepayment movement and established statewide Blue Cross hospital insurance plans allowing free choice of hospital. By 1940, 39 Blue Cross plans controlled by the private hospital industry had enrolled over 6 million people. The Great Depression reduced the amount patients could pay physicians out of pocket, and in 1939, the California Medical Association set up the first Blue Shield plan to cover physician services. These plans, controlled by state medical societies, followed Blue Cross in spreading across the nation (Starr, 1982; Fein, 1986).\n\nIn contrast to the consumer-driven development of health insurance in European nations, coverage in the United States was initiated by health care providers seeking a steady source of income. Hospital and physician control over the \"Blues,\" a major sector of the health insurance industry, guaranteed that reimbursement would be generous and that cost control would remain on the back burner (Law, 1974; Starr, 1982).\n\nThe rapid growth of employment-based private insurance was spurred by an accident of history. During World War II, wage and price controls prevented companies from granting wage increases, but allowed the growth of fringe benefits. With a labor shortage, companies competing for workers began to offer health insurance to employees such as Rose Riveter as a fringe benefit. After the war, unions picked up on this trend and negotiated for health benefits. The results were dramatic: Enrollment in group hospital insurance plans grew from 12 million in 1940 to 142 million in 1988.\n\nWith employment-based health insurance, employers usually pay most of the premium that purchases health insurance for their employees (Figure 2\u20133). However, this flow of money is not as simple as it looks. The federal government views employer premium payments as a tax-deductible business expense. The government does not treat the health insurance fringe benefit as taxable income to the employee, even though the payment of premiums could be interpreted as a form of employee income. Because each premium dollar of employer-sponsored health insurance results in a reduction in taxes collected, the government is in essence subsidizing employer-sponsored health insurance. This subsidy is enormous, estimated at $260 billion per year (Gruber, 2010).\n\n**Figure 2\u20133.** Employment-based private insurance. In addition to the direct employer subsidy, indirect government subsidies occur through the tax-free status of employer contributions for health insurance benefits.\n\nThe growth of employment-based health insurance attracted commercial insurance companies to the health care field to compete with the Blues for customers. The commercial insurers changed the entire dynamic of health insurance. The new dynamic was called **experience rating.** (The following discussion of experience rating can be applied to individual as well as employment-based private insurance.)\n\n_Healthy Insurance Company insures three groups of people\u2014a young healthy group of bank managers, an older healthy group of truck drivers, and an older group of coal miners with a high rate of chronic illness. Under experience rating, Healthy sets its premiums according to the experience of each group in using health services. Because the bank managers rarely use health care, each pays a premium of $200 per month. Because the truck drivers are older, their risk of illness is higher, and their premium is $400 per month. The miners, who have high rates of black lung disease, are charged a premium of $600 per month. The average premium income to Healthy is $400 per member per month._\n\n_Blue Cross insures the same three groups and needs the same $400 per member per month to cover health care plus administrative costs for these groups. Blue Cross sets its premiums by the principle of community rating. For a given health insurance policy, all subscribers in a community pay the same premium. The bank managers, truck drivers, and mine workers all pay $400 per month._\n\nHealth insurance provides a mechanism to distribute health care more in accordance with human need rather than exclusively on the basis of ability to pay. To achieve this goal, funds are redistributed from the healthy to the sick, a subsidy that helps pay the costs of those unable to purchase services on their own.\n\n**Community rating** achieves this redistribution in two ways:\n\n1. Within each group (bank managers, truck drivers, and mine workers), people who become ill receive benefits in excess of the premiums they pay, while people who remain healthy pay premiums while receiving few or no health benefits.\n\n2. Among the three groups, the bank managers, who use less health care than their premiums are worth, help pay for the miners, who use more health care than their premiums could buy.\n\nExperience rating is far less redistributive than community rating. Within each group, those who become ill are subsidized by those who remain well, but among the different groups, healthier groups (bank managers) do not subsidize high-risk groups (mine workers). Thus the principle of health insurance, which is to distribute health care more in accordance with human need rather than exclusively on the ability to pay, is weakened by experience rating (Light, 1992).\n\nIn the early years, Blue Cross plans set insurance premiums by the principle of community rating, whereas commercial insurers used experience rating as a \"weapon\" to compete with the Blues (Fein, 1986). Commercial insurers such as Healthy Insurance Company could offer cheaper premiums to low-risk groups such as bank managers, who would naturally choose a Healthy commercial plan at $200 over a Blue Cross plan at $400. Experience rating helped commercial insurers overtake the Blues in the private health insurance market. While in 1945 commercial insurers had only 10 million enrollees, compared with 19 million for the Blues, by 1955 the score was commercials 54 million and the Blues 51 million.\n\nMany commercial insurers would not market policies to such high-risk groups as mine workers, leaving Blue Cross with high-risk patients who were paying relatively low premiums. To survive the competition from the commercial insurers, Blue Cross had no choice but to seek younger, healthier groups by abandoning community rating and reducing the premiums for those groups. In this way, many Blue Cross and Blue Shield plans switched to experience rating. Without community rating, older and sicker groups became less and less able to afford health insurance.\n\nFrom the perspective of the elderly and those with chronic illness, experience rating is discriminatory. Healthy persons, however, might have another viewpoint on the situation and might ask why they should voluntarily transfer their wealth to sicker people through the insurance subsidy. The answer lies in the unpredictability of health care needs. When purchasing health insurance, an individual does not know if he or she will suddenly change from a state of good health to one of illness. Thus, _within a group,_ people are willing to risk paying for health insurance, even though they may not use it. _Among different groups,_ however, healthy people have no economic incentive to voluntarily pay for community rating and subsidize another group of sicker people. This is why community rating cannot survive in a market-driven competitive private insurance system (Aaron, 1991).\n\nThe most positive aspect of health insurance\u2014that it assists people with serious illness to pay for their care\u2014has also become one of its main drawbacks\u2014the difficulty in controlling costs in an insurance environment. With direct purchase, the \"invisible hand\" of each individual's ability to pay holds down the price and quantity of health care. However, if a patient is well insured and the cost of care causes no immediate fiscal pain, the patient will use more services than someone who must pay for care out of pocket. In addition, particularly before the advent of fee schedules, health care providers could increase fees more easily if a third party was available to foot the bill.\n\nThus health insurance was originally an attempt by society to solve the problem of unaffordable health care under an out-of-pocket payment system, but its very capacity to make health care more affordable created a new problem. If people no longer had to pay out of their own pockets for health care, they would use more health care; and if health care providers could charge insurers rather than patients, they could more easily raise prices, especially during the era when the major insurers (the Blues) were controlled by hospitals and physicians. The solution of insurance fueled the problem of rising costs. As private insurance became largely experience rated and employment based, persons who had low incomes, who were chronically ill, or who were elderly found it increasingly difficult to afford private insurance.\n\n#### **Government Financing**\n\n_In 1984 at age 74 Rose Riveter developed colon cancer. She was now covered by Medicare, which had been enacted in 1965. Even so, her Medicare premium, hospital deductible expenses, physician copayments, short nursing home stay, and uncovered prescriptions cost her $2700 the year she became ill with cancer._\n\nEmployment-based private health insurance grew rapidly in the 1950s, helping working people and their families to afford health care. But two groups in the population received little or no benefit: the poor and the elderly. The poor were usually unemployed or employed in jobs without the fringe benefit of health insurance; they could not afford insurance premiums. The elderly, who needed health care the most and whose premiums had been partially subsidized by community rating, were hard hit by the trend toward experience rating. In the late 1950s, less than 15% of the elderly had any health insurance (Harris, 1966). Only one program could provide affordable care for the poor and the elderly: tax-financed government health insurance.\n\nGovernment entered the health care financing arena long before the 1960s through such public programs as municipal hospitals and dispensaries to care for the poor and through state-operated mental hospitals. But only with the 1965 enactment of Medicare (for the elderly) and Medicaid (for the poor) did public insurance payments for privately operated health services become a major feature of health care in the United States. Medicare Part A (Table 2\u20132) is a hospital insurance plan for the elderly financed largely through social security taxes from employers and employees. Medicare Part B (Table 2\u20133) insures the elderly for physician services and is paid for by federal taxes and monthly premiums from the beneficiaries. Medicare Part D, enacted in 2003, offers prescription drug coverage and is paid for by federal taxes and monthly premiums from beneficiaries. Medicaid (Table 2\u20134) is a program run by the states that is funded by federal and state taxes, which pays for the care of certain low-income groups. In 2009, Medicare and Medicaid expenditures totaled $502 and $374 billion, respectively (Martin et al, 2011).\n\n**Table 2\u20132.** Summary of Medicare Part A, 2011\n\n**Table 2\u20133.** Summary of Medicare Part B, 2011\n\n**Table 2\u20134.** Summary of Medicaid, 2011\n\nWith its large deductibles, copayments, and gaps in coverage, Medicare paid for only 48% of the average beneficiary's health care expenses in 2006 (Kaiser Family Foundation, 2010a). Most of the 47 million Medicare beneficiaries (2010) have supplemental coverage. In 2010, nearly 30% of beneficiaries had additional coverage from their previous employment, about 20% purchased supplemental private insurance (called \"Medigap\" plans), 24% were enrolled in the Medicare Advantage program, and 19% were enrolled in both Medicare and Medicaid (Kaiser Family Foundation, 2010b).\n\nThe Medicare Modernization Act (MMA) of 2003 made two major changes in the Medicare program: the expansion of the role of private health plans (the Medicare Advantage program, Part C) and the establishment of a prescription drug benefit (Part D). Under the Medicare Advantage program, a beneficiary can elect to enroll in a private health plan contracting with Medicare, with Medicare subsidizing the premium for that private health plan rather than paying hospitals, physicians, and other providers directly as under Medicare Parts A and B. Beneficiaries joining a Medicare Advantage plan sacrifice some degree of freedom of choice of physician and hospital in return for lower out-of-pocket payments and are only allowed to receive care from health care providers who are connected with that plan. Two-thirds of Medicare Advantage plans are health maintenance organizations (HMOs) (see Chapter 6). In order to channel more patients into Medicare Advantage plans, the MMA provided generous payments to those plans, with the result that they cost the federal government 14% more than the government paid for health care services for similar Medicare beneficiaries in the traditional Part A and Part B programs. The 2010 health care reform law passed by the Obama Administration (the Accountable Care Act) reduced payments to Medicare Advantage plans with the goal of saving the Medicare program $136 billion over the following 10 years (Kaiser Family Foundation, 2010c).\n\nMedicare Part D provides partial coverage for prescription drugs. In 2010, 82% of Part D was financed through tax revenues, with 10% coming from beneficiary premiums (Kaiser Family Foundation, 2010a). As of 2010, 59% of Medicare beneficiaries had enrolled in the voluntary Medicare Part D program. Part D has been criticized because (1) there are major gaps in coverage, (2) coverage has been farmed out to private insurance companies rather than administered by the federal Medicare program, and (3) the government is not allowed to negotiate with pharmaceutical companies for lower drug prices. These 3 features of the program have caused confusion for beneficiaries, physicians, and pharmacists and a high cost for the program. Beneficiaries desiring Medicare Part D can enroll in one of 1500 stand-alone private prescription drug plans or receive their Part D coverage through a Medicare Advantage plan. Different plans cover different medications and require different premiums, deductibles, and coinsurance payments. The standard plan in 2010 had a $310 yearly deductible and 25% coinsurance up to an initial coverage limit of $2830 in total drug costs, after which coverage stops until the beneficiary has spent $4550 out of pocket (excluding premiums) for prescription drugs. Above $4550, coverage resumes with 5% coinsurance. The coverage gap, called the \"donut hole,\" becomes a major problem for patients with chronic illness needing several medications. The Accountable Care Act of 2010 gradually reduces the amounts beneficiaries must pay in the donut hole.\n\nIn 2009, the trustees of the Medicare program estimated that the Part A trust fund would be depleted by 2017. The Accountable Care Act, by raising social security payments and reducing expenditures, has extended Medicare's solvency through 2029.\n\nThe Medicaid program (Table 2\u20134) is jointly administered by the federal and state governments. Although designed for low-income Americans, not all poor people are eligible for Medicaid. In addition to being poor, Medicaid has required that people also meet \"categorical\" eligibility criteria such as being a young child, pregnant, elderly, or disabled. Medicaid enrollment is growing dramatically, increasing from 32 million to 58 million people between 2000 and 2010 (9 million of whom are \"dual eligibles\" receiving both Medicare and Medicaid). The Accountable Care Act includes a huge expansion of Medicaid starting in 2014, eliminating the categorical eligibility criteria and offering the program to all citizens and legal residents with family income below 133% of the federal poverty line. The additional 16 million people on Medicaid will be financed largely by the federal government at a cost of over $40 billion per year in new dollars (see Chapter 15).\n\nFrom 2000 to 2010, Medicaid expenditures rose from $200 billion to $374 billion. To slow down this expenditure growth, the federal government ceded to states enhanced control over Medicaid programs through Medicaid waivers, which allow states to reduce the number of people eligible for Medicaid, make alterations in the scope of covered services, require Medicaid recipients to pay part of their costs, and obligate Medicaid recipients to enroll in managed care plans (see Chapter 4). In 2010, over half of Medicaid recipients were enrolled in managed care plans. Because Medicaid pays physicians an average of 72% of Medicare fees, the majority of adult primary care physicians limit the number of Medicaid patients they will see; these patients are increasingly concentrated in academic health centers and community health centers.\n\nIn 1997, the federal government created the State Children's Health Insurance Program (SCHIP), a companion program to Medicaid. SCHIP covers children in families with incomes at or below 200% of the federal poverty level, but above the Medicaid income eligibility level. States legislating a SCHIP program receive generous federal matching funds and can administer SCHIP through Medicaid or by creating a separate program. In 2009, almost 8 million children were enrolled in the program.\n\nGovernment health insurance for the poor and the elderly added a new factor to the health care financing equation: the taxpayer (Figure 2\u20134). With government-financed health plans, the taxpayer can interact with the health care consumer in two distinct ways:\n\n**Figure 2\u20134.** Government-financed insurance. Under the social insurance model (eg, Medicare Part A), only individuals paying taxes into the public plan are eligible for benefits. In other models (eg, Medicaid), an individual's eligibility for benefits may not be directly linked to payment of taxes into the plan.\n\n1. The social insurance model, exemplified by Medicare, allows only those who have paid a certain amount of social security taxes to be eligible for Part A and only those who pay a monthly premium to receive benefits from Part B. As with private insurance, social insurance requires people to make a contribution in order to receive benefits.\n\n2. The contrasting model is the Medicaid public assistance model, in which those who contribute (taxpayers) may not be eligible for benefits (Bodenheimer and Grumbach, 1992).\n\nIt must be remembered that private insurance contains a subsidy: redistribution of funds from the healthy to the sick. Tax-funded insurance has the same subsidy and usually adds another: redistribution of funds from upper- to lower-income groups. Under this double subsidy, exemplified by Medicare and Medicaid, healthy middle-income employees generally pay more in social security payments and other taxes than they receive in health services, whereas unemployed, disabled, and lower-income elderly persons tend to receive more in health services than they contribute in taxes.\n\nThe advent of government financing improved financial access to care for some people, but, in turn, aggravated the problem of rising costs. The federal government and state governments have responded by attempting to limit Medicare and Medicaid payments to physicians and hospitals. At the same time, the rising costs of private insurance continue to place employment-based coverage out of the fiscal reach of many employers and employees.\n\n### **THE BURDEN OF FINANCING HEALTH CARE**\n\nDifferent methods of financing health care place different burdens on the various income levels of society. Payments are classified as **progressive** if they take a rising percentage of income as income increases, **regressive** if they take a falling percentage of income as income increases, and **proportional** if the ratio of payment to income is the same for all income classes (Pechman, 1985).\n\nWhat principle should underlie the choice of revenue source for health care? A central purpose of the health care system is to maintain and improve the health of the nation's population. As discussed in Chapter 3, rates of mortality and disability are far higher for low-income people than for the wealthy. Burdening low-income families with high levels of payments for health care (ie, regressive payments) reduces their disposable income, amplifies the ill effects of poverty, and thereby worsens their health. It makes little sense to finance a health care system\u2014whose purpose is to improve health\u2014with payments that worsen health. Thus, regressive payments could be considered \"unhealthy.\"\n\n_Rita Blue earns $10,000 per year for her family of 4. She develops pneumonia, and her out-of-pocket health costs come to $1000, 10% of her family income._\n\n_Cathy White earns $100,000 per year for her family of 4. She develops pneumonia, and her out-of-pocket health costs come to $1000, 1% of her family income._\n\nOut-of-pocket payments are a regressive mode of financing. According to the 1987 National Medical Care Expenditure Survey, out-of-pocket payments took 12% of the income of families in the nation's lowest-income quintile, compared with 1.2% for families in the wealthiest 5% of the population (Bodenheimer and Sullivan, 1997). This pattern is confirmed by the 2000 Medical Expenditure Panel Survey (MEPS, 2003). Many economists and health policy experts would consider this regressive burden of payment as unfair. Aggravating the regressivity of out-of-pocket payments is the fact that lower-income people tend to be sicker and thus have more out-of-pocket payments than the wealthier and healthier.\n\n_Jim Hale is a young, healthy, self-employed accountant whose monthly income is $6000, with a health insurance premium of $200, or 3% of his income._\n\n_Jack Hurt is a disabled mine worker with black lung disease. His income is $1800 per month, of which $400 (22%) goes for his health insurance._\n\nExperience-rated private health insurance is a regressive method of financing health care because increased risk of illness tends to correlate with reduced income. If Jim Hale and Jack Hurt were enrolled in a community-rated plan, each with a premium of $300, they would respectively pay 5% and 17% of their incomes for health insurance. With community rating, the burden of payment is regressive, but less so than with experience rating.\n\nMost private insurance is not individually purchased but rather obtained through employment. How is the burden of employment-linked health insurance premiums distributed?\n\n_Jill is an assistant hospital administrator. To attract her to the job, the hospital offered her a package of salary plus health insurance of $6500 per month. She chose to take $6200 in salary, leaving the hospital to pay $300 for her health insurance._\n\n_Bill is a nurse's aide, whose union negotiated with the hospital for a total package of $2800 per month; of this amount $2500 is salary and $300 pays his health insurance premium._\n\nDo Jill and Bill pay nothing for their health insurance? Not exactly. Employers generally agree on a total package of wages and fringe benefits; if Jill and Bill did not receive health insurance, their pay would probably go up by nearly $300 per month. That is why employer-paid health insurance premiums are generally considered deductions from wages or salary, and thus paid by the employee (Blumberg et al, 2007). For Jill, health insurance amounts to only 5% of her income, but for Bill it is 12%. The MEPS corroborates the regressivity of employment-based health insurance; in 2001\u20132003, premiums took an average of 10.9% of the income of families in between 100% and 200% of the federal poverty line compared with 2.3% for those above 500% of poverty (Blumberg et al, 2007).\n\n_Larry Lowe earns $10,000 and pays $410 in federal and state income taxes, or 4.1% of his income._\n\n_Harold High earns $100,000 and pays $12,900 in income taxes, or 12.9% of his income._\n\nThe progressive income tax is the largest tax providing money for government-financed health care. Most other taxes are regressive (eg, sales and property taxes), and the combined burden of all taxes that finance health care is roughly proportional (Pechman, 1985).\n\nIn 2009, 46% of health care expenditures were financed through out-of-pocket payments and premiums, which are regressive, while 47% was funded through government revenues (Martin et al, 2011), which are proportional. The sum total of health care financing is regressive. In 1999, the poorest quintile of households spent 18% of income on health care, while the highest-income quintile spent only 3% (Cowan et al, 2002). Overall, the US health care system is financed in a manner that is unhealthy.\n\n### **CONCLUSION**\n\nNeither Fred Farmer nor his great-grandson Ted had health insurance, but the modern-day Mr. Farmer's predicament differs drastically from that of his ancestor. Third-party financing of health care has fueled an expansive health care system that offers treatments unimaginable a century ago, but at tremendous expense.\n\nEach of the four modes of financing health care developed historically as a solution to the inadequacy of the previous modes. Private insurance provided protection to patients against the unpredictable costs of medical care, as well as protection to providers of care against the unpredictable ability of patients to pay. But the private insurance solution created three new, interrelated problems:\n\n1. The opportunity for health care providers to increase fees to insurers caused health services to become increasingly unaffordable for those with inadequate insurance or no insurance.\n\n2. The employment-based nature of group insurance placed people who were unemployed, retired, or working part-time at a disadvantage for the purchase of insurance, and partially masked the true costs of insurance for employees who did receive health benefits at the workplace.\n\n3. Competition inherent in a deregulated private insurance market gave rise to the practice of experience rating, which made insurance premiums unaffordable for many elderly people and other medically needy groups.\n\nTo solve these problems, government financing was required, but government financing fueled an even greater inflation in health care costs.\n\nAs each \"solution\" was introduced, health care financing improved for a time. But rising costs have jeopardized private and public coverage for many people and made services unaffordable for those without a source of third-party payment. The problems of each financing mode, and the problems created by each successive solution, have accumulated into a complex crisis characterized by inadequate access for some and high costs for everyone.\n\n### **REFERENCES**\n\nAaron HJ. _Serious and Unstable Condition: Financing America's Health Care_. Washington, DC: Brookings Institution; 1991.\n\nArrow KJ. Uncertainty and the welfare economics of medical care. _Am Econ Rev_. 1963;53:941.\n\nBlumberg LJ et al. Setting a standard of affordability for health insurance coverage. _Health Affairs_. 2007;26:w463-w473.\n\nBodenheimer T, Grumbach K. Financing universal health insurance: Taxes, premiums, and the lessons of social insurance. _J Health Polit Policy Law_. 1992;17:439.\n\nBodenheimer T, Sullivan K. The logic of tax-based financing for health care. _Int J Health Services_. 1997;27:409.\n\nCowan CA et al. Burden of health care costs: Businesses, households, and governments, 1987\u20132000. _Health Care Financ Rev_. 2002;23:131.\n\nEvans RG. _Strained Mercy_. Toronto, Ontario, Canada: Butterworths; 1984.\n\nFein R. _Medical Care, Medical Costs_. Cambridge, MA: Harvard University Press; 1986.\n\nGruber J. The tax exclusion for employer-sponsored health insurance. _National Bureau of Economic Research_ ; February 2010. www.nber.org\/papers\/w15766. Accessed November 11, 2011.\n\nHarris R. _A Sacred Trust_. New York, NY: New American Library; 1966.\n\nKaiser Family Foundation. Medicare Spending and Financing. 2010a. www.kff.org. Accessed August 3, 2011.\n\nKaiser Family Foundation. Medicare at a Glance. 2010b. www.kff.org. Accessed August 3, 2011.\n\nKaiser Family Foundation. Medicare Advantage 2010 Data Spotlight. 2010c. www.kff.org. Accessed August 3, 2011.\n\nKaiser Family Foundation. The Medicaid Program at a Glance. 2010d. www.kff.org. Accessed August 3, 2011.\n\nLaw SA. _Blue Cross: What Went Wrong?_ New Haven, CT: Yale University Press; 1974.\n\nLight DW. The practice and ethics of risk-rated health insurance. _JAMA_. 1992;267:2503.\n\nMartin A et al. Recession contributes to slowest annual rate of increase in health spending in five decades. _Health Affairs_. 2011;30:11.\n\nMedical Expenditure Panel Survey. Health insurance coverage of the civilian non-institutionalized population, first half of 2002. Agency for Healthcare Research and Quality, June 2003. www.meps.ahrq.gov. Accessed November 11, 2011.\n\nPechman JA. _Who Paid the Taxes, 1966\u20131985_. Washington, DC: Brookings Institution; 1985.\n\nStarr P. _The Social Transformation of American Medicine_. New York, NY: Basic Books; 1982.\n\n## **3 Access to Health Care**\n\nAccess to health care is the ability to obtain health services when needed. Lack of adequate access for millions of people is a crisis in the United States.\n\nAccess to health care has two major components. First and most frequently discussed is ability to pay. Second is the availability of health care personnel and facilities that are close to where people live, accessible by transportation, culturally acceptable, and capable of providing appropriate care in a timely manner and in a language spoken by those who need assistance. The first and longest portion of this chapter dwells on financial barriers to care. The second portion touches on nonfinancial barriers. The final segment explores the influences other than health care (in particular, socioeconomic status and race) that are important determinants of the health status of a population.\n\n### **FINANCIAL BARRIERS TO HEALTH CARE**\n\n#### **Lack of Insurance**\n\n_Ernestine Newsome was born into a low-income working family living in South Central Los Angeles. As a young child, she rarely saw a physician and was behind on her childhood immunizations. When Ernestine was 7 years old, her mother began working for the telephone company, and this provided the family with health insurance. Ernestine went to a neighborhood physician for regular checkups. When she reached 19, she left home and began work as a part-time secretary. She was no longer eligible for her family's health insurance coverage, and her new job did not provide insurance. She has not seen a physician since starting her job._\n\nHealth insurance coverage, whether public or private, is a key factor in making health care accessible. In 1980, 25 million people were uninsured, but by 2009 the number had increased to 51 million (Table 3\u20131 and Figure 3\u20131) (US Census Bureau, 2010). The particular pattern of uninsurance is related to the employment-based nature of health care financing. Most people, like Ernestine Newsome, obtain health insurance when employers voluntarily decide to offer group coverage to employees and their families and their employers help pay for the costs of health insurance. People whose employers choose not to provide health insurance, are self-employed, or are unemployed are left to fend for themselves outside of the employer-sponsored group health insurance market, with the result that many are uninsured. Often people without employment-based insurance are not eligible for public programs such as Medicare and Medicaid, and are unable to purchase individual private coverage because they cannot afford the premiums.\n\n**Table 3\u20131.** Estimated principal source of health insurance, 2009\n\n**Figure 3\u20131.** Number of uninsured persons in the United States, 1980 to 2009 (US Census Bureau, 2010).\n\nBetween the 1930s and mid-1970s, because of the growth of private health insurance and the 1965 passage of Medicare and Medicaid, the number of uninsured persons declined steadily, but since 1976, the number has been growing. The single most important factor explaining the growing number of uninsured is a 25-year trend of decreasing private insurance coverage in the United States. Virtually all people aged 65 and older are covered by Medicare, and the number of people enrolled in Medicaid has increased. However, a dwindling proportion of children and working age adults are covered by private insurance, exposing the limitations of the employment-linked system of private insurance in the United States. If the 2010 health care reform law, the Accountable Care Act, is fully implemented, the number of uninsured people is expected to drop from 51 million to 22 million (Buettgens et al, 2010).\n\n##### **Why People Lack Insurance?**\n\n_Joe Fortuno dropped out of high school and went to work for Car Doctor auto body shop in 2003. His employer paid the full cost of health insurance forJoe and his family. Joe's younger cousin Pete Luckless got a job working at an auto mechanic shop in 2005. The company did not offer health insurance benefits. In 2008, Car Doctor, after experiencing a doubling of health insurance premium rates over the prior few years, began requiring that its employees pay $150 per month for the employer-sponsored health plan. Joe could not afford the monthly payments and lost his health insurance._\n\nWhy has private health insurance coverage decreased over the past decades, creating the uninsurance crisis? There are several explanations:\n\n1. The skyrocketing cost of health insurance has made coverage unaffordable for many businesses and individuals. From 2000 to 2010, employer-sponsored health insurance premiums rose by 114%. In 2010, the average annual cost of health insurance, including employer and employee contributions, was $5049 for individuals and $13,770 for families (Claxton et al, 2010). Some employers responded to rising health insurance costs by dropping insurance policies for their workers. Many employers have shifted more of the cost of health insurance premiums and health services onto their employees, resulting in employees dropping health coverage because of unaffordability. On average, employee contributions represent 19% of the premium for individual employee coverage and 30% for family coverage, though some employees have to pay more than half of the premium for family coverage (Claxton et al, 2010). Low-income workers are hit especially hard by the combination of rising insurance costs and declining employer subsidies.\n\n_Jean Irons worked for Bethlehem Steel as a clerk and her fringe benefits included health insurance. Bethlehem Steel was bought by a global corporation and her plant moved to another country. She found a job as a food service worker in a small restaurant. Her pay decreased by 35%, and the restaurant did not provide health insurance._\n\n2. During the past few decades, the economy in the United States has undergone a major transition. The number of highly paid, largely unionized, full-time manufacturing workers with employer-sponsored health insurance has declined, and the workforce has shifted toward more low-wage, increasingly part-time, nonunionized service, and clerical workers whose employers are less likely to provide insurance (Renner and Navarro, 1989). Between 1980 and 2006, the number of workers in the manufacturing sector decreased by 30% while the number working in the service sector increased by 75%. From 1957 to 2000, the percentage of workers with part-time jobs\u2014generally without health benefits\u2014increased from 12% to 21%.\n\nThese two factors\u2014increasing health care costs and a changing labor force\u2014eroded private insurance coverage. One countervailing trend has been a major expansion of public insurance coverage through the Medicaid and State Children's Health Insurance Program (SCHIP) programs. Without these changes, many more millions of Americans would currently be uninsured.\n\n_Sally Lewis worked as a receptionist in a physician's office. She received health insurance through her husband, who was a construction worker. They got divorced, she lost her health insurance, and her physician employer told her he could not provide her with health insurance because of the cost._\n\n3. The link of private insurance with employment inevitably produces interruptions in coverage because of the unstable nature of employment. People who are laid off from their jobs or who leave jobs because of illness may also lose their insurance. Family members insured through the workplace of a spouse may lose their insurance in cases of divorce, job loss, or death of the working family member. People who leave their employment may be eligible to pay for continued coverage under their group plan for 18 months, as stipulated in the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), with the requirement that they pay the full cost of the premium; however, many people cannot afford the premiums, which may exceed $1000 per month for a family.\n\nThe often transient nature of employment-linked insurance is compounded by difficulties in maintaining eligibility for Medicaid. Small increases in family income can mean that families no longer qualify for Medicaid. The net result is that millions of people cycle in and out of the ranks of the uninsured every month. A total of 87 million people, 29% of the entire US population, went without health insurance for all or part of the 2-year period 2007\u20132008 (Families USA, 2009). Health insurance may be a fleeting benefit.\n\n##### **Who Are the Uninsured?**\n\nIn 2009, 12% of non-Hispanic whites were uninsured, compared with 21% of African Americans, 17% of Asians, and 32% of Latinos (Figure 3\u20132). Twenty-seven percent of individuals with annual household incomes less than $25,000 were uninsured, compared with 9% of individuals with household incomes of $75,000 or more (Figure 3\u20133) (US Census Bureau, 2010).\n\n**Figure 3\u20132.** Percentage of population lacking health insurance by race and ethnicity in 2009 (US Census Bureau, 2010).\n\n**Figure 3\u20133.** Lack of insurance by income in 2009 (US Census Bureau, 2010).\n\n_Morris works for a corner grocery store that employs five people. Morris once asked the owner whether the employees could receive health insurance through their work, but the owner said it was too expensive. Morris, his wife, and their three kids are uninsured._\n\n_Norris, a shipyard worker, was laid off 3 years ago, and at age 60 is unable to get another job. He lives on county general assistance of $400 per month, but is ineligible for Medicaid because he is not a parent, not older than 65, and not disabled. He is uninsured._\n\nThe uninsured can be divided into two major categories: the employed uninsured (Morris) and the unemployed uninsured (Norris). Seventy-five percent of the uninsured are employed or the spouses and children of those who work. Most of the jobs held by the employed uninsured are low paying, in small firms, and may be part time (Figures 3\u20134 and 3\u20135). Twenty-five percent of the uninsured are unemployed, often with incomes below the poverty line, but like Norris are ineligible for Medicaid.\n\n**Figure 3\u20134.** Lack of insurance by employment status in 2009 (US Census Bureau, 2010).\n\n**Figure 3\u20135.** Lack of job-based insurance by size of employer in 2007 (Kaiser Family Foundation, Health Insurance Coverage in America, 2008, www.kff.org).\n\n##### **Does Health Insurance Make a Difference?**\n\n_Two US senators are debating the issue of access to health care. One decries the stigma of uninsurance and claims that people without insurance receive less care and suffer worse health than those with insurance. The other disagrees, claiming that hospitals and physicians deliver large amounts of charity care, which allows uninsured people to receive the services they need._\n\nTo resolve this debate, the US Congress Office of Technology Assessment (1992) conducted a comprehensive review to determine whether health insurance makes a difference in the use of health care and in health outcomes. The findings, corroborated by the Institute of Medicine (2002), proved that people lacking health insurance receive less care and have worse health outcomes.\n\n##### **Health Insurance and Use of Health Services**\n\n_Percy, a child whose parents were both employed but not insured, was refused admission by a private hospital for treatment of an abscess. Outpatient treatment failed, and his mother attempted to admit Percy to other area hospitals, which also refused care. Finally an attorney arranged for the original hospital to admit the child; the parents then owed the hospital $6000._\n\nAccess to health care is most simply measured by the number of times a person uses health care services. Commonly used data are numbers of physician visits, hospital days, and preventive services received. In addition, access can be quantified by surveys in which respondents report whether or not they failed to seek care or delayed care when they felt they needed it. In 2009, 56% of uninsured adults, compared with 10% of those with insurance, had no usual source of care, 32%, compared with 8% of those with insurance, postponed seeking care due to cost, and 26%, compared with 4% for those with insurance, went without needed care due to cost (Kaiser Family Foundation, 2010a).\n\n##### **Health Insurance and Health Outcomes**\n\n_Dan Sugarman noticed that he was urinating a lot and feeling weak. His friend told him that he had diabetes and needed medical care, but lacking health insurance, Mr. Sugarman was afraid of the cost. Eight days later, his friend found him in a coma. He was hospitalized for diabetic ketoacidosis._\n\n_Penny Evans worked in a Nevada casino. She was uninsured and ignored a growing mole on her chest. After many months of delay, she saw a dermatologist and was diagnosed with malignant melanoma, which had metastasized. She died 2 years later at the age of 44._\n\n_Leo Morelli, a hypertensive patient, was doing well until his company relocated to Mexico and he lost his job. Lacking both paycheck and health insurance, he became unable to afford his blood pressure medications. Six months later, he collapsed with a stroke._\n\nThe uninsured suffer worse health outcomes than those with insurance. Compared with insured persons, the uninsured like Mr. Sugarman have more avoidable hospitalizations; like both Mr. Sugarman and Ms. Evans, they tend to be diagnosed at later stages of life-threatening illnesses, and they are on average more seriously ill when hospitalized (American College of Physicians, 2000). Higher rates of hypertension and cervical cancer and lower survival rates for breast cancer among the uninsured, compared with those with insurance, are associated with less frequent blood pressure screenings, Pap smears, and clinical breast examinations (Ayanian et al, 2000). People without insurance have greater rates of uncontrolled hypertension, diabetes, and elevated cholesterol than those with insurance (Wilper et al, 2009). Most significantly, people who lack health insurance suffer a higher overall mortality rate than those with insurance. After adjusting for age, sex, education, poorer initial health status, and smoking, it was found that lack of insurance alone increased the risk of dying by 25% (Franks et al, 1993). The Institute of Medicine estimated that lack of health insurance accounts for 18,000 deaths annually in the United States (Institute of Medicine, 2004).\n\n##### **Does Medicaid Make a Difference?**\n\nMedicaid, the federal and state public insurance plan, has made great strides in improving access to care for two-thirds of people with incomes below the federal poverty level, but Medicaid has its limitations.\n\n##### **Medicaid and Use of Health Services**\n\n_Concepcion Ortiz lived in a town of 25,000 persons. When she became pregnant, her sister told her that she was eligible for Medicaid, which she obtained. She called each obstetrician in town and none would take Medicaid patients. When she reached her sixth month, she became desperate._\n\nFor those people with Medicaid coverage, access to care is by no means guaranteed. Medicaid pays physicians far less than does Medicare or private insurance with the result that many physicians do not accept Medicaid patients.\n\nAs a rule, people with Medicaid have a level of access to medical care that is intermediate between those without insurance and those with private insurance. Compared with uninsured people, those with Medicaid are more likely to have a regular source of medical care and are less likely to report delays in receiving care. But these access measures for Medicaid recipients are not as good as for people with private insurance (Kaiser Family Foundation, 2010a).\n\n##### **Medicaid and Health Outcomes**\n\nHealth outcomes for Medicaid recipients lag behind those for privately insured people. Compared with privately insured people, Medicaid recipients have lower rates of immunizations, screening for breast and cervical cancer, hypertension and diabetes control, and timeliness of prenatal care. (Landon et al, 2007). Medicaid patients with cancer have their disease detected at significantly later stages than privately insured patients, with the delays in diagnosis comparable for uninsured and Medicaid patients (Halpern et al, 2007). Persons with Medicaid are sometimes relegated, with the uninsured, to the lowest tier of the health care system.\n\n#### **Underinsurance**\n\nHealth insurance does not guarantee financial access to care. Many people are underinsured; that is, their health insurance coverage has limitations that restrict access to needed services (Table 3\u20132). An estimated 20% of insured Americans between the ages of 19 and 64 were underinsured in 2007, up from 12% in 2003 (Gabel et al, 2009).\n\n**Table 3\u20132.** Categories of underinsurance\n\n##### **Limits to Insurance Coverage**\n\nIn 2007, 71% of privately insured people with low incomes and substantial medical expenditures were underinsured. This number is rising as health care costs rise and insurance coverage becomes less comprehensive (Gabel et al, 2009). In 2007, 62% of bankruptcies in the United States were caused by inability to pay medical bills; 75% of these individuals had health insurance at the onset of their illness (Himmelstein et al, 2009).\n\n##### **Insurance Deductibles and Copayments**\n\n_Eva Stefanski works as a legal secretary and has a Blue Cross high-deductible health plan policy with a $2500 deductible. Last year, she failed to show up for her mammogram appointment because she did not have $150 to pay for the test. This year, she also decides to forego making an appointment for her periodic pap test._\n\nFor people with low or moderate incomes, insurance deductibles and copayments may represent a substantial financial problem. From 2006 to 2010, the percent of people with employer-sponsored insurance having a deductible of $1000 or more for single (not family) coverage grew from 10% to 27%. In 2010, 13% of insured employees (up from 4% in 2006) had high-deductible insurance plans, with families paying an average deductible of $3500 plus the employee premium contribution and copayments (Claxton et al, 2010).\n\n##### **Gaps in Medicare Coverage**\n\n_Corazon Estacio suffers from angina, congestive heart failure, and high blood pressure, in addition to diabetes. She takes 17 pills per day: four each of glyburide and metformin, three isosor-bide, two carvedilol and two furosemide, and one each of benazepril and aspirin. Because of the deductibles and the \"doughnut hole\" in her Medicare Part D plan, her yearly medication bill comes to $3840._\n\n_Ferdinand Foote was covered by Medicare and had no Medigap, Medicare Advantage, or Medicaid coverage. He was hospitalized for peripheral vascular disease caused by diabetes and a non-healing infected foot ulcer. He spent 4 days in the acute hospital and 1 month in the skilled nursing facility and made weekly physician visits following his discharge. The costs of illness not covered by Medicare included a $1132 deductible for acute hospital care, a $141.50 per day copayment for days 21 to 30 of the skilled nursing facility stay, a $162 physician deductible, and a 20% ($12) physician copayment per visit for 12 visits. The total came to $2853 not including the cost of uncovered outpatient medications._\n\nMedicare paid for only 48% of the average beneficiary's health care expenses in 2006 (Kaiser Family Foundation, 2010b). For the 5% of beneficiaries in poorest health, uncovered costs in 2004 averaged $7646, up 48% from 1992 (Riley, 2008). As discussed in Chapter 2, Medicare Part D requires beneficiaries to continue shouldering large out-of-pocket expenses for their medications, a situation that is expected to improve with the Accountable Care Act of 2010.\n\n##### **Lack of Coverage for Long-Term Care**\n\n_Victoria and Gus Pappas had $80,000 in the bank when Gus had a stroke. After his hospitalization, he was still paralyzed on the right side and unable to speak or swallow. After 18 months in the nursing home, most of the $80,000 was gone. At that point, Medicaid picked up the nursing home costs._\n\nMedicare paid only 20% of the elderly's nursing home bills in 2009, and private insurance policies picked up only an additional 8% (see Chapter 12). Many elderly families spend their life savings on long-term care, qualifying for Medicaid only after becoming impoverished.\n\n##### **The Effects of Underinsurance**\n\nDoes underinsurance represent a serious barrier to the receipt of medical care? The famous Rand Health Insurance Experiment compared nonelderly individuals who had health insurance plans with no out-of-pocket costs and those who had plans with varying amounts of patient cost sharing (deductibles or copayments). The study found that cost sharing reduces the rate of ambulatory care use, especially among the poor, and that patients with cost-sharing plans demonstrate a reduction in both appropriate and inappropriate medical visits. For low-income adults, the cost-sharing groups received Pap smears 65% as often as the free-care group. Hypertensive adults in the cost-sharing groups had higher diastolic pressures, and children had higher rates of anemia and lower rates of immunization (Brook et al, 1983; Lohr et al, 1986; Lurie et al, 1987).\n\nIn 2003, underinsured adults aged 19 to 64 with health problems were much more likely than well-insured adults to skip recommended tests or follow-up, forego seeing a physician when they felt sick, and fail to fill a prescription on account of cost (Schoen et al, 2005). In 2006, 20% of Medicare beneficiaries with Part D coverage did not fill, or delayed filling, a prescription due to inability to pay the uncovered costs (Neuman et al, 2007). In summary, lack of comprehensive insurance reduces access to health care services and may contribute to poorer health outcomes.\n\n### **NONFINANCIAL BARRIERS TO HEALTH CARE**\n\nNonfinancial barriers to health care include inability to access care when needed, language, literacy, and cultural differences between patients and health caregivers, and factors of gender and race. Excellent discussions of these issues can be found in the book \"Medical Management of Vulnerable and Underserved Patients\" (King and Wheeler, 2007).\n\n#### **Lack of Prompt Access**\n\nMedical practices often fail to provide their patients with access at the time when the patient needs care. This problem has worsened with the growing shortage of primary care practitioners. In 2008, 28% of Medicare beneficiaries without a primary care physician reported difficulty finding such a physician, a 17% increase from 2006. Thirty-one percent of privately insured patients had an unwanted delay in obtaining an appointment for routine care in 2008. In 2006, only 27% of adults with a usual source of care could easily contact their physician by phone, obtain care or advice after hours, and experience timely office visits. After Massachusetts passed its health insurance expansion in 2006, demand for primary care increased without an increase in supply, resulting in the average wait time to see a primary care internist increasing from 17 days in 2005 to 31 days in 2008. Fewer primary care physicians are accepting Medicaid patients, and inappropriate emergency department visits are growing, especially for Medicaid patients, due to inability to access timely primary care (Bodenheimer and Pham, 2010).\n\n#### **Gender and Access to Health Care**\n\n_Olga Madden is angry. Her male physician had not listened. He told her that her incontinence was from too many childbirths and that she would have to live with it. She had questions about the hormones he was prescribing, but he always seemed too busy, so she never asked. Ms. Madden calls her HMO and gets the names of two female physicians, a female physician assistant, and a nurse practitioner. She calls them. Their receptionists tell her that none of them is accepting new patients; they are all too busy._\n\nAccess problems for women often begin with finding a physician who communicates effectively. Women are 50% more likely than men to report leaving a physician because of dissatisfaction with their care, and they are more than twice as likely to report that their physician \"talked down\" to them or told them their problems were \"all in their head\" (Leiman et al, 1997). Female physicians have a more patient-centered style of communicating and spend more time with their patients than do male physicians (Roter and Hall, 2004). In a study of patients with insurance coverage for Pap smears and mammo-grams, the patients of female physicians were almost twice as likely to receive a Pap smear and 1.4 times as likely to have a mammogram than the patients of male physicians (Lurie et al, 1993).\n\nPhysicians are less likely to counsel women than men about cardiac prevention\u2014diet, exercise, and weight reduction. After having a heart attack, women are less likely than men to receive recommended diagnostic tests and are less likely to be prescribed recommended aspirin and beta-blockers (Agency for Healthcare Research and Quality, 2005).\n\nBecause women are more likely than men to have a chronic condition, women use more chronic medications and are more likely than men not to fill a prescription because of cost. Because more women than men are Medicaid recipients, they are more likely to be turned away from physicians who do not accept Medicaid. Fewer than one-third of women of reproductive age have received counseling about emergency contraception, sexually transmitted diseases, or domestic violence (Kaiser Family Foundation, 2005b).\n\nFor those women who wish to terminate a pregnancy, access to abortions is limited in many areas of the country. In 2009, 87% of US counties had no identifiable abortion provider. While women have reduced access to certain kinds of care, an equally serious problem may be instances of inappropriate care. A study conducted in a managed-care medical group in California found that 70% of hysterectomies were inappropriate (Broder et al, 2000).\n\n#### **Race and Access to Health Care**\n\n_Jose is suffering. The pain from his fractured femur is excruciating, and the emergency department physician has given him no pain medication. In the next room, Joe is asleep. He has received 10 mg of morphine for his femur fracture._\n\nAt a California emergency department, 55% of Latino patients with extremity fractures received no pain medication compared with 26% of non-Latino whites. This marked difference in treatment was attributable not to insurance status but to ethnicity (Todd et al, 1993). African American patients similarly receive poorer pain control than whites (Todd et al, 2000).\n\nBecause a far higher proportion of minorities than whites is uninsured, has Medicaid coverage, or is poor, access problems are amplified for these groups. African Americans and Latinos in the United States are less likely to have a regular source of care or to have had a physician visit in the past year (King and Wheeler, 2007). Racial and ethnic differences in access to care are not always a matter of differences in financial resources and insurance coverage. Studies have shown that African Americans and Latinos receive fewer services even when compared with non-Hispanic whites who have the same level of health insurance and income (Agency for Healthcare Research and Quality, 2009).\n\nStudies have also detected such disparities in quality of care. Looking at 38 measures of quality for such conditions as diabetes, asthma, HIV\/AIDS, cardiac care, and cancer, African Americans receive poorer quality of care than whites for 66% of these quality measures; American Indians and Alaska Natives and Latinos also have lower quality indicators (King and Wheeler, 2007).\n\nNeighborhoods that have high proportions of African American or Latino residents have far fewer physicians practicing in these communities. African American and Latino primary care physicians are more likely than white physicians to locate their practices in underserved communities (Komaromy et al, 1996).\n\nWhat explains these disparities in access to care across racial and ethnic groups that are not fully accounted for by differences in insurance coverage and socioeconomic status? Several hypotheses have been proposed. Cultural differences may exist in patients' beliefs about the value of medical care and attitudes toward seeking treatment for their symptoms. However, differences in patient preferences do not account for substantial amounts of the racial variations seen in cardiac surgery rates (Mayberry et al, 2000). A related factor may be ineffective communication between patients and caregivers of differing races, cultures, and languages. African Americans are more likely than whites to report that their physicians did not properly explain their illness and its treatment (LaVeist et al, 2000). Access barriers related to communication problems may be particularly acute for the subset of Latino patients for whom Spanish is the primary language. However, language issues do not fully account for access barriers faced by Latinos. In the study of emergency department pain medication cited previously, even Latinos who spoke English as their primary language were much less likely than non-Latino whites to receive pain medication.\n\nBecause many of these hypotheses do not satisfactorily explain the observed racial disparities in access to care, an important consideration is whether racism may also contribute to these patterns (King and Wheeler, 2007). Medicine in the United States has not escaped the nation's legacy of institutionalized racism toward many minority groups. Many hospitals, including institutions in the North, were for much of the twentieth century either completely segregated or had segregated wards, with inferior facilities and services available to nonwhites. Explicit segregation policies persisted in many hospitals until a few decades ago. Racial barriers to entry into the medical profession gave rise to the establishment of black medical schools such as the Howard, Morehouse, and Meharry schools of medicine. Although such overt racism is a diminishing feature of medicine in the United States, more insidious and often unconscious forms of discrimination may continue to color the interactions between patients and their caregivers and influence access to care for minorities (Van Ryn, 2002).\n\n### **THE RELATION BETWEEN HEALTH CARE AND HEALTH STATUS**\n\nAccess to health care does not by itself guarantee good health. A complex array of factors, only one of which is health care, determines whether a person is healthy or not.\n\n_Ace Banks is 48, an executive vice president, with four grandparents who lived past 90 years of ageand parents alive and well in their late 70s. Mr. Banks went to an Ivy League college where he was a star athlete. He has never seen a physician except for a sprained ankle._\n\n_Keith Cole is a coal miner who at age 48 developed pneumonia. He had excellent health insurance through his union and went to see the leading pulmonologist in the state. He was hospitalized but became less and less able to breathe because the pneumonia was severely complicated by black lung disease, which he contracted through his job. He received high-quality care in the intensive care unit at a fully insured cost of $65,000, but he died._\n\n_Bill Downes, an African American man, knew that his father was killed by high blood pressure and his mother died of diabetes. Mr. Downes spent his childhood in poverty living with eight children at his grandmother's house. He had little to eat except what was provided at the school lunch program, a diet heavily laden with cheese and butter. To support the family, he left school at age 15 and got a job. At age 24, he was diagnosed with high blood pressure and diabetes. He did not smoke and was meticulous in following the diet prescribed by his physician. He had private health insurance through his job as a security guard and was cared for by a professor of medicine at the medical school. In spite of excellent medical care, his glucose and cholesterol levels and blood pressure were difficult to control, and he developed retinopathy, kidney failure, and coronary heart disease. At age 48, he collapsed at work and died of a heart attack._\n\n#### **Health Status and Income**\n\nThe gap between the rich and the poor has widened markedly in the United States. Between 1952 and 2005, the proportion of pretax income reported by the wealthiest decile of the population increased from 31% to 44%; the share of income for the richest 1% doubled from 8% in 1980 to 17% in 2005. At the same time, income is decreasing for the great majority of households (Woolf, 2007). As the stories of Ace Banks, Keith Cole, and Bill Downes suggest, the health of an individual or a population is influenced less by medical care than by broad socioeconomic factors such as income and education (Braveman et al, 2010). People in the United States with incomes above four times the poverty level live on average 7 years longer than those with incomes below the poverty level (Table 3\u20133). The mortality rate for heart disease among laborers is more than twice the rate for managers and professionals. The incidence of cancer increases as family income decreases, and survival rates are lower for low-income cancer patients. Higher infant mortality rates are linked to low income and low educational level. Not only does the income level of individuals affect their health and life expectancy, the way in which income is distributed within communities also appears to influence the overall health of the population. In the United States, overall mortality rates are higher in states that have a more unequal distribution of income, with greater concentration of wealth in upper income groups (Lochner et al, 2001). Some social scientists have concluded that the toxic health effects of social inequality in developed nations result from the psychosocial stresses of social hierarchies and social oppression, not simply from material deprivation (Kawachi and Kennedy, 1999).\n\n**Table 3\u20133.** Income, race, and life expectancy in years (at age 25) _a_\n\n#### **Health Status and Race**\n\nAfrican Americans experience dramatically worse health than white Americans. Life expectancy is lower for African Americans than for other racial and ethnic groups in the United States (Table 3\u20134). Infant mortality rates among African Americans are more than double those for whites (Table 3\u20135), and the relative disparity in infant mortality has widened during the past decade. Mortality rates for African Americans exceed those for whites for 7 of the 10 leading causes of death in the United States, including the most common killers in the US population\u2014heart disease, strokes, and cancer (Table 3\u20136) (US Department of Health and Human Services, 2009). African American men younger than 45 years have 10 times the likelihood of dying of hypertension than white men in the same age group. Although the incidence of breast cancer is lower in African American women than in white women, in African American women this disease is diagnosed at a more advanced stage of illness, and thus they are more likely to die of breast cancer (Institute of Medicine, 2003; Halpern et al, 2007).\n\n**Table 3\u20134.** Life expectancy in years\n\n**Table 3\u20135.** Infant mortality, 2006 (per 1000 live births)\n\n**Table 3\u20136.** Age-adjusted death rates per 100,000 population, 2006\n\nNative Americans are another ethnic group with far poorer health than that of whites. Native Americans younger than 45 years have far higher death rates than whites of comparable age, and the Native American infant mortality rate is 50% higher than the rate of whites (US Department of Health and Human Services, 2009).\n\nLatinos and Asians and Pacific Islanders are minority groups characterized by great diversity. Health status varies widely between Cuban Americans, who tend to be more affluent, and poor Mexican American migrant farm workers, as well as between Japanese families, who are more likely to be middle class, and Laotians, who are often indigent. Compared with whites, Latinos have markedly higher death rates for diabetes and the acquired immune deficiency syndrome. Overall, Latinos have lower age-adjusted mortality rates than whites because of less cardiovascular disease and cancer. Asians in the United States have lower death rates than whites for all age groups (US Department of Health and Human Services, 2009).\n\nSome of the differences in mortality rates of African Americans and Native Americans compared with whites are related to the higher rates of poverty among these minority groups. In 2009, the white poverty rate was 12% compared with 26% for African Americans, and 25% for Latinos (US Census Bureau, 2010). However, even compared with whites in the same income class, African Americans as a group have inferior health status. Although mortality rates decline with rising income among both African Americans and whites, at any given income level, the mortality rate for African Americans is consistently higher than the rate for whites (Table 3\u20133). Thus, social factors and stresses related to race itself seem to contribute to the relatively poorer health of African Americans. The inferior health outcomes among African Americans, such as higher mortality rates for heart disease, cancer, and stroke, are in part explained by the lower rate of access to health services among this group.\n\nIf lower income is associated with poorer health, and if Latinos tend to be poorer than non-Latino whites in the United States, then why do Latinos have overall lower mortality rates than non-Latino whites? This is possibly related to the fact that many Latinos are immigrants, and foreign-born people often have lower mortality rates than people born in the United States at the same level of income (Abraido-Lanza et al, 1999; Goel et al, 2004). This phenomenon is often referred to as the \"healthy immigrant\" effect. If this is the case, mortality rates for Latinos may rise as a higher proportion of their population is born in the United States.\n\n### **CONCLUSION**\n\nHealth outcomes are determined by multiple factors. Socioeconomic status appears to be the dominant influence on health status; yet medical care and public health interventions are also extremely important (King and Wheeler, 2007). The advent of the polio vaccine markedly reduced the number of paralytic polio cases. From 1970 to 2004, age-adjusted death rates from stroke decreased by more than 100%\u2014a successful result of hypertension diagnosis and treatment. Early prenatal care can prevent low-birth-weight and infant deaths. Irradiation and chemotherapy have transformed the prognosis of some cancers (eg, Hodgkin disease) from a certain fatal outcome toward complete cure. A 1980 study of mortality rates in 400 counties in the United States found that after controlling for income, education, cigarette consumption, and prevalence of disability, a 10% increase in per capita medical care expenditures was associated with a reduced average mortality rate of 1.57% (Roemer, 1991). 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Obesity among US immigrant subgroups by duration of residence. _JAMA_. 2004;292:2860.\n\nHalpern MT et al. Insurance status and stage of cancer at diagnosis among women with breast cancer. _Cancer_. 2007;110:231.\n\nHimmelstein DU et al. Medical bankruptcy in the United States, 2007. _Am J Med_. 2009;122:741.\n\nInstitute of Medicine. _Care Without Coverage: Too Little, Too Late_. Washington, DC: National Academies Press; 2002.\n\nInstitute of Medicine. _Unequal Treatment_. Washington, DC: National Academies Press; 2003.\n\nInstitute of Medicine. _Insuring America's Health_. Washington, DC: National Academies Press; 2004.\n\nKaiser Family Foundation. The Uninsured and the Difference Health Insurance Makes. September 2010a. www.kff.org.\n\nKaiser Family Foundation. Medicare Spending and Financing. 2010b. www.kff.org.\n\nKaiser Family Foundation: _Women and Health Care_. Menlo Park, CA: Kaiser Family Foundation; July 2005. www.kff.org.\n\nKawachi I, Kennedy BP. Income inequality and health: Pathways and mechanisms. _Health Serv Res._ 1999;34:215.\n\nKing TE, Wheeler MB. _Medical Management of Vulnerable and Underserved Patients_. New York, NY: McGraw-Hill; 2007.\n\nKomaromy M et al. The role of Black and Hispanic physicians in providing health care for underserved populations. _N Engl J Med._ 1996;334:1305.\n\nLandon BE et al. Quality of care in Medicaid managed care and commercial health plans. _JAMA_. 2007;298:1674.\n\nLaVeist TA et al. Attitudes about racism, medical mistrust, and satisfaction with care among African American and white cardiac patients. _Med Care Res Rev_. 2000;57(Suppl 1):146.\n\nLeiman JM et al. _Selected Facts on U.S. Women's Health: A Chart Book._ New York: The Commonwealth Fund; 1997.\n\nLochner K et al. State-level income inequality and individual mortality risk: A prospective, multilevel study. _Am J Public Health_. 2001;91:385.\n\nLohr KN et al. Use of medical care in the Rand Health Insurance Experiment. _Med Care._ 1986;24(Suppl):S1.\n\nLurie N et al. Preventive care: Do we practice what we preach? _Am J Public Health._ 1987;77:801.\n\nLurie N et al. Preventive care for women: Does the sex of the physician matter? _N Engl J Med._ 1993;329:478.\n\nMayberry RM et al. Racial and ethnic differences in access to medical care. _Med Care Res Rev._ 2000;57(Suppl 1):108.\n\nNeuman P et al. Medicare prescription drug benefit progress report. _Health Aff (Millwood)_. 2007;26:w630.\n\nRenner C, Navarro V. Why is our population of uninsured and underinsured persons growing? The consequences of the \"deindustrialization\" of the United States. _Int J Health Serv._ 1989;19:433.\n\nRiley GF. Trends in out-of-pocket healthcare costs among older community-dwelling Medicare beneficiaries. _Am J Manag Care_. 2008;14:692.\n\nRoemer MI. _National Health Systems of the World_. New York: Oxford University Press; 1991.\n\nRoter DL, Hall JA. Physician gender and patient-centered communication. _Annu Rev Public Health._ 2004;25:497.\n\nSchoen et al. Insured but not protected: How many adults are underinsured? _Health Affairs Web Exclusive_. June 14, 2005:w5\u2013289. <http:\/\/content.healthaffairs.org>. Accessed November 11, 2011.\n\nTodd KH et al. Ethnicity and analgesic practice. _Ann Emerg Med._ 2000;35:11.\n\nTodd KH et al. Ethnicity as a risk factor for inadequate emergency department analgesia. _JAMA_. 1993;269: 1537.\n\nUS Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States, 2009; pp. 60\u2013238, September, 2010.\n\nUS Congress, Office of Technology Assessment. _Does Health Insurance Make a Difference_? OTA-BP-H-99. US Government Printing Office; 1992.\n\nUS Department of Health and Human Services. _Health United States 2009_. www.cdc.gov.\n\nVan Ryn M. Research on the provider contribution to race\/ethnicity disparities in medical care. _Med Care._ 2002;40(Suppl):I-140.\n\nWilper et al. Hypertension, diabetes, and elevated cholesterol among insured and uninsured U.S. adults. _Health Aff (Millwood)._ 2009;28:1151.\n\nWoolf SH. Future health consequences of the current decline in US household income. _JAMA_. 2007;298:1931.\n\n## **4 Reimbursing Health Care Providers**\n\nChapter 2 described the different modes of financing health care: out-of-pocket payments, individual health insurance, employment-based health insurance, and government financing. Each of these mechanisms attempted to solve the problem of unaffordable care for certain groups, but each \"solution\" in turn created new problems by stimulating rapid rises in health care costs. One of the factors contributing to this inflation was reimbursement of physicians and hospitals by insurance companies and government programs. Therefore, new methods of reimbursement have been tried as one way of lowering the growth rate in health care costs.\n\n_Dr. Mary Young has recently finished her family medicine residency and joined a small group practice, PrimaryCare. On her first day, she has the following experiences with health care financing: her first patient is insured by Blue Shield; Primary Care is paid a fee for the physical examination and for the electrocardiogram (ECG) performed. Dr. Young's second patient requires the same services, for which PrimaryCare receives no payment but is forwarded $10 for each month that the patient is enrolled in the practice. In the afternoon, a hospital utilization review physician calls Dr. Young, explains the diagnosis-related group (DRG) payment system, and suggests that she send home a patient hospitalized with pneumonia. In the evening, she goes to the emergency department, where she has agreed to work two shifts per week for $85 per hour._\n\nDuring the course of a typical day, some physicians will be involved with four or five distinct types of reimbursement. This chapter will describe the different ways in which physicians and hospitals are paid. Although reimbursement has many facets, from the setting of prices to the processing of claims, this discussion will focus on one of its most basic elements: establishing the unit of payment. This basic principle must be grasped before one can understand the key concept of physician-borne risk.\n\n### **UNITS OF PAYMENT**\n\nMethods of payment can be placed along a continuum that extends from the least to the most aggregated unit. The methods range from the simplest (one fee for one service rendered) to the most complex (one payment for many types of services rendered), with many variations in between (Table 4\u20131).\n\n**Table 4\u20131.** Units of payment\n\n#### **Definitions of Methods of Payment**\n\n##### **Fee-for-Service Payment**\n\nThe unit of payment is the visit or procedure. The physician or hospital is paid a fee for each office visit, ECG, intravenous fluid, or other service or supply provided. This is the only form of payment that is based on individual components of health care. All other reimbursement modes aggregate or group together several services into one unit of payment.\n\n##### **Payment by Episode of Illness**\n\nThe physician or hospital is paid one sum for all services delivered during one illness, as is the case with global surgical fees for physicians and DRGs for hospitals.\n\n##### **Per Diem Payments to Hospitals**\n\nThe hospital is paid for all services delivered to a patient during 1 day.\n\n##### **Capitation Payment**\n\nOne payment is made for each patient's care during a month or year.\n\n##### **Payment for All Services Delivered to All Patients within a Certain Time Period**\n\nThis includes global budget payment of hospitals and salaried payment of physicians.\n\n#### **Managed Care Plans**\n\nTraditionally physicians and hospitals have been paid on a fee-for-service basis. The development of managed care plans introduced changes in the methods by which hospitals and physicians are paid, for the purpose of controlling costs. Managed care is discussed in more detail in Chapter 6; in this chapter, only those aspects needed to understand physician and hospital reimbursement will be considered.\n\nThere are three major forms of managed care: fee-for-service practice with utilization review, preferred provider organizations (PPOs), and health maintenance organizations (HMOs).\n\n##### **Fee-for-Service Reimbursement with Utilization Review**\n\nThis is the traditional type of payment, with the addition that the third-party payer (whether private insurance company or government agency) assumes the power to authorize or deny payment for expensive medical interventions such as hospital admissions, extra hospital days, and surgeries.\n\n##### **Preferred Provider Organizations**\n\nPPOs are loose-knit organizations in which insurers contract with a limited number of physicians and hospitals who agree to care for patients, usually on a discounted fee-for-service basis with utilization review.\n\n##### **Health Maintenance Organizations**\n\nHMOs are organizations whose patients are required (except in emergencies) to receive their care from providers within that HMO. There are several types of HMOs which are discussed in Chapter 6. Some HMOs pay physicians and hospitals by more highly bundled units of payment (eg, per diem, capitation, or salary).\n\n### **METHODS OF PHYSICIAN PAYMENT**\n\n#### **Payment per Procedure: Fee-for-Service**\n\n_Roy Sweet, a patient of Dr. Weisman, is seen for recent onset of diabetes. Dr. Weisman spends 20 minutes performing an examination, fingerstick blood glucose test, urinalysis, and ECG. Each service has a fee set by Dr. Weisman: $92 for a complex visit, $8 for a fingerstick glucose test, $15 for a urinalysis, and $70 for an ECG. Because Mr. Sweet is uninsured, Dr. Weisman reduces the total bill from $185 to $90._\n\n_In 1988, Dr. Lenz, an ophthalmologist, requested that Dr. Weisman do a medical consultation for Gertrude Rales, who developed congestive heart failure and arrhythmias following cataract surgery. Dr. Weisman took 90 minutes to perform the consultation and was paid $100 by Medicare. Dr. Lenz had spent 90 minutes on the surgery plus pre- andpostoperative care and received $1600 from Medicare. In 1998, Dr. Weisman did a similar consultation for Dr. Lenz and received $130; Dr. Lenz was sent $900 for the operation._\n\n_Melissa High, a Medicaid recipient, makes three visits to Dr. Weisman for hypertension. He bills Medicaid $92 for one complex visit and $52 each for two shorter visits. He is paid $26 per visit, 40% of his total charges. Under Medicaid, Dr. Weisman may not bill Ms. High for the balance of his fees._\n\n_Dr. Weisman contracted with Blue Cross to care for its PPO patients at 70% of his normal fee. Rick Payne, a PPO patient, comes in with a severe headache and is found to have left arm weakness and hyperreflexia. Dr. Weisman is paid $84.40 for a complex visit. Before a magnetic resonance imaging (MRI) scan can be ordered, the PPO must be asked for authorization._\n\nTraditionally, private physicians have been reimbursed by patients and insurers through the fee-for-service mechanism. Before the passage of Medicare and Medicaid, physicians often discounted fees for elderly or poor patients, and even afterward many physicians have continued to assist uninsured people in this way.\n\nPrivate insurers, as well as Medicare and Medicaid in the early years, usually reimbursed physicians according to the usual, customary, and reasonable (UCR) system, which allowed physicians a great deal of latitude in setting fees. As cost containment became more of a priority, the UCR approach to fees was largely supplanted by payer-determined fee schedules. An example of this is Melissa High's three visits, which incurred charges of $196 of which Medicaid paid only $78 ($26 per visit).\n\nIn the early 1990s, Medicare moved to a fee schedule determined by a resource-based relative-value scale (RBRVS). With this system, fees (which vary by geographic area) are set for each service by estimating the time, mental effort and judgment, technical skill, physical effort, and stress typically related to that service (Bodenheimer et al, 2007). The RBRVS system made a somewhat feeble attempt to correct the bias of physician payment that has historically paid for surgical and other procedures at a far higher rate than primary care and cognitive services. In 1998, Dr. Weisman was paid nearly 15% of Dr. Lenz's surgery fee, compared with 6% of that fee in 1988, before the advent of RBRVS.\n\nPPO managed care plans often pay contracted physicians on a discounted fee-for-service basis and require prior authorization for expensive procedures.\n\nWith fee-for-service payments, physicians have an economic incentive to perform more services because more services bring in more payments (see Chapter 10). The fee-for-service incentive to provide more services contributed to the rapid rise in health care costs in the United States (Relman, 2007).\n\n#### **Payment per Episode of Illness**\n\n_Dr. Nick Belli removes Tom Stone's gallbladder and is paid $1300 by Blue Cross. Besides performing the cholecystectomy, Dr. Belli sees Mr. Stone three times in the hospital and twice in his office for postoperative visits. Because surgery is paid by means of a global fee, Dr. Belli may not bill separately for the visits, which are included in his $1300 cholecystectomy fee._\n\n_Joan Flemming complains of having had coughing, fever, and green sputum for 1 week. Dr. Violet Gramm analyzes a sputum smear and orders a chest x-ray and makes the diagnosis of pneumonia. She treats Ms. Flemming as an outpatient with azithromycin, checking her once a week for 3 weeks. With the experimental episode-based system, Dr. Gramm is paid one fee for all services and procedures involved in treating Ms. Flemming's pneumonia._\n\nSurgeons usually receive a single payment for several services (the surgery itself and postoperative care) that have been grouped together, and obstetricians are paid in a similar manner for a delivery plus pre- and postnatal care. This bundling together of payments is often referred to as reimbursement at the unit of the case or episode.\n\nWith payment by episode, surgeons have an economic incentive to limit the number of postoperative visits because they do not receive extra payment for extra visits. On the other hand, they continue to have an incentive to perform more surgeries, as with the traditional fee-for-service system. Some health care experts recommend paying physicians through an episode-based system similar to that used by Medicare for hospital reimbursement (Pham et al, 2010). Under such a system one fee would be paid for one episode of illness, no matter how many times the patient visited the physician.\n\nAt this point, it is helpful to introduce the important concept of risk. Risk refers to the potential to lose money, earn less money, or spend more time without additional payment on a reimbursement transaction. With the traditional fee-for-service system, the party paying the bill (insurance company, government agency, or patient) absorbs all the risk; if Dr. Weisman sees Rick Payne ten times rather than five times for his headaches, Blue Cross pays more money and Mr. Payne spends more in copayments. Bundling of services transfers a _portion_ of the risk from the payer to the physician; if Dr. Belli sees Tom Stone ten times rather than five times for follow-up after cholecystectomy, he does not receive any additional money. However, Blue Cross is also partially at risk; if more Blue Cross enrollees require gallbladder surgery, Blue Cross is responsible for more $1300 payments. As a general rule, the more services bundled into one payment, the larger the share of financial risk that is shifted from payer to provider. ( _Payer_ is a general term referring to whomever pays the bill; in Chapter 16, a distinction is made between purchasers of health insurance such as employers, and insurers, who can both be payers.)\n\n#### **Payment per Patient: Capitation**\n\nCapitation payments (per capita payments or payments \"by the head\") are monthly payments made to a physician for each patient signed up to receive care from that physician\u2014generally a primary care physician. The essence of capitation is a shift in financial risk from insurers to providers. Under fee-for-service, patients who require expensive health services cost their health plan more than they pay the plan in insurance premiums; the insurer is at risk and loses money. Physicians and hospitals who provide the care earn more money for treating ill people. In a 180-degree role reversal, capitation frees insurers of risk by transferring risk to providers. An HMO that pays physicians via capitation has little to fear in the short run from patients who become ill. The HMO pays a fixed sum no matter how many services are provided. The providers, in contrast, earn no additional money yet spend a great deal of time and incur large office and hospital expenditures to care for people who are sick. (In the long term, HMOs do want to limit services in order to reduce provider pressure for higher capitation payments.)\n\nCertain methods have been developed to mitigate the financial risk associated with capitation payment. One method involves reintroducing fee-for-service payments for specified services. Such types of services provided but not covered within the capitation payment are called _carve-outs;_ their reimbursement is \"carved out\" of the capitation payment and paid separately. Pap smears, immunizations, office ECGs, and minor surgical procedures may be carved out and paid on a fee-for-service basis.\n\nA common method of managing risk is called \"risk-adjusted capitation.\" For physicians paid by capitation, patients with serious illnesses require a great deal more time without any additional payment, creating an incentive to sign up healthy patients and avoid those who are sick. Risk-adjusted capitation provides higher monthly payments for elderly patients and for those with chronic illnesses. However, risk adjustment poses a major challenge. Researchers have investigated measures for risk-adjusting capitation payments by appraising an individual's state of health or risk of needing health care services (Brown et al, 2010).\n\nCapitation has potential merits as a way to control costs by providing an alternative to the inflationary tendencies of fee-for-service payment. In addition, capitation has been advocated for its potential beneficial influence on the organization of care. Capitation payments require patients to register with a physician or group of physicians. The clear enumeration of the population of patients in a primary care practice offers advantages for monitoring appropriate use of services and planning for these patients' needs. Capitation also potentially allows for more flexibility at the practice level in how to most effectively and efficiently organize and deliver services. For example, fee-for-service typically only pays for an in-person visit with a physician; under capitation payment, a physician could substitute \"virtual visits\" such as e-mail and telephone contacts for in-person visits for following up on blood pressure or diabetes control, or delegate routine preventive care tasks to nurses or medical assistants in the practice, without experiencing a financial disincentive for these alternative ways of delivering care. Capitation also explicitly defines\u2014in advance\u2014the amount of money available to care for an enrolled population of patients, providing a better framework for rational allocation of resources and innovation in developing better modes of delivering services. For a large group of primary care physicians, the sheer size of the aggregated capitation payments provides clout and flexibility over how to best arrange ancillary and specialty services.\n\n##### **Capitation with Two-Tiered Structures**\n\n_Jennifer is a young woman in England who develops an ear infection; her general practitioner, Dr. Walter Liston, sees her and prescribes antibiotics. Jennifer pays no money at the time of the visit and receives no bill. Dr. Liston is paid the British equivalent of $12 per month to care for Jennifer, no matter how many times she requires care. When Jennifer develops appendicitis and requires an x-ray and surgical consultation, Dr. Liston sends her to the local hospital for these services; payment for these referral services is incorporated into the hospital's operating budget paid for separately by the National Health Service._\n\n_**British System**_ \u2014Capitation payments to physicians in the United States are complicated, as will shortly be seen. But in the United Kingdom, they have traditionally been simple (see Chapter 14). Under the traditional British National Health Service, each person enrolls with a general practitioner, who becomes the primary care physician (PCP). For each person on the general practitioner's list, the physician receives a monthly capitation payment. The more patients on the list, the more money the physician earns. Patients are required to route all nonemergency medical needs through the general practitioner \"gatekeeper,\" who when necessary makes referrals for specialist services or hospital care. Patients can freely change from one general practitioner to another. This simple arrangement, illustrated in Figure 4\u20131, is referred to as a two-tiered capitation structure. One tier is the health plan (the government in the case of the UK) and the other tier the individual PCP or a small number of physicians in group practice.\n\n_**United States System**_ \u2014In the United States, capitation payment is associated with HMO plans and not with traditional or PPO insurance. Some HMO plans have two-tiered structures, with HMOs paying capitation fees directly to PCPs (Figure 4\u20131). However, capitation payment in US managed care organizations more often involves a three-tiered structure.\n\n**Figure 4\u20131.** Two-tiered capitated payment structures. The health plan pays the primary care physician by capitation and pays for referral services (eg, x-rays and specialist consultations) through a different reimbursement stream.\n\n##### **Capitation with Three-Tiered Structures**\n\nIn three-tiered structures, HMOs do not pay capitation fees directly to individual physicians or small group practices, but instead rely on an intermediary administrative structure for processing these payments (Robinson and Casalino, 1995). In one variety of such three-tiered structures (Figure 4\u20132A), physicians remain in their own private offices but join together into physician groups called independent practice associations (IPAs).\n\n**Figure 4\u20132.** Three-tiered capitated payment structures. **(A)** The CapCap Associates type of arrangement, in which primary physicians receive a capitation payment plus a bonus from the IPA if there is an end-of-the-year surplus in the pool for paying for referral services. **(B)** The CapFee Associates type of arrangement, in which the IPA receives capitation payments from the health plans, but pays its primary care physicians on a fee-for-service basis.\n\n_George is enrolled through his employer in Smart-Care, an HMO run by Smart Insurance Company. SmartCare has contracted with two IPAs to provide physician services for its enrollees in the area where George lives. George has chosen to receive his care from Dr. Bunch, a PCP affiliated with one of these IPA groups, CapCap Associates IPA. Smart-Care pays CapCap Associates a $60 monthly capitation fee on George's behalf for all physician and related outpatient services. CapCap Associates in turn pays Dr. Bunch a $15 monthly capitation fee to serve as George's primary care physician._\n\n_George develops symptoms of urinary obstruction consistent with benign prostatic hyperplasia. Dr. Bunch orders some laboratory tests and refers George to a urologist for cystoscopy. The laboratory and the urologist bill CapCap Associates on a fee-for-service basis and are paid by the IPA from a pool of money (called a risk pool) that the IPA has set aside for this purpose from the capitation payments CapCap Associates receives from Smart-Care. At the end of the year, CapCap Associates has money left over in this diagnostic and specialist services risk pool. CapCap Associates distributes this surplus revenue to its PCPs as a bonus._\n\nSorting out the flow of payments and nature of risk sharing becomes difficult in this type of three-tiered capitation structure. In most three-tiered HMOs, the financial risk for diagnostic and specialist services is borne by the overall IPA organization and spread among all the participating PCPs in the IPA. In the 1980s and 1990s, the CapCap Associates type of IPA often provided financial incentives to PCPs to limit the use of diagnostic and specialist services by returning to these physicians any surplus funds that remain at the end of the year. This method of reimbursement is known as capitation-plus-bonus payment. The less frequent the use of diagnostic and specialist services, the higher the year-end bonus for IPA physician gatekeepers. This arrangement came under criticism as representing a conflict of interest for PCPs because their personal income was increased by denying diagnostic and specialty services to their patients (Rodwin, 1993). More recently some managed care organizations have begun to tie bonus payments to quality measures\u2014\"pay for performance\"\u2014rather than to cost control (see Chapter 10). A considerable price must be paid for setting up a three-tiered structure because administrative costs are substantial for both the health plan and the IPA.\n\n_George's brother Steve works for the same company as George and also has SmartCare insurance. Steve, however, obtains his primary care from a physician in the other SmartCare IPA plan, CapFee Associates. Like CapCap Associates, CapFee Associates is an IPA that receives $60 per month in capitation fees for every patient enrolled. Unlike CapCap Associates, CapFee Associates pays its PCPs on a fee-for-service basis._\n\nThree-tiered IPA structures become even more confusing when the unit of reimbursement differs across tiers. In the CapCap Associates model, capitation is the basic payment method for both the IPA as a whole and its constituent primary care physicians. However, in the CapFee Associates model the IPA receives capitation payments from the health insurance plan but then reimburses its participating PCPs on a fee-for-service basis (Figure 4\u20132B). Under this arrangement, the fees billed by the IPA physicians may well exceed the amount of money the IPA has received from the insurance plan on a capitated basis to pay for physician and related outpatient services. To reduce this risk, many IPAs of the CapFee Associates type pay their physicians only a portion, perhaps 60%, of a predetermined fee schedule and withhold the other 40%. If money is left over at the end of the year, the physicians receive a portion of the withheld money.\n\nWith the CapFee system, the IPA is the main entity at risk because provision of more services can cause the IPA to lose money. But individual physicians are also partially at risk because if expenditures by the IPA are high, they will not receive the withheld funds. The economic incentive for individual primary care physicians is a mixed one. It is to the physician's financial advantage to schedule as many patient visits as possible because the physician receives a fee for each visit. But a large number of visits overall by IPA patients, as well as high use of laboratory and x-ray studies and specialist services, will deplete the IPA budget, thereby increasing the possibility that the IPA could go bankrupt, leaving its physicians with thousands of unpaid charges.\n\n#### **Payment per Time: Salary**\n\n_Dr. Joyce Parto is employed as an obstetrician-gynecologist by a large staff model HMO. She considers the financial security and lack of business worries in her current work setting an improvement over the stresses she faced as a solo fee-for-service practitioner before joining the HMO. However, she has some concerns that the other obstetricians are allowing the hospital's obstetric house staff to manage most of the deliveries during the night, and wonders if the lack of financial incentives to attend deliveries may be partly to blame. She is also annoyed by the bureaucratic hoops she has to jump through to cancel an afternoon clinic to attend her son's school play._\n\nIn contrast with traditional private physicians, physicians in the public sector (municipal, Veterans Health Administration and military hospitals, state mental hospitals), and in community clinics are usually paid by salary. Salaried practice aggregates payment for all services delivered during a month or year into one lump sum. Managed care has brought salaried practice to the private sector, sometimes with a salary-plus-bonus arrangement, particularly in integrated medical groups and group and staff model HMOs (see Chapter 6). Group and staff model HMOs bring physicians and hospitals under one organizational roof.\n\nThe distinction between staff and group model HMOs is analogous to the difference between the two-and three-tiered IPA model HMOs discussed previously. The staff model HMO is a two-tiered payment structure, with an HMO insurance plan directly employing physicians on a salaried basis (Figure 4\u20133A). In the group model HMO, the HMO insurance plan contracts on a capitated basis with an intermediary physician group, which in turn pays its individual physicians a salary (Figure 4\u20133B).\n\n**Figure 4\u20133.** Salaried payment. **(A)** In the staff model HMO, the plan directly employs physicians. **(B)** In the group model HMO, a \"prepaid group practice\" receives capitation payments from the plan and then reimburses its physicians by salary.\n\nHMO physicians paid purely by salary bear little if any individual financial risk; the HMO or physician group is at risk if expenses are too great. To manage risk, administrators at group and staff model HMOs may place constraints on their physician employees, such as scheduling them for a high volume of patient visits or limiting the number of available specialists. Salaried physicians are at risk of not getting extra pay for extra work hours. For a physician paid an annual salary without allowances for overtime pay, a high volume of complex patient visits may turn an 8-hour day into a 12-hour day with no increase in income. HMOs and medical groups may offer bonuses to salaried physicians if overall expenses are less than the amounts budgeted for these expenses or if the physician performs high quality care (pay for performance).\n\n### **METHODS OF HOSPITAL PAYMENT**\n\n#### **Payment per Procedure: Fee-for-Service**\n\n_Kwin Mock Wong is hospitalized for a bleeding ulcer. At the end of his 4-day stay, the hospital sends a $14,000 seven-page itemized hospital bill to Blue Cross, Mr. Wong's insurer._\n\nIn the past, insurance companies made fee-for-service payments to private hospitals based on the principle of \"reasonable cost,\" a system under which hospitals had a great deal of influence in determining the level of payment. Because the American Hospital Association and Blue Cross played a large role in writing reimbursement regulations for Medicare, that program initially paid hospitals according to a similar reasonable cost formula (Law, 1974). More recently, private and public payers concerned with cost containment have begun to question hospital charges and negotiate lower payments, or to shift financial risk toward the hospitals by using per diem, DRG, or capitation payments.\n\n#### **Payment per Day: Per Diem**\n\n_John Johnson, an HMO patient, with a severe headache is admitted to the hospital. During his 3-day stay, he undergoes MRI scanning, lumbar puncture, and cerebral arteriography, procedures that are all costly to the hospital in terms of personnel and supplies. The hospital receives $4800, or $1600 per day from the HMO; Mr. Johnson's stay costs the hospital $7200._\n\n_Tom Thompson, in the same HMO, is admitted for congestive heart failure. He receives intravenous furosemide for 3 days and his condition improves. Diagnostic testing is limited to a chest x-ray, ECG, and basic blood work. The hospital receives $4800; the cost to the hospital is $4200._\n\nMany insurance companies and Medicaid plans contract with hospitals for per diem payments rather than paying a fee for each itemized service (room charge, MRI, arteriogram, chest x-ray, and ECG). The hospital receives a lump sum for each day the HMO patient is in the hospital. The insurer may send a utilization review nurse to the hospital to review the charts of its patients, and if the nurse decides that a patient is not acutely ill, the HMO may stop paying for additional days.\n\nPer diem payments represent a bundling of all services provided for one patient on a particular day into one payment. With traditional fee-for-service payment, if the hospital performs several expensive diagnostic studies, it makes more money because it charges for each study, whereas with per diem payment the hospital receives no additional money for expensive procedures. Per diem bundling of services into one fee removes the hospital's financial incentive because it loses, rather than profits, by performing expensive studies.\n\nWith per diem payment, the insurer continues to be at risk for the number of days a patient stays in the hospital because it must pay for each additional day. However, the hospital is at risk for the number of services performed on any given day because it incurs more costs without additional payment when it provides more services. It is in the insurer's interest to conduct utilization reviews to reduce the number of hospital days, but the insurer is less concerned about how many services are performed within each day; that fiscal concern has been transferred to the hospital.\n\n#### **Payment per Episode of Hospitalization: Diagnosis-Related Groups**\n\n_Bill is a 67-year-old man who enters the hospital for acute pulmonary edema. He is treated withfurosemide and oxygen in the emergency room, spends 36 hours in the hospital, and is discharged. The cost to the hospital is $5200. The hospital receives a $7000 DRG payment from Medicare._\n\n_Will is an 82-year-old man who enters the hospital for acute pulmonary edema. In spite of repeated treatments with furosemide, captopril, digoxin, and nitrates, he remains in heart failure. He requires telemetry, daily blood tests, several chest x-rays, electrocardiograms, and an echocardio-gram, and is finally discharged on the ninth hospital day. His hospital stay costs $23,000 and the hospital receives $7000 from Medicare._\n\nThe DRG method of payment for Medicare patients started in 1983. Rather than pay hospitals on a fee-for-service basis, Medicare pays a lump sum for each hospital admission, with the size of the payment dependent on the patient's diagnoses. The DRG system has gone one step further than per diem payments in bundling services into one payment. While per diem payment lumps together all services performed during one day, DRG reimbursement lumps together all services performed during one hospital episode. (Although an episode of illness may extend beyond the boundaries of the acute hospitalization [eg, there may be an outpatient evaluation preceding the hospitalization and transfer to a nursing facility for rehabilitation afterward], the term _episode_ under the DRG system refers only to the portion of the illness actually spent in the acute care hospital.)\n\nWith the DRG system, the Medicare program is at risk for the number of admissions, but the hospital is at risk for the length of hospital stay and the resources used during the hospital stay. Medicare has no financial interest in the length of stay, which (except in unusually long \"outlier\" stays) does not affect Medicare's payment. In contrast, the hospital has an acute interest in the length of stay and in the number of expensive procedures performed; a long, costly hospitalization such as Will's produces a financial loss for the hospital, whereas a short stay yields a profit. Hospitals therefore conduct internal utilization review to reduce the costs incurred by Medicare patients.\n\n#### **Payment per Patient: Capitation**\n\n_Jane is enrolled in Blue Cross HMO, which contracts with Upscale Hospital to care for Jane if she requires hospitalization. Upscale receives $60 per month as a capitation fee for each patient enrolled in the HMO. Jane is healthy, and during the 36 months that she is an HMO member, the hospital receives $2160, even though Jane never sets foot in the hospital._\n\n_Wayne is also enrolled in Blue Cross HMO. Twenty-four months following his enrollment, he contracts Pneumocystis carinii pneumonia, and in the following 12 months he spends 6 weeks in Upscale Hospital at a cost of $35,000. Upscale receives a total of $2160 (the $60 capitation fee per month for 36 months) for Wayne's care._\n\nWith capitation payment, hospitals are at risk for admissions, length of stay, and resources used; in other words, hospitals bear all the risk and the insurer, usually an HMO, bears no risk. Capitation payment to hospitals has almost disappeared as a method of payment.\n\n#### **Payment per Institution: Global Budget**\n\n_Don Samuels, a member of the Kaiser Health Plan, suffers a sudden overwhelming headache and is hospitalized for 1 week at Kaiser Hospital in Oakland, California, for an acute cerebral hemorrhage. He goes into a coma and dies. No hospital bill is generated as a result of Mr. Samuels' admission, and no capitation payments are made from any insurance plan to the hospital._\n\nKaiser Health Plan is a large integrated delivery system that in some regions of the United States operates its own hospitals. Kaiser hospitals are paid by the Kaiser Health Plan through a global budget: a fixed payment is made for all hospital services for 1 year. Global budgets are also used in Veterans Health Administration, Department of Defense, and local municipal or county hospitals in the United States, as well as being a standard payment method in Canada and many European nations. In managed care par-lance, one might say that the hospital is entirely at risk because no matter how many patients are admitted and how many expensive services are performed, the hospital must figure out how to stay within its fixed budget. Global budgets represent the most extensive bundling of services: Every service performed on every patient during 1 year is aggregated into one payment.\n\n### **CONCLUSION**\n\nDuring the 1990s, the push for cost containment created a movement to change\u2014in two ways\u2014how physicians and hospitals are paid:\n\n1. Private insurers, Medicare, and Medicaid often replaced fee-for-service payment, which encourages use of more services, with reimbursement mechanisms that place economic pressure on physicians and hospitals to limit the number and cost of services offered. The bundling of services into one payment tends to shift financial risk away from payers toward physicians and hospitals.\n\n2. Whereas levels of payment were formerly set largely by providers themselves (reasonable cost reimbursement for hospitals and usual, customary, and reasonable fees for physicians), payment levels are increasingly determined by negotiation between payers and providers or by fee schedules set by payers.\n\nThe second of these trends appears to be a permanent feature of provider payment. But the first change, the substitution of capitation and other bundled mechanisms in place of fee-for-service, was largely reversed for physician payment, although more bundled forms of payment are still common for hospital reimbursement. Fee-for-service made a comeback. However, with the accelerating health cost crisis, a great deal of discussion has been taking place since 2010 about reintroducing alternatives to fee for service.\n\nOne of the challenges in designing an optimal payment system is striking the right balance between economic incentives for overtreatment and undertreatment (Casalino, 1992). The British National Health Service has traditionally mixed units of payment for general practitioners, paying a global budget for overhead costs (eg, office rent and staff), a capitation payment for each patient enrolled in the practice, and fee-for-service payments selectively for preventive services (eg, vaccinations and Pap tests) and some home visits in order to encourage provision of these items. In the United States, some managed care organizations are following the British example, creating blended payments for physicians that include elements of both capitation and fee for service (Robinson, 1999). This innovation has the potential to balance overtreatment and undertreatment incentives.\n\n### **REFERENCES**\n\nBodenheimer T et al. The primary care-specialty income gap: Why it matters. _Ann Intern Med._ 2007;146:301.\n\nBrown J et al. Does Risk Adjustment Reduce Selection in the Private Health Insurance Market?, 2010. www.wcas.north-western.edu\/csio\/Conferences\/DugganPaper.pdf. Accessed November 23, 2011.\n\nCasalino LP. Balancing incentives: How should physicians be reimbursed? _JAMA_. 1992;267:403.\n\nLaw SA. _Blue Cross: What Went Wrong?_ New Haven, CT: Yale University Press; 1974.\n\nPham HH et al. Episode-Based Payments: Charting a Course for Health Care Payment Reform. Center for Studying Health System Change Policy Analysis, January 2010. www.hschange.com.\n\nRelman A. _Second Opinion: Rescuing America's Health Care_. New York: Public Affairs; 2007.\n\nRobinson JC. Blended payment methods in physician organizations under managed care. _JAMA_. 1999;282:1258.\n\nRobinson JC, Casalino LP. The growth of medical groups paid through capitation in California. _N Engl J Med._ 1995;333:1684.\n\nRodwin MA. _Medicine, Money, and Morals: Physicians' Conflicts of Interest_. New York, NY: Oxford University Press; 1993.\n\n## **5 How Health Care Is Organized\u2014I: Primary, Secondary, and Tertiary Care**\n\n_Frank Hope has walked with a limp since contracting polio in the 1940s. When he watches his daughter run after her young toddler, he feels a sense of gratitude that the era of vaccination has protected his child and grandchild from such a disabling infection. He recalls the excitement that gripped the nation as the Salk polio vaccine was first tested and then adopted into widespread use. In Frank's mind, these types of scientific breakthroughs attest to the wonders of the US health care system._\n\n_Frank's grandson attends a day-care program. Ruby, a 3-year-old girl in the program, was recently hospitalized for a severe asthma attack complicated by pneumococcal pneumonia. She spent 2 weeks in a pediatric intensive care unit, including several days on a respirator. Ruby's mother works full-time as a bus driver while raising three children. She has comprehensive private health insurance through her job but finds it difficult to keep track of all her children's immunization schedules and to find a physician's office that offers convenient appointment times. She takes Ruby to an evening-hours urgent care center when Ruby has some wheezing but never sees the same physician twice. Ruby never received all her pneumococcal vaccinations or consistent prescription of a steroid inhaler to prevent a severe asthma attack. Ruby's mother blames herself for her child's hospitalization._\n\nPeople in the United States rightfully take pride in the technologic accomplishments of their health care system. Innovations in biomedical science have almost eradicated scourges such as polio and measles and have allowed such marvels as organ transplantation, \"knifeless\" gamma-ray surgery for brain tumors, and intensive care technology that saves the lives of children with asthma complicated by pneumonia. Yet for all its successes, the health care system also has its failures. For example, asthma is the most common cause of hospitalization in childhood (Akinbami et al, 2009). Proper medical care can markedly reduce the frequency of severe asthma symptoms and of asthma hospital admissions. In cases such as Ruby's, the failure to prevent severe asthma flare-up is not related to financial barriers, but rather reflects organizational problems, particularly in the delivery of primary care and preventive services.\n\nThe organizational task facing all health care systems is one of \"assuring that the right patient receives the right service at the right time and in the right place\" (Rodwin, 1984). An additional criterion could be \"... and by the right caregiver.\" The fragmented care Ruby received for her asthma is an example of this challenge. Who is responsible for planning and ensuring that every child receives the right service at the right time? Can an urgent care center or an in-store clinic at Wal-Mart designed for episodic needs be held accountable for providing comprehensive care to all patients passing through its doors? Should parents be expected to make appointments for routine visits at medical offices and clinics, or should public health nurses travel to homes and day-care centers to provide preventive services out in the community? What is the proper balance between intensive care units that provide life-saving services to critically ill patients and primary care services geared toward less dramatic medical and preventive needs?\n\nThe previous chapters have emphasized financial transactions in the health care system. In this chapter and the following one, the organization of the health care system will be the main focus. While considerable debate has dwelled on how to improve financial access to care, less emphasis has been given to the question \"access to what?\" In this chapter, organizational systems will be viewed through a wide-angle lens, with emphasis on such broad concepts as the relationship between primary, secondary, and tertiary levels of care, and the influence of the biomedical paradigm and medical professionalism in shaping US health care delivery. In Chapter 6, a zoom lens will be used to focus on specific organizational models that have appeared (often only to disappear) in this country over the past century.\n\n### **MODELS OF ORGANIZING CARE**\n\n#### **Primary, Secondary, and Tertiary Care**\n\nOne concept is essential in understanding the topography of any health care system: the organization of care into primary, secondary, and tertiary levels. In the Lord Dawson Report, an influential British study written in 1920, the author (1975) proposed that each of the three levels of care should correspond with certain unique patient needs.\n\n1. Primary care involves common health problems (eg, sore throats, diabetes, arthritis, depression, or hypertension) and preventive measures (eg, vaccinations or mammograms) that account for 80% to 90% of visits to a physician or other caregiver.\n\n2. Secondary care involves problems that require more specialized clinical expertise such as hospital care for a patient with acute renal failure.\n\n3. Tertiary care, which lies at the apex of the organizational pyramid, involves the management of rare and complex disorders such as pituitary tumors and congenital malformations.\n\nTwo contrasting approaches can be used to organize a health care system around these levels of care: (1) the carefully structured Dawson model of regionalized health care and (2) a more free-flowing model.\n\n1. One approach uses the Dawson model as a scaffold for a highly structured system. This model is based on the concept of regionalization: the organization and coordination of all health resources and services within a defined area (Bodenheimer, 1969). In a regionalized system, different types of personnel and facilities are assigned to distinct tiers in the primary, secondary, and tertiary levels, and the flow of patients across levels occurs in an orderly, regulated fashion. This model emphasizes the primary care base.\n\n2. An alternative model allows for more fluid roles for caregivers, and more free-flowing movement of patients, across all levels of care. This model tends to place a higher value on services at the tertiary care apex than at the primary care base.\n\nAlthough most health care systems embody elements of both models, some gravitate closer to one polarity or the other. The British National Health Service (NHS) and some large integrated delivery systems in the United States resemble the regionalized approach, while US health care as a whole traditionally followed the more dispersed format.\n\n#### **The Regionalized Model: The Traditional British National Health Service**\n\n_Basil, a 60-year-old man living in a London suburb, is registered with Dr. Prime, a general practitioner in his neighborhood. Basil goes to Dr. Prime for most of his health problems, including hay fever, back spasms, and hypertension. One day, he experiences numbness and weakness in his face and arm. By the time Dr. Prime examines him later that day, the symptoms have resolved. Suspecting that Basil has had a transient ischemic attack, Dr. Prime prescribes aspirin and refers him to the neurologist at the local hospital, where a carotid artery sonogram reveals high-grade carotid stenosis. Dr. Prime and the neurologist agree that Basil should make an appointment at a London teaching hospital with a vascular surgeon specializing in head and neck surgery. The surgeon recommends that Basil undergo carotid endarterectomy on an elective basis to prevent a major stroke. Basil returns to Dr. Prime to discuss this recommendation and inquires whether the operation could be performed at a local hospital closer to home. Dr. Prime informs him that only a handful of London hospitals are equipped toperform this type of specialized operation. Basil schedules his operation in London and several months later has an uncomplicated carotid endarterectomy. Following the operation, he returns to Dr. Prime for his ongoing care._\n\nThe British NHS has traditionally typified a relatively regimented primary\u2014secondary\u2014tertiary care structure (Figure 5\u20131).\n\n**Figure 5\u20131.** Organization of services under the traditional National Health Service model in the United Kingdom. Care is organized into distinct levels corresponding to specific functions, roles, administrative units, and population bases.\n\n1. For physician services, the primary care level is virtually the exclusive domain of general practitioners (commonly referred to as GPs), who practice in small- to medium-sized groups and whose main responsibility is ambulatory care. Two-thirds of all physicians in the United Kingdom are GPs.\n\n2. The secondary tier of care is occupied by physicians in such specialties as internal medicine, pediatrics, neurology, psychiatry, obstetrics and gynecology, and general surgery. These physicians are located at hospital-based clinics and serve as consultants for outpatient referrals from GPs, in turn routing most patients back to GPs for ongoing care needs. Secondary-level physicians also provide care to hospitalized patients.\n\n3. Tertiary care subspecialists such as cardiac surgeons, immunologists, and pediatric hematologists are located at a few tertiary care medical centers.\n\nHospital planning follows the same regionalized logic as physician services. District hospitals are local facilities equipped for basic inpatient services. Regional tertiary care medical centers handle highly specialized inpatient care needs.\n\nPlanning of physician and hospital resources within the NHS occurs with a population focus. GP groups provide care to a base population of 5000 to 50,000 persons, depending on the number of GPs in the practice. District hospitals have a catchment area population of 50,000 to 500,000, while tertiary care hospitals serve as referral centers for a population of 500,000 to 5 million (Fry, 1980).\n\nPatient flow moves in a stepwise fashion across the different tiers. Except in emergency situations, all patients are first seen by a GP, who may then steer patients toward more specialized levels of care through a formal process of referral. Patients may not directly refer themselves to a specialist.\n\nWhile nonphysician health professionals, such as nurses, play an integral role in staffing hospitals at the secondary and tertiary care levels, especially noteworthy is the NHS' multidisciplinary approach to primary care. GPs work in close collaboration with practice nurses (similar to nurse practitioners in the United States), home health visitors, public health nurses, and midwives (who attend most deliveries in the United Kingdom). Such teamwork, along with accountability for a defined population of enrolled patients and universal health care coverage, helps to avert such problems as missed childhood vaccinations. Public health nurses visit all homes in the first weeks after a birth to provide education and assist with scheduling of initial GP appointments. A national vaccination tracking system notifies parents about each scheduled vaccination and alerts GPs and public health nurses if a child has not appeared at the appointed time. As a result, more than 85% of British preschool children receive a full series of immunizations. (The British NHS is discussed at greater length in Chapter 14.)\n\nA number of other nations, ranging from industrialized countries in Scandinavia to developing nations in Latin America, have adopted a similar approach to organizing health services. In developing nations, the primary care tier relies more on community health educators and other types of public health personnel than on physicians.\n\n#### **The Dispersed Model: Traditional United States Health Care Organization**\n\n_Polly Seymour, a 55-year-old woman with private health insurance who lives in the United States, sees several different physicians for a variety of problems: a dermatologist for eczema, a gastroenterologist for recurrent heartburn, and an orthopedist for tendinitis in her shoulder. She may ask her gastroenterologist to treat a few general medical problems, such as borderline diabetes. On occasion, she has gone to the nearby hospital emergency department for treatment of urinary tract infections. One day, Polly feels a lump in her breast and consults a gynecologist. She is referred to a surgeon for biopsy, which indicates cancer. After discussing treatment options with Polly, the surgeon performs a lumpectomy and refers her to an oncologist and radiation therapy specialist for further therapy. She receives all these treatments at a local hospital, a short distance from her home._\n\nThe US health care system has had a far less structured approach to levels of care than the British NHS. In contrast to the stepwise flow of patient referrals in the United Kingdom, insured patients in the United States, such as Polly Seymour, have traditionally been able to refer themselves and enter the system directly at any level. While many patients in the United Kingdom have a primary care physician (PCP) to initially evaluate all their problems, many people in the United States have become accustomed to taking their symptoms directly to the specialist of their choice.\n\nOne unique aspect of the US approach to primary care has been to broaden the role of internists and pediatricians. While general internists and general pediatricians in the United Kingdom and most European nations serve principally as referral physicians in the secondary tier, their US counterparts share in providing primary care. Moreover, the overlapping roles among \"generalists\" in the United States (GPs, family physicians, general internists, and general pediatricians) are not limited to the outpatient sector. PCPs in the United States have assumed a number of secondary care functions by providing substantial amounts of inpatient care. Only recently has the United States moved toward the European model that removes inpatient care from the domain of PCPs and assigns this work to \"hospitalists\"\u2014physicians who exclusively practice within the hospital (Wachter and Goldman, 1996).\n\nIncluding general internists and general pediatricians, the total supply of generalists amounts to approximately one-third of all physicians in the United States, a number well below the 50% or more found in Canada and many European nations (Starfield, 1998). To fill in the primary care gap, some physicians at the tertiary care level in the United States have also acted as PCPs for some of their patients. In contrast to physicians, nurse practitioners and physician assistants are more likely to work in primary care settings and are a key component of the nation's clinical workforce.\n\nUS hospitals are not constrained by rigid secondary and tertiary care boundaries. Instead of a pyramidal system featuring a large number of general community hospitals at the base and a limited number of tertiary care referral centers at the apex, hospitals in the United States each aspire to offer the latest in specialized care. In most urban areas, for example, several hospitals compete with each other to perform open heart surgery, organ transplants, radiation therapy, and high-risk obstetric procedures. The resulting structure resembles a diamond more than a pyramid, with a small number of hospitals (mostly rural) that lack specialized units at the base, a small number of elite university medical centers providing highly superspecialized referral services at the apex, and the bulk of hospitals providing a wide range of secondary and tertiary services in the middle.\n\n#### **Which Model Is Right?**\n\nCritics of the US health care system find fault with its \"top-heavy\" specialist and tertiary care orientation and lack of organizational coherence. Analyses of health care in the United States over the past half century abound with such descriptions as \"a nonsystem with millions of independent, uncoordinated, separately motivated moving parts,\" \"fragmentation, chaos, and disarray,\" and \"uncontrolled growth and pluralism verging on anarchy\" (Somers, 1972; Halvorson and Isham, 2003). The high cost of health care has been attributed in part to this organizational disarray. Quality of care may also suffer. For example, when many hospitals each perform small numbers of surgical procedures such as coronary artery bypass grafts, mortality rates are higher than when such procedures are regionalized in a few higher-volume centers (Grumbach et al, 1995).\n\nDefenders of the dispersed model reply that pluralism is a virtue, promoting flexibility and convenience in the availability of facilities and personnel. In this view, the emphasis on specialization and technology is compatible with values and expectations in the United States, with patients placing a high premium on direct access to specialists and tertiary care services, and on autonomy in selecting caregivers of their choice for a particular health care need. Similarly, the desire for the latest in hospital technology available at a convenient distance from home competes with plans to regionalize tertiary care services at a limited number of hospitals.\n\n#### **Balancing the Different Levels of Care**\n\n_Dr. Billie Ruben completed her residency training in internal medicine at a major university medical center. Like most of her fellow residents, she went on to pursue subspecialty training, in her case gastroenterology. Dr. Ruben chose this career after caring for a young woman who developed irreversible liver failure following toxic shock syndrome. After a nerve-racking, touch-and-go effort to secure a donor liver, transplantation was performed and the patient made a complete recovery._\n\n_Upon completion of her training, Dr. Ruben joined a growing subspecialty practice at Atlantic Heights Hospital, a successful private hospital in the city. Even though the metropolitan area of 2 million people already has two liver transplant units, Atlantic Heights has just opened a third such unit, feeling that its reputation for excellence depends on delivering tertiary care services at the cutting edge of biomedical innovation. In her first 6 months at the hospital, Dr. Ruben participates in the care of only two patients requiring liver transplantation. Most of her patients seek care for chronic, often illdefined abdominal pain and digestive problems. As Dr. Ruben begins seeing these patients on a regular basis, she starts to give preventive care and treat nongastrointestinal problems such as hypertension and diabetes. At times she wishes she had experienced more general medicine during her training._\n\nAdvocates of a stronger role for primary care in the United States believe that it is too important to be considered an afterthought in health planning. In this view, overemphasis on the tertiary care apex of the pyramid creates a system in which health care resources are not well matched to the prevalence and incidence of health problems in a community. In an article entitled \"The Ecology of Medical Care\" published more than four decades ago, Kerr White recorded the monthly prevalence of illness for a general population of 1000 adults (White et al, 1961). In this group, 750 experienced one or more illnesses or injuries during the month. Of these patients, 250 visited a physician at least once during the month, nine were admitted to a hospital, and only one was referred to a university medical center. Dr. White voiced concern that the training of health care professionals at tertiary care\u2013oriented academic medical centers gave trainees like Dr. Billie Ruben an unrepresentative view of the health care needs of the community.\n\n_Serious questions can be raised about the nature of the average medical student's experience, and perhaps that of some of this student's clinical teachers, with the substantive problems of health and disease in the community. In general, this experience must be both limited and unusually biased if, in a month, only 0.0013 of the \"sick\" adults.... or 0.004 of the patients . . . . in a community are referred to university medical centers. . . . Medical, nursing, and other students of the health professions cannot fail to receive unrealistic impressions of medicine's task in contemporary Western society. . . . (White et al, 1961)_\n\nUpdating Kerr White's findings, Larry Green found precisely the same patterns four decades later (Green et al, 2001).\n\nAn English GP, John Fry (1980) conducted a related study of the ecology of care, in which he systematically recorded the types of health problems that brought patients to his office in the 1970s. Because of the GP's function as a gatekeeper under the NHS, Dr. Fry's investigation provides a close approximation of the full incidence and prevalence of diseases requiring medical attention among his population of registered patients (Table 5\u20131). The dominant pathology in this unselected population consisted of minor ailments (many of which would have improved without treatment), chronic conditions such as hypertension and arthritis, and gradations of mental illness. The incidence of new cancers was relatively rare, and only a handful of patients manifested complex syndromes such as multiple sclerosis. Although the specific pattern of illnesses differs for a US family physician practicing in the 21st century compared with the pattern for a British GP in the 1970s (eg, human immunodeficiency virus infection and Alzheimer disease do not appear in Table 5\u20131), the general pattern remains true. Dr. Fry's study confirms the adage that \"common disorders commonly occur and rare ones rarely happen.\"\n\n**Table 5\u20131.** Persons per year seeking care in a general practitioner practice with a registered population of 2500, according to problem\n\nAlthough these analyses suggest that most health needs can be met at the primary care level, this observation should not imply that most health care resources should be devoted to primary care. The minority of patients with severe or complicated conditions requiring secondary or tertiary care will command a much larger share of health care resources per capita than the majority of people with less dramatic health care needs. Treating a patient with liver failure costs a great deal more than treating a patient for a sore throat. Even in the United Kingdom, where the 65% of physicians who are GPs provide 60% of all ambulatory care, expenditures on their services account for less than 10% of the overall NHS budget, whereas the cost of inpatient and outpatient hospital care at the secondary and tertiary levels consumes nearly two-thirds of the budget. Thus, the pyramidal shape shown in Figure 5\u20131 better represents the distribution of health care problems in a community than the apportionment of health care expenditures. While almost all industrialized nations devote a dominant share of health care resources to secondary and tertiary care, the ecologic view reminds us that most people have health care needs at the primary care level.\n\n#### **The Functions and Value of Primary Care**\n\n_Dr. O. Titus Wells has cared for all six of Bruce and Wendy Smith's children. As a family physician whose practice includes obstetrics, Dr. Wells attended the births of all but one of the children. The Smiths' 18-month-old daughter Ginny has had many ear infections. Even though this is a common problem, Dr. Wells finds that it presents a real medical challenge. Sometimes examination of Ginny's ears indicates a raging infection and at other times shows the presence of middle ear fluid, which may or may not represent a bona fide bacterial infection. He tries to reserve antibiotics for clear-cut cases of bacterial otitis. He feels it is important that he be the one to examine Ginny's ears because her eardrums never look entirely normal and he knows what degree of change is suspicious for a genuinely new infection._\n\n_When Ginny is 2 years old, Dr. Wells recommends to the Smiths that she see an otolaryngologist andaudiologist to check for hearing loss and language impairment. The audiograms show modest diminution of hearing in one ear. The otolaryngologist informs the Smiths that ear tubes are an option. At Ginny's return visit with Dr. Wells, he discusses the pros and cons of tube placement with the Smiths. He also uses the visit as an opportunity to encourage Mrs. Smith to quit smoking, mentioning that research has shown that exposure to tobacco smoke may predispose children to ear infections._\n\nBarbara Starfield, one of the world's foremost scholars in the field of primary care, conceptualized the key tasks of primary care as (1) first contact care, (2) longitudinality, (3) comprehensiveness, and (4) coordination. Dr. Wells' care of the Smith family illustrates these essential features of primary care. He is the first-contact physician performing the initial evaluation when Ginny or other family members develop symptoms of illness. _Longitudinality_ (or _continuity_ ) refers to sustaining a patient\u2013caregiver relationship over time. Dr. Wells' familiarity with Ginny's condition helps him to better discern an acute infection. Comprehensiveness consists of the ability to manage a wide range of health care needs, in contrast with specialty care, which focuses on a particular organ system or procedural service. Dr. Wells' comprehensive, family-oriented care makes him aware that Mrs. Smith's smoking cessation program is an important part of his treatment plan for Ginny. Coordination builds upon longitudinality. Through referral and follow-up, the primary care provider integrates services delivered by other caregivers. These tasks performed by Dr. Wells meet the definition of primary care as defined by the Institute of Medicine: \"Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with patients, and practicing in the context of family and community\" (Institute of Medicine, 1996).\n\nA functional approach helps characterize which health care professionals truly fill the primary care niche. Among physicians in the United States, family physicians, general internists, and general pediatricians typically provide first contact, longitudinal, comprehensive, coordinated care. Emergency medicine physicians provide first contact care that may be relatively comprehensive for acute problems, but they do not provide continuity of care or coordinate care for patients on an ongoing basis. Some obstetrician-gynecologists provide first contact and longitudinal care, but usually only for reproductive health conditions; it is the rare obstetrician-gynecologist who is trained and inclined to comprehensively care for the majority of a woman's health needs throughout the lifespan (Rivo et al, 1994). Similarly, a patient with kidney failure or a patient with cancer may have a strong continuity of care relationship with a nephrologist or an oncologist, but these medical subspecialists rarely assume responsibility for comprehensive care of clinical problems outside of their specialty area or coordinate most ancillary and referral services (Rosenblatt et al, 1998).\n\nIn addition to physicians, many generalist nurse practitioners and physician assistants in the United States deliver the four key Starfield functions and serve as primary care providers for their patients. Research performed in a selected number of practices have demonstrated comparable quality of care for patients treated by primary care physicians and nurse practitioners (Horrocks et al, 2002).\n\nStudies have found that the core elements of good primary care advance the \"triple aims\" of health system improvement: better patient experiences, better patient outcomes, and lower costs (Starfield, 1998). For example, continuity of care is associated with greater patient satisfaction, higher use of preventive services, reductions in hospitalizations, and lower costs (Saultz and Albedaiwi, 2004; Saultz and Lochner, 2005). There is evidence that having a regular source of care results in better control of hypertension and less reliance on emergency department services (Shea et al, 1992). A Canadian study found that children undergoing tonsil-lectomy were more likely to have the operation performed for appropriate indications when they were referred to the otolaryngologist by a pediatrician than when care was directly sought from the otolaryngologist (Roos, 1979). Persons whose care meets a primary care\u2013oriented model have better perceived access to care are more likely to receive recommended preventive services, are more likely to adhere to treatment, and are more satisfied with their care (Bindman et al, 1996; Stewart et al, 1997; Safran et al, 1998). International comparisons have indicated that nations with a greater primary care orientation tend to have more satisfied patients and better performance on health indicators such as infant mortality, life expectancy, and total health expenditures (Starfield et al, 2005). Within the United States, states with more PCPs per capita have lower total mortality rates, lower heart disease and cancer mortality rates, and higher life expectancy at birth compared with states having fewer PCPs, adjusting for other factors such as age and per capita income. In contrast, increases in specialist supply are associated with greater costs but not improved quality (Starfield et al, 2005). In an analysis of quality and cost of care across states for Medicare beneficiaries, Baicker and Chandra (2004) found that states with more PCPs per capita had lower per capita Medicare costs and higher quality. States with more specialists per capita had lower quality and higher per capita Medicare expenditures.\n\n#### **Care Coordination and \"Gatekeeping\"**\n\n_Polly Seymour, described earlier in the chapter, feels terrible. Every time she eats, she feels nauseated and vomits frequently. She has lost 8 pounds, and her oncologist is worried that her breast cancer has spread. She undergoes blood tests, an abdominalCT scan, and a bone scan, all of which are normal. She returns to her gastroenterologist, who tells her to stop the ibuprofen she has been taking for tendinitis. Her problem persists, and the gastroenterologist performs an endoscopy, which shows mild gastric irritation. A month has passed, $3000 has been spent, and Polly continues to vomit._\n\n_Polly's friend Martha recommends a nurse practitioner who has been caring for Martha for many years and who, in Martha's view, seems to spend more time talking with patients than do many physicians. Polly makes an appointment with the nurse practitioner, Sara Steward. Ms. Steward takes a complete history, which reveals that Polly is taking tamoxifen for her breast cancer and that she began to take aspirin after stopping the ibuprofen. Ms. Steward explains that either of these medications can cause vomiting and suggests that they be stopped for a week. Polly returns in a week, her nausea and vomiting resolved. Ms. Steward then consults with Polly's oncologist, and together they decide to restart the tamoxifen but not the aspirin. Polly becomes nauseated again, but eventually begins to feel well and gains weight while taking a reduced dose of tamoxifen. In the future, Ms. Steward handles Polly's medical problems, referring her to specialty physicians when needed, and making sure that the advice of one consultant does not interfere with the therapy of another specialist._\n\nA concept that incorporates many of the elements of primary care is that of the primary care provider as gatekeeper. Gatekeeping took on pejorative connotations in the heyday of managed care, when, as described in Chapter 4, some types of financial arrangements with PCPs provided incentives for them to \"shut the gate\" in order to limit specialist referrals, diagnostic tests, and other services (Grumbach et al, 1998). A more accurate designation of the role of the PCP in helping patients navigate the complexities of the health care system is that of coordinator of care (Franks et al, 1992). Stories such as Polly's demonstrate the importance of having a generalist care coordinator who can advocate on behalf of his or her patients and work in partnership with patients to integrate an array of services involving multiple providers to avoid duplication of services, enhance patient safety, and care for the whole person.\n\n#### **The Patient-Centered Medical Home**\n\n_Dr. Retro is counting the days until he can retire from his solo practice of family medicine. He feels overwhelmed most days. The next available appointment in his office is in 10 weeks, and patients call every day frustrated about not being able to get appointments. A health plan just sent him a quality report card indicating that many diabetic patients in his practice have not achieved the targeted levels of control of their blood sugar, blood pressure, and lipids. He is also behind in keeping his patients up to date on their mammograms and colorectal cancer screening. Many days he has trouble finding information in the thick paper medical records about when his patients last received their preventive care services or diabetic tests. He was hoping to recruit a new family medicine residency graduate to take over his practice, but most young physicians in his region are pursuing more highly paid careers in non-primary care specialties._\n\n_Dr. Avantgard has always embraced innovation. When she read a series of articles in the Journal of the American Medical Association about new primary care practice models (Bodenheimer and Grumbach, 2007), she proposed to her 3 physician and 2 nurse practitioner partners that their primary care practice become a Patient Centered Medical Home. Dr. Avantgard starts by identifying a consultant to help the practice completely revamp their scheduling system to a \"same-day\" appointment system, where 50% of appointment slots are to be left unbooked until the day prior so that patients can call and be guaranteed a same day or next day appointment. Despite her partners' concerns about being overrun with patient appointments, the new scheduling system results in the same number of patients being seen each day, but with happier patients who are delighted to be able to get prompt access to care. The practice buys an electronic medical record system and uses the EMR to develop registries of all the patients in the practice due for preventive and chronic care services. Dr. Avantgard and her associates train their medical assistants to use the EMR, along with standing orders, to proactively order mammograms and blood lipid tests whendue and to administer vaccinations and screen for depression during patient intake at medical visits. Now that many of the routine preventive and chronic care tasks are being capably handled by other staff, Dr. Avantgard and her clinician colleagues have more time during office visits to focus on the problems patients want to talk with them about and to work through complex medical problems. With the quality indicators and patient satisfaction scores for the practice rising to the top decile of scores for practitioners in the region, Dr. Avantgard plans to start negotiations with several health plans to add a monthly care coordination payment to the current fee-for-service payments they pay, so that the practice can be compensated for all the work they perform in care coordination outside of office visits._\n\nBy the turn of the 21st century, primary care in the US had reached a critical juncture (Bodenheimer, 2006). In 2006, the American College of Physicians sounded the alarm about an \"impending collapse of primary care medicine\" (American College of Physicians, 2006). Primary care clinicians like Dr. Retro struggled to meet patient demands for accessible, comprehensive, well-coordinated care. Many gaps in quality existed, and care often fell short of being patient centered. PCPs were demoralized by outmoded practice models ill-equipped to meet the demands of modern-day primary care and an ever-widening gap between their take-home pay and the escalating earnings of specialists. In response to this crisis, the 4 major professional organizations representing the nation's primary care physicians\u2014the American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, and American Osteopathic Association\u2014came together in 2007 and issued a report on a shared vision for reform of primary care. The _Joint Principles of a Patient-Centered Medical Home_ has served as a rallying point for building a broad movement to revitalize primary care in the US (Grundy et al, 2010).\n\nThe term \"medical home\" dates back to 1967, when it was first used by the American Academy of Pediatrics to describe the notion of a primary care practice that would coordinate care for children with complex needs. While the _Joint Principles_ have several specific elements, Rittenhouse and Shortell (2009) have provided a straightforward conceptualization of the patient-centered medical home as consisting of four basic cornerstones: primary care, patient-centered care, new-model practice, and payment reform. This framework begins by reaffirming the fundamental functions of primary care and the goal of delivering accessible, comprehensive, longitudinal, and coordinated care. The concept then builds on those foundational principles by calling for greater attention to patient-centeredness, such as the type of same-day scheduling methods adopted by Dr. Avantgard; implementation of innovative practice models, such as Dr. Avantgard's development of team-care models that reengineer workflows and tasks; and changes in physician payment, such as blending fee-for-service with partial capitation and quality incentives. Another perspective on the patient-centered medical home is shown in Table 5\u20132.\n\n**Table 5\u20132.** \"Old\" and \"new\" model primary care: some elements of transforming a practice into a patient-centered medical home\n\nThe primary care reform movement in the United States has gathered momentum, with many large employers and consumer groups joining the physician organizations authoring the _Joint Principles_ and other health professional groups to form the Patient Centered Primary Care Collaborative (Grundy et al, 2010). The Collaborative advocates and provides technical assistance for policy reforms to support primary care and transformation of practices into patient-centered medical homes. The push to enact the Affordable Care Act in 2010 focused lawmakers' attention on primary care. President Obama and many members of Congress recognized that expanding insurance coverage requires an adequate primary care workforce to provide first contact care for millions of newly insured people. The Affordable Care Act includes several measures to strengthen primary care, including increases in Medicare fees for primary care and support of patient-centered medical home reforms. Evaluation of the first wave of practices and systems implementing the types of practice innovations called for under patient-centered medical home reforms have demonstrated improvements in patient satisfaction and quality of care and reductions in use of costly emergency department and hospital services (Grumbach and Grundy, 2010). Whether the new-found enthusiasm for reform and renewal of primary care can be sustained and lead to a fundamental reorientation of the health system in the United States remains to be determined.\n\n### **FORCES DRIVING THE ORGANIZATION OF HEALTH CARE IN THE UNITED STATES**\n\n#### **The Biomedical Model**\n\nThe growth of the dispersed mode of health care delivery in the United States was shaped by several forces. One factor was the preeminence of the biomedical model among medical educators and young physicians throughout the 20th century. The combination of stricter state licensing laws and an influential national study, the Flexner report of 1906, led to consolidation of medical training in academically oriented medical schools (Starr, 1982). These academic centers embraced the biomedical paradigm that was the legacy of such renowned 19th-century European microbiologists as Pasteur and Koch. The antimicrobial model engendered the faith that every illness has a discrete, ultimately knowable cause and that \"magic bullets\" can be crafted to eradicate these sources of disease. Physicians were trained to master pathophysiologic changes within a particular organ system, leading to the development of specialization (Luce and Byyny, 1979).\n\nAdvocates of a larger role for generalism and primary care in US health care have not so much rejected the concepts of scientific medicine and professional specialism as they have attempted to broaden the interpretation of these terms. They have called for a more integrated scientific approach to understanding health and illness that incorporates information about the individual's psychosocial experiences and family, cultural, and environmental context as well as physiologic and anatomic constitution (Engel, 1977). The attempt to more rigorously define the scientific and clinical basis of generalism contributed to the emergence of family medicine in the 1970s as a specialty discipline in its own right, and the 1-year general practice internship was replaced by a 3-year residency program and specialty board certification.\n\n#### **Financial Incentives**\n\nA second and related factor influencing the structure of health care was the financial incentive for physician specialization and hospital expansion, which played out in a number of ways.\n\n1. Insurance benefits first offered by Blue Cross covered hospital costs but not physician visits and other outpatient services.\n\n2. As physician services came to be covered later under Blue Shield and other plans, a growing differential in reimbursement between generalist and specialist physicians developed. New technologic and other procedures often required considerable physician time when first introduced, and higher fees were justified for these procedures. But as the procedures became routine, fees remained high, while the time and effort required to perform them declined (Starr, 1982); this resulted in an increasing disparity in income between PCPs and specialists (Bodenheimer et al, 2007). In the mid-1980s, the average PCP's income was 75% of the average specialist's income; by 2006, PCP income had dropped to only 50% of specialists' income (Council of Graduate Medical Education, 2010). As Figure 5\u20132 shows, the percentage of graduating medical students planning to enter careers in primary care tracks the PCP-specialist income gap closely, with the proportion of students entering primary care decreasing as the earnings of PCPs relative to specialists declines.\n\n**Figure 5\u20132.** Proportion of US medical students entering primary care strongly tracks relative incomes of primary care physicians. The figure shows trends over time in the average income of primary care physicians relative to specialist physicians in the United States, and in the percentage of graduating medical students in the United States planning on entering careers in primary care. In 1990, when the average primary care physician income was about half that of specialists, fewer than 20% of graduating students planned to enter primary care fields. By 1997, when primary care physician incomes had risen to more than 60% that of specialists, the proportion of graduating students entering primary care had increased in a parallel direction with 40% of graduates planning to enter primary care fields in 1997. Both relative incomes and intentions to enter primary care decreased after 1997. (From the Council on Graduate Medical Education. _Twentieth Report: Advancing Primary Care,_ December 2010).\n\n3. Federal involvement in health care financing further fueled the expansion of hospital care and specialization. The Hill\u2013Burton Hospital Construction Act of 1946 allocated nearly $4 billion between 1946 and 1971 for expansion of hospital capacity rather than development of ambulatory services (Starr, 1982). The enactment of Medicare and Medicaid in 1965 perpetuated the private insurance tradition of higher reimbursement for procedurally oriented specialists than for generalists. Medicare further encouraged specialization through its policy of extra payments to hospitals to cover costs associated with residency training. Linking Medicare teaching payments to the hospital sector added yet another bias against community-based primary care training.\n\nThe growth of hospitals and medical specialization was intertwined. As medical practice became more specialized and dependent on technology, the site of care increasingly shifted from the patient's home or physician's office to the hospital. The emphasis on acute hospital care had an effect on the nursing profession comparable to that on physicians. World War I was a watershed period in the transition of nursing from a community-based to a hospital-based orientation. During the war, US military hospitals overseas were much heralded for their success in treating acute war injuries. At the war's conclusion, the nation rallied behind a policy of boosting the civilian hospital sector. According to Rosemary Stevens (1989),\n\n_Before the war, public-health nursing was the elite area; nurses had been instrumental in the campaigns against tuberculosis and for infant welfare. In contrast, the war emphasized the supremacy and glamour of hospitals. . . . nurses, like physicians, were trained\u2014and ready\u2014to perform in an increasingly specialized, acute-care medical environment rather than to expand their interests in social medicine and public health (Stevens, 1989)._\n\n#### **Professionalism**\n\nThe final factor accounting for the organizational evolution of US health care delivery was the nature of control over health planning. The United States is unique in its relative laxity of public regulation of health care resources. In most industrialized nations, governments wield considerable control over health planning through measures such as regulation of hospital capacity and technology, allocation of the number of residency training positions in generalist and specialist fields, and coordination of public health with medical care services. In the United States, the government has provided much of the financing for health care, but without an attendant degree of administrative control. The Hill\u2013Burton program, for example, did not make grants for hospital construction contingent upon any rigorous community-wide plan for regionalized hospital services. Medicare funding for physician training did not stipulate any particular distribution of residency positions according to specialty.\n\nWith government controls kept largely at bay, the professional \"sovereignty\" of physicians emerged as the preeminent authority in health care (Starr, 1982). Societies grant certain occupations special status as \"professions\" because of the unique knowledge and skill required of members of the profession, and the expectation that this knowledge and skill will be applied beneficially (Friedson, 1970; Light and Levine, 1988). Professionalism thus involves a social contract; in return for the privilege of autonomy, physicians bear the responsibility for acting as the patient's agent, and the profession must regulate itself to preserve the public trust.\n\nTheir professional status vested physicians with special authority to guide the development of the US health care system. As described in Chapter 2, third-party payment for physician services was established with physician control of the initial Blue Shield insurance plans. Physician judgment about the need for technology and greater inpatient capacity drove the expansion of hospital facilities.\n\nWhat was the nature of the profession that so heavily influenced the development of the US health care organization? It was a profession that, because of the primacy of the biomedical paradigm and the nature of financial incentives, was weighted toward hospital and specialty care. Small wonder that US health care has emphasized its tertiary care apex over its primary care base. In Chapter 16, we discuss the shifting power relationships in health care that are challenging the professional dominance of physicians.\n\n### **CONCLUSION**\n\n_Jeff leaves a town forum at the local medical center feeling confused. It featured two speakers, one of whom criticized the medical center as being out of touch with the community's needs, and the other of whom defended the center's contributions to society. Jeff found the first speaker very convincing about the need to pay more attention to primary care, prevention, and public health. He had never had a regular primary care physician, and the idea of having a family physician appealed to him. He was equally impressed by the second speaker, whose account of how research atthe medical center had led to life-saving treatment of children with a hereditary blood disorder was very moving, and whose description of the hospital's plan for a new imaging center was spellbinding. Jeff felt that if he ever became seriously ill, he would certainly want all the specialized services the medical center had to offer._\n\nThe professional model and the biomedical paradigm are responsible for many of the attractive characteristics of the US health care system. The biomedical model has instilled respect for the scientific method and has helped to curtail medical quackery. Professionalism has directed physicians to serve as agents acting in their patients' best interests and has made the practice of medicine more than just another business. Expansion of hospital facilities has meant that people with health insurance have had convenient access to tertiary care services and new technology. Patients have been able to take advantage of the expertise and availability of a wide variety of specialists. In many circumstances, the system is well organized to deliver the \"right care.\" For a patient in cardiogenic shock, the right place to be is an intensive care unit; for a patient with a detached retina, an ophthalmologist's office is the right place to be.\n\nHowever, there is widespread concern that despite the benefits of biomedical science and medical professionalism, the US health care system is precariously off balance. A model of excellence focused on specialization, technology, and curative medicine has led to relative inattention to basic primary care services, including such needs as disease prevention and supportive care for patients with chronic and incurable ailments. The value placed on individualism and autonomy for health care professionals and institutions has contributed to a pluralistic delivery system in which care is often fragmented and lacking coordination. A system that prizes specialists who focus on organ systems and researchers who concentrate on splitting genes has bred apprehension that health care has somehow lost sight of the whole person and the whole community. The net result is a system structured to perform miraculous feats for individuals who are ill, but at great expense and often without satisfactorily attending to the full spectrum of health care needs of the entire population. During the 2009 debate in Congress leading up to the passage of the Affordable Care Act, one of the harshest critiques of the status quo in US health care came not from a Congressional Democrat, but from Senator Orrin Hatch, the senior Republican Senator from Utah. At a hearing on health reform, Senator Hatch said, \"The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine. How do we transform the system to do this?\" (Grundy et al, 2010).\n\n### **REFERENCES**\n\nAkinbami LJ et al. Status of childhood asthma in the United States, 1980\u20132007. _Pediatrics_. 2009;123(Suppl 3):S131-45.\n\nAmerican College of Physicians. _The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care_. January 30, 2006. <http:\/\/www.acponline.org\/advocacy\/events\/state_of_healthcare\/statehc06_1.pdf>.\n\nBaicker K, Chandra A. Medicare spending, the physician work-force, and beneficiaries' quality of care. _Health Aff (Millwood)_. 2004:W4-184.\n\nBindman AB et al. Primary care and receipt of preventive services. _J Gen Intern Med_. 1996;11:269.\n\nBodenheimer T. Regional medical programs: No road to regionalization. _Med Care Rev_. 1969;26:1125.\n\nBodenheimer T. Primary care\u2014will it survive? _N Engl J Med_. 2006;355:861.\n\nBodenheimer T et al. The primary care-specialty income gap: Why it matters. _Ann Intern Med_. 2007;146:301.\n\nBodenheimer T, Grumbach K. _Improving Primary Care. Strategies and Tools for a Better Practice_. New York, NY: McGraw-Hill; 2007.\n\nCouncil on Graduate Medical Education. _Twentieth Report: Advancing Primary Care_ , December 2010.\n\nDawson W. Interim report on the future provision of medical and allied services. In: Saward EW, ed. _The Regionalization of Personal Health Services_. London, England: Prodist; 1975.\n\nEngel GL. The need for a new medical model: A challenge for biomedicine. _Science_. 1977;196:129.\n\nFranks P et al. Gatekeeping revisited: Protecting patients from overtreatment. _N Engl J Med_. 1992;327:424.\n\nFriedson E. _Professional Dominance: The Social Structure of Medicine_. Atherton, CA: Atherton Publishing; 1970.\n\nFry J. Primary care. In: Fry J, ed. _Primary Care_. London, England: William Heinemann; 1980.\n\nGreen LA et al. The ecology of medical care revisited. _N Engl J Med_. 2001;344:2021.\n\nGrumbach K, Grundy P. _Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of EvidenceFrom Prospective Evaluation Studies in the United States_. Washington, DC: Patient Centered Primary Care Collaborative, 2010. <http:\/\/www.pcpcc.net\/files\/evidence_outcomes_in_pcmh.pdf>.\n\nGrumbach K et al. Primary care physicians' experience of financial incentives in managed care systems. _N Engl J Med_. 1998;339:1516.\n\nGrumbach K et al. Regionalization of cardiac surgery in the United States and Canada: Geographic access, choice, and outcomes. _JAMA_. 1995;274:1282.\n\nGrundy P et al. The multi-stakeholder movement for primary care renewal and reform. _Health Affairs_. 2010;29:791.\n\nHalvorson GC, Isham GJ. _Epidemic of Care_. San Francisco, CA: Jossey-Bass; 2003.\n\nHorrocks S et al. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. _BMJ_. 2002;324:819.\n\nInstitute of Medicine. _Primary Care: America's Health in a New Era._ Washington, DC: National Academies Press; 1996.\n\nLight D, Levine S. The changing character of the medical profession: A theoretical overview. _Milbank Mem Fund Q_. 1988;66:10.\n\nLuce JM, Byyny RL. The evolution of medical specialism. _Perspect Biol Med_. 1979;22:377.\n\nRivo ML et al. Defining the generalist physician's training. _JAMA_. 1994;271:1499.\n\nRodwin VG. _The Health Planning Predicament._ Berkeley, CA: University of California Press; 1984.\n\nRoos N. Who should do the surgery? Tonsillectomy-adenoidectomy in one Canadian province. _Inquiry_. 1979;16:73.\n\nRosenblatt RA et al. The generalist role of specialty physicians: is there a hidden system of primary care? _JAMA_. 1998;279:1364.\n\nSafran DG et al. Linking primary care performance to outcomes of care. _J Fam Pract_. 1998;47:213.\n\nSaultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: A critical review. _Ann Fam Med_. 2004;2:445.\n\nSaultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. _Ann Fam Med_. 2005;3:159.\n\nShea S et al. Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. _N Engl J Med_. 1992;327:776.\n\nSomers AR. Who's in charge here? Alice searches for a king in Mediland. _N Engl J Med_. 1972;287:849.\n\nStarfield B. _Primary Care._ New York, NY: Oxford University Press; 1998.\n\nStarfield B et al. Contribution of primary care to health systems and health. _Milbank Q_. 2005;83:457.\n\nStarr P. _The Social Transformation of American Medicine_. New York, NY: Basic Books; 1982.\n\nStevens R. _In Sickness and in Wealth: American Hospitals in the Twentieth Century._ New York, NY: Basic Books; 1989.\n\nStewart AL et al. Primary care and patient perceptions of access to care. _J Fam Pract_. 1997;44:177.\n\nWachter RM, Goldman L. The emerging role of \"hospitalists\" in the American health care system. _N Engl J Med_. 1996;335:514.\n\nWhite KL et al. The ecology of medical care. _N Engl J Med_. 19; 265:885.\n\n## **6 How Health Care Is Organized\u2014II: Health Delivery Systems**\n\nThe last chapter explored some general principles of health care organization, including levels of care, regionalization, physician and other practitioner roles, and patient flow through the system. This chapter looks more closely at actual structures of medical practice.\n\nThe traditional dispersed model of the US medical practice has been referred to as a \"cottage industry\" of independent private physicians working as solo practitioners or in small groups. A number of alternative organizational forms have existed in the United States, ranging from community health centers to prepaid group practices. The traditional model is in competition with a system of larger practice organizations and networks structured along a more integrated model of health care delivery.\n\n### **THE TRADITIONAL STRUCTURE OF MEDICAL CARE**\n\n#### **Physicians and Hospitals**\n\n_Dr. Harvey Commoner finished his residency in general surgery in 1956. For the next 30 years, he and another surgeon practiced medicine together in a middle-class suburb near St. Peter's Hospital, a nonprofit church-affiliated institution. Dr. Commoner received most of his cases from general practitioners and internists on the St. Peter's medical staff. By 1965, the number of surgeons operating at St. Peter's had grown. Because Dr. Commoner was not getting enough cases, he and his partner joined the medical staff of Top Dollar Hospital, a for-profit facility 3 miles away, and University Hospital downtown. On an average morning, Dr. Commoner drove to all three hospitals to perform operations or to do postoperative rounds on his patients. The afternoon was spent seeing patients in his office. He was on call every other night and weekend._\n\n_Dr. Commoner was active on the St. Peter's medical staff executive committee, where he frequently proposed that the hospital purchase new radiology and operating room equipment needed to keep up with advances in surgery. Because the hospital received hundreds of thousands of dollars each year for providing care to Dr. Commoner's patients, and because Dr. Commoner had the option of admitting his patients to Top Dollar or University, the St. Peter's administration usually purchased the items that Dr. Commoner recommended. The Top Dollar Hospital administrator did likewise._\n\nDuring the period when Dr. Commoner was practicing, most medical care was delivered by fee-for-service private physicians in solo or small group practices. Most hospitals were private nonprofit institutions, sometimes affiliated with a religious organization, occasionally with a medical school, often run by an independent board of trustees composed of prominent people in the community. Most physicians in traditional fee-for-service practice were not employees of any hospital, but joined one or several hospital medical staffs, thereby gaining the privilege of admitting patients to the hospital and at times acquiring the responsibility to assist the hospital through work on medical staff committees or by caring for emergency department patients who have no physician.\n\nFor many years, the physicians were the dominant power in the hospital, because physicians admit the patients, and hospitals without patients have no income. Because physicians were free to admit their patients to more than one hospital, the implicit threat to take their patients elsewhere gave them influence. Under traditional fee-for-service medicine, physicians used informal referral networks, often involving other physicians on the same hospital medical staff. In metropolitan areas with a high ratio of physician specialists to population, referrals could become a critical economic issue. Most surgeons obtained their cases by referral from primary care physicians (PCPs) or medical specialists; surgeons like Dr. Commoner who were not readily available when called soon found their case load drying up.\n\n### **THE SEEDS OF NEW MEDICAL CARE STRUCTURES**\n\nThe dispersed structure of independent fee-for-service private practice was not always the dominant model in the United States. When modern medical care took root in the first half of the twentieth century, a variety of structures blossomed. Among these were multispecialty group practices, community health centers, and prepaid group practices. Some of these flourished but then wilted, while others became the seeds from which the future health care system of the twenty-first century may germinate.\n\n#### **Multispecialty Group Practice**\n\n_In 1905, Dr. Geraldine Giemsa joined the department of pathology at the Mayo Clinic. The clinic, led by the brothers William and Charles Mayo, was becoming a nationally renowned referral center for surgery and was recruiting pathologists, microbiologists, and other specialized diagnosticians to support the work of the clinic's group of surgeons. Dr. Giemsa received a salary and became an employee of the group practice. With time, she became a senior partner and part owner of the Mayo Clinic._\n\nTogether with their father, the Mayo brothers, who were general practitioners skilled at surgical techniques, formed a group practice in the small town of Rochester, MN, in the 1890s. As the brothers' reputation for clinical excellence grew, the practice added several surgeons and physicians in laboratory-oriented specialties. By 1929, the Mayo Clinic had more than 375 physicians and 900 support staff and eventually went on to open its own hospitals (Starr, 1982). Although the clinic paid its physician staff by salary, the clinic itself billed patients, and later third-party insurance plans, on a fee-for-service basis. The Mayo Clinic was the inspiration for other group practices that developed in the United States, such as the Menninger Clinic in Topeka, KS, and the Palo Alto Medical Foundation in California. These clinics were owned and administered by physicians and featured physicians working in various specialties\u2014hence the common use of the term _multispecialty group practice_ to describe this organizational model. As in the case of the Mayo Clinic, these multispecialty group practices were innovative in the manner in which they brought a large number of physicians together under one roof to deliver care.\n\nBy formally integrating specialists into a single clinic structure, group practice attempted to promote a collaborative style of care. Lacking a strong role for the PCP as coordinator of services, the specialty-oriented group practice model attempted to use the structure of the practice organization itself as a means of creating an environment for coordinated care among specialist physicians. Enhancement of quality of care was also expected from the greater opportunity for formal and informal peer review and continuing education when colleagues worked together and shared responsibility for the care of patients. Critics of group practice warned that large practice structures would jeopardize the intimate patient\u2013physician relationship possible in a solo or small group setting, arguing that large groups would subject patients to an impersonal style of care with no single physician clearly accountable for the patient's welfare.\n\nIn 1932, the blue ribbon Committee on the Costs of Medical Care recommended that the delivery of care be organized around large group practices (Starr, 1982). The eight physicians in private practice who were members of the committee dissented from the recommendations, roundly criticizing the sections on group practice. An editorial in the _Journal of the American Medical Association_ was even more scathing in its attack on the committee's majority report:\n\n_The physicians of this country must not be misled by utopian fantasies of a form of medical practice,which would equalize all physicians by placing them in groups under one administration. The public will find to its cost, as it has elsewhere, that such schemes do not answer that hidden desire in each human breast for human kindliness, human forbearance, and human understanding. It is better for the American people that most of their illnesses be treated by their own physicians rather than by industries, corporations, or clinics. (The Committee on the Costs of Medical Care, 1932)_\n\nSeveral multispecialty group practices flourished during the period between the world wars, and to this day remain among the most highly regarded systems of care in the United States. Yet multispecialty group practice did not become the dominant organizational structure. In part, resistance to this model by professional societies blunted the potential for growth. In addition, as hospitals assumed a central role in medical care, group practice lost some of its unique attractions. Hospitals could provide the ancillary services physicians needed for the increasingly specialized and technology-dependent work of medicine. Hospitals also served as an organizational focus for the informal referral networks that developed among private physicians in independent practice.\n\n#### **Community Health Centers**\n\nOne of the most far-reaching alternatives to fee-for-service medical practice is the community health center, emphasizing primary and preventive care and also striving to take responsibility for the health status of the community served by the health center. An early twentieth-century example of such an institution was the Greater Community Association at Creston, IA. The association brought together civic, religious, education, and health care groups in a coordinated system centered on the community hospital serving a six-county area with 100,000 residents. The plan placed its greatest emphasis on preventive care and public health measures administered by public health nurses. In describing the association, Kepford (1919) wrote:\n\n_The motto of the Greater Community Association is \"Service.\" Among the principles of the hospital management are the precept that it shall be a long way from the threshold of the hospital to the operating room. . . . We have a hospital that makes no attempt to pattern after the great city institutions, but is organized to meet the needs of a rural neighborhood. The Greater Community Association has been taught to regard the hospital as a repair shop, necessary only where preventive medicine has failed. (Kepford, 1919)_\n\n_In 1928, Sherry Kidd joined the Frontier Nursing Service in Appalachia as a nurse midwife. For $5 per year, families could enroll in the service and receive pregnancy-related care. Sherry was responsible for all enrolled families within a 100-mile radius. She referred patients with complications to an obstetrician in Lexington, KY, who was the service's physician consultant._\n\nAnother pioneering model, the Frontier Nursing Service was established by Mary Breckinridge, an English-trained midwife, in 1925 (Dye, 1983). Breckin-ridge designed the service to meet the needs of a poor rural area in Kentucky that lacked basic medical and obstetric care and suffered from high rates of maternal and infant mortality. The Frontier Nursing Service shared many of the features of the Creston, IA, model: regionalized services planned on a geographic basis to serve rural populations with an emphasis on primary care and health education. Like the Creston system, the service relied on nurses to provide primary care, with physicians reserved for secondary medical services on a referral basis.\n\nThese rural programs had their urban counterparts in health centers that focused on maternal and child health services during the early 1900s (Rothman, 1978; Stoeckle and Candib, 1969). The clinics primarily served populations in low-income districts in large cities and were often involved with large immigrant populations. As in the rural systems, public health nurses played a central role in an organizational model geared toward health education, nutrition, and sanitation. Both the urban and rural models of community health centers waned during the middle years of this century. Public health nursing declined in prestige as hospitals became the center of activity for nursing education and practice (Stevens, 1989). A team model of nurses working in collaboration with physicians withered under a system of hierarchical professional roles.\n\nThe community health center model was revived in 1965, when the federal Office of Economic Opportunity, the agency created to implement the \"War on Poverty,\" initiated its program of community health centers. The program's goals included the combining of comprehensive medical care and public health to improve the health status of defined low-income communities, the building of multidisciplinary teams to provide health services, and participation in the governance of the health centers by community members.\n\n_Dr. Franklin Jefferson was professor of hematology at a prestigious medical school. His distinguished career was based on laboratory research, teaching, and subspecialty medical practice, with a focus on sickle cell anemia. Dr. Jefferson felt that his work was serving his community, but that he would like to do more. In 1965, with the advent of the federal neighborhood health center program, he left his laboratory in the hands of a well-trained assistant and began to talk with community leaders in the poor neighborhood that surrounded the medical school. After a year, the trust that was developed between Dr. Jefferson and members of the neighborhood bore fruit in a decision to approach the medical school dean about a joint medical school\u2013community application for funds to create a neighborhood health center. Two years later, the center opened its doors, with Dr. Jefferson as its first medical director._\n\nBy the early 1980s, 800 federally funded community health centers were in operation in the United States, administered by governing boards that included patients enrolled in the health center. Many of the centers trained community members as outreach workers, who became members of health care teams that included public health nurses, physicians, mental health workers, and health educators. Some of the health centers made a serious attempt to meld clinical services with public health activities in programs of community-oriented primary care. For example, the rural health center in Mound Bayou, MS, helped organize a cooperative farm to improve nutrition in the county, dig wells to supply safe drinking water, and train community residents to become health care professionals. By improving the care of low-income ambulatory patients, the centers were able to reduce hospitalization and emergency department visits by their patients. Community health centers also had some success in improving community health status, particularly by reducing infant and neonatal mortality rates among African Americans (Geiger, 1984). In the past decade, the federal government invested in a new period of expansion of community health centers, and these health centers are viewed as a critical access point for the reforms enacted in the Affordable Care Act of 2010. In 2008, more than 1000 community health centers at 7500 sites were serving 17 million people, three-quarters of them uninsured or covered by Medicaid (Kaiser Commission, 2010).\n\n#### **Prepaid Group Practice and Health Maintenance Organizations**\n\nHistorically, one alternative to small office-based, fee-for-service practice became the major challenge to that traditional model: prepaid group practice, one of the models upon which the modern HMO is based.\n\nIn 1929, the Ross\u2013Loos Clinic began to provide medical services for employees of the Los Angeles Department of Water and Power on a prepaid basis. By 1935, the clinic had enrolled 37,000 employees and their dependents, who each paid $2 per month for a specified list of services. Also in 1929, an idealistic physician, Dr. Michael Shadid, organized a medical cooperative in Elk City, OK, based on four principles: group practice, prepayment, preventive medicine, and control by the patients, who were members of the cooperative. In the late forties, more than a hundred rural health cooperatives were founded, many in Texas, but they tended to fade away, partly from the stiff opposition of organized medicine. In the 1950s, another version of the consumer-managed prepaid group practice sprang up in Appalachia, where the United Mine Workers established union-run group practice clinics, each receiving a budget from the union-controlled, coal industry\u2013financed medical care fund. Meanwhile, the Group Health Association of Washington, DC, had been organized in 1937 as a prepaid group practice whose board was elected by the cooperative's membership. A few years later in Seattle, Group Health Cooperative of Puget Sound acquired its own hospital, began to grow, and by the mid-1970s had 200,000 subscribers, a fifth of the Seattle-area population. In 1947, the Health Insurance Plan of New York opened its doors, operating 22 group practices; within 10 years, Health Insurance Plan's enrollment approached 500,000 (Starr, 1982).\n\nThe most successful of the prepaid group practices that emerged in the 1930s and 1940s was the Kaiser Health Plan. In 1938, a surgeon named Sidney Garfield began providing prepaid medical services for industrialist Henry J. Kaiser's employees working at the Grand Coulee Dam in Washington State. Rather than receiving a salary from Kaiser, Garfield was prepaid a fixed sum per employee, a precursor to modern capitation payment. Kaiser transported this concept to 200,000 workers in his shipyards and steel mills on the West Coast during World War II (Garfield, 1970; Starr, 1982). In this way, company-sponsored medical care in a remote area gave birth to today's largest alternative to fee-for-service practice. Kaiser opened its doors to the general public after World War II. Kaiser now operates in nine states and Washington, DC, with nearly 9 million patients enrolled.\n\nThe contemporary systems that grew out of the Kaiser and consumer cooperative models share several important features. Rather than preserving a separation between insurance plans and the providers of care, these models attempt to meld the financing and delivery of care into a single organizational structure. Paying a premium for health insurance coverage in this approach does not just mean that a third-party payer will reimburse some or all the costs of care delivered by independent practitioners. Rather, the premium serves to directly purchase, in advance, health services from a particular system of care. This is the notion of \"prepaid\" care that is one component of the prepaid group practice model. (As discussed in Chapter 2, the Baylor Hospital plan in the 1930s was a parallel attempt to develop a model of prepaid hospital care.) The second component is care delivered by a large group of practitioners working under a common administrative structure\u2014the \"group practice\" aspect of prepaid group practice.\n\nSystems such as Kaiser and Group Health Cooperative of Puget Sound were commonly referred to as _prepaid group practices_ until the 1970s, when terminology underwent a transformation as part of a political effort to sell the public and Congress on this model of care as a centerpiece of health care reform under the Nixon administration. Paul Ellwood, a Minnesota physician and advisor to President Nixon, suggested that prepaid group practices be referred to as \"health maintenance organizations\" (Ellwood et al, 1971; Starr, 1982). This change in name was intended in part to break from the political legacy of the prepaid group practice movement, a legacy colored with populist tones from the cooperative plans and tainted by organized medicine's common criticism of prepaid group practice as a socialist threat. The term _health maintenance_ was also designed to suggest that these systems would place more emphasis on preventive care than had the traditional medical model. Although HMOs were initially synonymous with prepaid group practice, by the 1980s, several varieties of HMO plans emerged that departed from the prepaid group practice organizational form. We describe the Kaiser model to fully illustrate the first-generation HMO model, and then proceed to discuss the second-generation HMOs known as independent practice associations (IPAs) or network HMOs.\n\n### **FIRST-GENERATION HEALTH MAINTENANCE ORGANIZATIONS AND VERTICAL INTEGRATION: THE KAISER\u2013PERMANENTE MEDICAL CARE PROGRAM**\n\n_Mario Fuentes was a professor at the University of California. He and his family belonged to the Kaiser Health Plan, and the university paid his family's premium. Professor Fuentes had once fractured his clavicle, for which he went to the urgent care clinic at Kaiser Hospital in Oakland; otherwise, he had not used Kaiser's facilities. Mrs. Fuentes suffered from rheumatoid arthritis; her regular physician was a salaried rheumatologist at the Permanente Medical Clinic, the group practice in which Kaiser physicians work. One of the Fuentes' sons, Juanito, had been in an automobile accident a year earlier near a town 90 miles away from home. He had been taken to a local emergency department and released; Kaiser had paid the bill because no Kaiser facility was available in the town. Three days after returning home, Juanito developed a severe headache and became drowsy; he was taken to the urgent care clinic, received a CT scan, and was found to have a subdural hematoma. He was immediately transported to Kaiser's regional neurosurgery center in Redwood City, CA, where he underwent surgery to evacuate the hematoma._\n\n_Dr. Roberta Short had mixed feelings about working at Kaiser. She liked the hours, the salary, and the paucity of administrative tasks. She particularly liked working in the same building with other general internists and specialists, providingthe opportunity for frequent discussions on diagnostic and therapeutic problems. However, she was not happy about seeing 4 or 5 patients per hour. Such a pace left little time to talk to the patients or to make important phone calls to patients or specialists. It was tough for Dr. Short's patients to get appointments with her, and it was even harder to arrange prompt appointments with specialists, who were as busy as she was. Moreover, the rules for ordering magnetic resonance imaging scans and other expensive tests were strict, though by and large reasonable. Overall, Dr. Short felt that the Kaiser system worked well but needed more physicians per enrolled patient._\n\nThe Kaiser\u2013Permanente Medical Care Program is the largest of the nation's prepaid group practice HMOs, consisting of three interlocking administrative units:\n\n1. The Kaiser Foundation Health Plan, which performs the functions of health insurer, such as administering enrollment and other aspects of the financing of care.\n\n2. The Kaiser Foundation Hospitals Corporation, which owns and administers Kaiser hospitals (the same individuals sit on the boards of directors for the Health Plan and the Hospitals Corporation).\n\n3. Permanente medical groups, the physician organizations that administer the group practices and provide medical services to Kaiser plan members under a capitated contract with the Kaiser plan.\n\nThe organizational model typified in the Kaiser\u2013Permanente HMO has come to be known as vertical integration. _Vertical integration_ refers to consolidating under one organizational roof and common ownership all levels of care, from primary to tertiary care, and the facilities and staff necessary to provide this full spectrum of care (Figure 6\u20131). Although structures differ somewhat across Kaiser's regional health plans, most Kaiser\u2013Permanente regional units own their hospitals and clinics, hire the nurses and other personnel staffing these facilities, and contract with a single large group practice (Permanente) to exclusively serve patients covered by the Kaiser health plan.\n\n**Figure 6\u20131.** Vertical integration consolidates health services under one organizational roof.\n\nThe Kaiser form of HMO differs from traditional fee-for-service models in how it pays physicians (salary) and hospitals (global budget). It also differs in how health services are organized. Most obvious is the prepaid group practice structure that contrasts with the traditional US style of solo, independent private practice. In addition, Kaiser has typically regionalized tertiary care services at a select number of specialized centers. For example, Northern California Kaiser has centralized all neurosurgical care at only two hospitals; patients with spinal cord injuries, brain tumors, and other neurosurgical conditions are referred to these centers from other Northern California Kaiser hospitals. The distribution of specialties within the physician staff in The Permanente Medical Group is approximately half generalists and half specialists. Most regions have also integrated nonphysicians, such as nurse practitioners and physician assistants, into the primary care team.\n\nMany observers consider this ability to coherently plan and regionalize services to be a major strength of vertically integrated systems (Figure 6\u20131). Unlike a public district health authority in the United Kingdom, an HMO such as Kaiser\u2013Permanente is not responsible for the entire population of a region, but these private, vertically integrated systems in the United States do assume responsibility for organizing and delivering services to a population of plan enrollees. The prepaid nature of enrollment in the Kaiser plan permits Kaiser to orient its care more toward a population health model.\n\n### **SECOND-GENERATION HEALTH MAINTENANCE ORGANIZATIONS AND \"VIRTUAL INTEGRATION\": NETWORK MODEL HMOs, INDEPENDENT PRACTICE ASSOCIATIONS, AND INTEGRATED MEDICAL GROUPS**\n\n_As more and more of her patients switched from fee-for-service health plans to the new HMO plans run by commercial insurers that were capturing a growing share of the private health insurance market in California, Dr. Westcoast figured she had no choice but to start contracting with these HMOs if she wanted to retain her patients. She joined the Good Health Independent Practice Association (IPA), an organization that helped solo practitioners like Dr. Westcoast contract with different HMOs. Within 3 years, 30% of the patients in her internal medicine practice were covered by 4 HMO plans that contracted with the Good Health IPA._\n\n_Although having HMO contracts was clearly proving to be important for the viability of her practice, Dr. Westcoast found much of the new arrangements frustrating. Each HMO sent her annual reports on various quality-of-care measures for the diabetic patients that the HMO showed as having Dr. Westcoast as their PCP. The trouble was that, many of the patients were not actually patients in her practice, and it was hard to reconcile the reports for a few diabetic patients from each of the 4 HMOs with all the diabetic patients she saw, including many not enrolled in HMOs, to understand how she really was doing in meeting quality standards for all the diabetic patients in her practice. Good Health IPA sent her its own quality report about the diabetic patients that Good Health thought had Dr. Westcoast as a PCP, and the information in that report didn't match the data sent by the HMOs. To make matters worse, each HMO had a different formulary of the diabetic medications that were covered by the health plan, and Dr. West-coast spent a lot of time helping exasperated patients who needed their prescriptions changed to a different medication. She wondered about giving up her practice to join Kaiser, where she would be less independent but at least she wouldn't have to deal with so many different HMOs, each with their different set of rules._\n\nIn 1954, the medical society in San Joaquin County, CA, fretted about the possibility of Kaiser moving into the county. Private fee-for-service patients might go to the lower cost Kaiser, and physicians' incomes would fall. An idea was born: To compete with Kaiser, the San Joaquin Foundation for Medical Care was set up as a network of physicians in independent private practice to contract as a group with employers for a monthly payment per enrollee; the foundation would then pay the physicians on a discounted fee-for-service basis and conduct utilization review to discourage overtreatment (Starr, 1982). It was hoped that the plan would reduce the costs to employers, who would choose the foundation rather than Kaiser.\n\nWhen the Health Maintenance Organization Act of 1973 was enacted into law as the outcome of President Nixon's health care reform strategy, network model HMOs were included along with prepaid group practice as legitimate HMOs. The HMO law stimulated HMO development by requiring large- and mediumsized businesses that provided health insurance to their employees to offer at least one federally qualified HMO as an alternative to traditional fee-for-service insurance if such an HMO existed in the vicinity (Starr, 1982). Network-model HMOs were far easier to organize than prepaid group practices; a county or state medical society, a hospital, or an insurance company could simply recruit the office-based, fee-for-service physicians practicing in the community into network, and thereby create the basis for an HMO. The physicians could continue to see their non-HMO patients as well. The inclusion of the network form of HMO in the 1973 legislation ensured that the HMO movement would not produce rapid alterations in the traditional mode of delivering medical care.\n\nSome of the initial network-model HMOs were organized on the two-tiered payment model described in Chapter 4. Under this model, an HMO contracts with many individual physicians to care for HMO enrollees. Some network-model HMOs have evolved into models that use a three-tiered payment structure whereby the HMO does not contract directly with individual physicians but rather with a large group of physicians. These groups may take several forms. The San Joaquin Foundation for Medical Care was an early example of the Independent Practice Association (IPA) model, consisting of a network of physicians who agree to participate in an association for purposes of contracting with HMOs and other managed care plans. Physicians maintain ownership of their practices and administer their own offices. The IPA serves as a vehicle for negotiating and administering HMO contracts.\n\nUnlike the \"monogamous\" arrangement between each Kaiser region and its respective Permanente medical group, in network models physicians can establish contractual relationships with numerous HMOs and IPAs. A physician may participate in more than one IPA, and each IPA may in turn have contracts with many HMO and managed care plans. The result of this more open HMO\u2013physician relationship is a series of physician panels in the same community that overlap partially, but not completely, for patients covered by different HMOs. While this more open-ended network approach may have some appeal to physicians and patients in contrast to more tightly integrated HMO models like Kaiser, it can also produce the types of frustrations experienced by Dr. Westcoast. A PCP, who may see patients from several HMOs and participate in more than one IPA, often finds that a specialist or hospital participates in the network for one HMO or IPA but not another, causing disruption and confusion when it comes to figuring out which specialist or hospital is eligible to accept a referral (Bodenheimer, 2000). Patients may find that their PCP is in one IPA but their preferred specialist is not in the same network\u2014with physicians often moving in and out of various networks as contracts are renegotiated.\n\nIPAs initially did little more than to act as brokers between physicians and HMOs, replacing the need for physicians to negotiate contracts on an individual basis. As IPAs took on a larger portion of financial risk for care (see Chapter 4), they became more active in attempting to control costs and assumed responsibility for authorizing utilization of services, profiling physicians' practice patterns, and administering other cost control strategies. Some IPAs have attempted to fashion themselves into more than simply contractual and financial intermediaries by facilitating quality improvement efforts and adoption of electronic medical records among participating practices.\n\nAnother structure related to second-generation HMOs is the integrated medical group. Integrated medical groups have a tighter organizational structure than IPAs, consisting of groups in which physicians no longer own their practices and office assets, but become employees of an organization that owns and manages their practice. Some modern-day integrated groups are survivors of the original breed of multispecialty group practices, such as the Mayo Clinic and Palo Alto Medical Foundation described earlier. Others lack these clinics' historical genesis and consist of new organizations created in the managed care era. Some of these newer organizations were created by large, for-profit companies buying up the practices of formerly independent physicians and hiring these same physicians to work as employees of the medical group (Robinson and Casalino, 1996). Others are owned by hospitals or medical schools or are privately held companies with physician partners as owners. Similar to IPAs, integrated medical groups contract with multiple managed care plans and also typically care for patients in fee-for-service private insurance plans and Medicare.\n\nYet another organizational structure to have emerged is the Physician Hospital Organization (PHO). PHOs developed in the 1980s as an alternative to the IPA model. Instead of creating a physician association to negotiate health plan contracts, physicians partnered with a hospital to jointly contract with health plans for both physician and hospital payment rates. The physicians participating in PHOs often consisted of both private practitioners on the hospital's medical staff and physicians directly employed by the hospital. Formation of PHOs received a setback in the 1990s when the Federal Trade Commission deemed that some PHO arrangements constituted collusion in price setting between physicians and hospitals to an extent that violated anti-trust laws.\n\nThe network model HMO represents an alternative to the vertically integrated HMO. As shown in Figure 6\u20132, managed care relationships involving IPAs and medical groups consist of a network of contractual links between HMOs and autonomous physician groups, hospitals, and other provider units, rather than the \"everything-under-one-roof\" model of vertical integration. Observers have dubbed the network forms of managed care organization \"virtual integration,\" signifying an integration of services based on contractual relationships rather than unitary ownership (Robinson and Casalino, 1996). In these virtually integrated systems, HMOs do not directly provide health services through their own hospitals and physician organizations.\n\n**Figure 6\u20132.** Virtual integration involves contractual links between HMOs and physician groups, hospitals, and other provider units.\n\n### **COMPARING VERTICALLY AND VIRTUALLY INTEGRATED MODELS**\n\nIn 2009, about one in four people in the United States was enrolled in some type of HMO, including Medicare and Medicaid beneficiaries participating in HMOs (Kaiser Family Foundation, 2011) (Figure 6\u20133). There is wide variation across states in HMO enrollment, ranging from more than half of insured people in California to under 10% in many other states. For many years, policy analysts predicted that the organizational efficiency and coherence of vertically integrated, first-generation HMOs would position these systems of care to prevail as health care entered a more competitive era. These predictions have not come true, as enrollment in virtually integrated systems has surpassed that of traditional HMOs. Whereas most vertically integrated HMOs are regionally based, non-profit health plans, national for-profit commercial insurers operate the plans enrolling the majority of patients in virtual HMO models.\n\n**Figure 6\u20133.** Trends in HMO enrollment in the United States. Enrollment includes individuals enrolled through Medicare and Medicaid HMO options, as well as through employment-based and other privately insured HMO plans. (MCOL Managed Care Fact Sheets, 2011; <http:\/\/www.mcareol.com\/factshts\/factnati.htm>.)\n\nIn response to the reluctance of many patients to be locked into a limited panel of physicians and hospitals in conventional HMO plans, insurers have developed a variety of other products, such as the Preferred Provider Organization (PPO), which allow patients to see physicians not in the insurer's physician network, with the stipulation that patients pay a higher share of the cost out of pocket when they use non-network physicians and hospitals. Physicians joining the PPO network agree to accept discounted fees from the health plan with the hope that being listed as a \"preferred\" provider will attract more patients to their practice. PPO enrollment was about 50 million in 2009, compared with HMO enrollment of 70 million. Although both HMOs and PPOs are considered forms of \"managed care,\" PPOs are essentially a variation on insurance product benefit structure and, unlike HMOs, involve very little in the way of change in the organization of the delivery of care.\n\nVertically integrated HMOs clearly represent a significantly different organizational model than the traditional dispersed cottage industry model. Are IPAs and PHOs and the other organizational forms that predominate under network model HMOs a meaningful break from the dispersed model, offering a better framework for the delivery of health care? Or, are these virtual organizations just that\u2014loose confederacies of providers organized primarily for contracting and business objectives that offer little in the way of tangible gains in organizational coherence in the actual provision of health care?\n\nResearch suggests that more integrated organizational models have their advantages. Vertically integrated HMOs of the traditional prepaid group practice model tend to rank higher than network model HMOs on various measures quality of care, such as evidence-based care of chronic illnesses (Himmelstein et al, 1999). Integrated medical groups have been shown to perform better than IPAs in delivering up-to-date preventive care such as mammograms and Pap tests (Mehrotra et al, 2006). On general health plan satisfaction ratings, patients tend to rate integrated HMOs such as Kaiser ahead of network-model HMOs. Compared with physicians in IPAs or those not affiliated with any network, physicians in prepaid group practices report greater adoption of tools for quality improvement, such as more structured systems for planning and following through on care of patients with diabetes and other chronic illnesses (Rittenhouse et al, 2004). Size also seems to matter when it comes to the ability of medical groups to adopt the infrastructure for creating patient-centered medical homes; larger medical groups are more likely than small groups to have systems in place for care coordination, enhanced patient access, and related processes (Rittenhouse et al, 2008).\n\nThere is also evidence that moving from a completely dispersed model to a somewhat more organized model, even if only of a virtual network variety, can yield improvements in the delivery of care, especially when the network emphasizes linking patients with primary care clinicians and supports better coordination of care. An example is Community Care of North Carolina. Community Care linked North Carolina Medicaid and State Children's Health Insurance Program recipients with a primary care medical home at more than 1000 small private offices and community health centers and provided technical assistance to practices to improve chronic care services including a cadre of nurses to collaborate with practices in care management of high-risk patients. This model resulted in both better patient outcomes, such as reductions in emergency hospitalizations for children with asthma, and reductions in health care costs (Steiner et al, 2008).\n\nThe dispersed model does appear to have one important strength from the patient perspective, which is the satisfaction that comes from receiving care from a small practice where patients have a sense that clinicians and staff know them personally and the patient\u2013clinician relationship is less encumbered by organizational bureaucracy. Studies of patient preferences have found that satisfaction is highest when care is received in small offices rather than larger clinic structures (Rubin et al, 1993). People value having a familiar receptionist at the end of the line when they call about a child with a fever rather than experiencing the frustration of navigating impersonal HMO and clinic switchboard operators and voicemail systems\u2014what has been described as the \"chain store\" persona of some HMOs and large delivery systems (Mechanic, 1976). The computer era may be allowing many large medical groups and vertically integrated HMOs to jump ahead of small practices in providing the means for patients to communicate personally with their clinicians. Many large groups have implemented electronic medical records systems that allow patients to securely e-mail their clinicians and to promptly receive diagnostic test results through web-based \"patient portals\" providing patients direct access to their personal medical record.\n\n### **ACCOUNTABLE CARE ORGANIZATIONS**\n\nAs discussed in Chapter 5, the Affordable Care Act of 2010 is propelling not only an expansion of health insurance coverage, but also reform in how health care is organized and delivered. During the policy debates leading up to passage of the Affordable Care Act, the concept of Accountable Care Organizations (ACOs) emerged as a centerpiece of delivery system reform. ACOs have been defined as \"a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population\" (Rittenhouse et al, 2009). The Affordable Care Act authorized Medicare to initiate an ACO program beginning in 2012 (Health Policy Brief, 2010)\n\nACOs are envisioned as spanning a spectrum of organizational structures. On one end of this spectrum lie vertically integrated HMOs, with their medical groups and facilities well suited to provide comprehensive care to a defined population of enrolled patients under capitated payment. At the other end of the ACO spectrum lie loosely knit affiliations of providers in the traditional dispersed structure discussed at the beginning of this chapter, consisting of a hospital and the collection of private practice physicians who admit their patients to that hospital and maintain informal referral networks. Proponents of the ACO concept have proposed that Medicare could encourage such an informal hospital-physician network to function in a more cohesive and efficient manner by creating a \"shared savings\" program. Under the shared savings program, Medicare would still pay physicians by fee-for-service and hospitals by DRG, and patients would be allowed free choice of physician and hospital. However, Medicare would compare the costs and quality for the Medicare patients cared for by this virtual network; if the physicians were able to achieve certain targeted quality goals and keep costs below the predicted expenditures for these patients, Medicare would share a portion of the cost savings with the physicians and hospitals in this loosely affiliated ACO network. To qualify for such a shared-savings program, physicians and hospitals would have to create a formal ACO entity to accept shared savings payments. The variety of other organizational models discussed in this chapter, such as IPAs and PHOs, that fall between the poles of the hospital staff model and vertically integrated HMO would be other candidates for ACOs (Shortell et al, 2010).\n\nOne key difference between the proposed ACO program and the existing Medicare Advantage Program, discussed in Chapter 2, is the role of insurance companies. Medicare Advantage involves Medicare contracting with insurance plans that operate as HMOs, including both network and traditional prepaid group practice model HMOs. The Medicare ACO program is envisioned as a more direct financial relationship between Medicare and provider organizations. Prepaid group practice model HMOs could qualify as ACOs because they consist of an integrated delivery organization attached to a single insurance plan. However, network model HMO insurers would not, and, under the ACO program, Medicare would look to establish financial arrangements directly with IPAs, PHOs, and other provider-led organizations.\n\nWhether the Medicare ACO program will succeed in moving the US further along the road to more organized, integrated care structures that can improve quality and \"bend the cost curve\" remains to be determined. Regardless of whether the ACO program as articulated by its proponents will be fully realized, the ACO concept has stimulated considerable attention in the United States on reforming the delivery system to focus more on proactive care of a defined population of patients rather than just reactive care for individual patients, and on holding providers accountable for the quality and costs of care delivered.\n\n### **FROM MEDICAL HOMES TO MEDICAL NEIGHBORHOODS**\n\nIn Chapter 5, we discussed the concept of medical homes. Much of what has been discussed in this chapter on delivery system organization could aptly be described as the attempt to create well-functioning medical neighborhoods. The medical _neighborhood_ is a term coined by Fisher to describe the constellation of services, providers, and organizations in a health system that contributes to the care of a population of patients (Fisher, 2008). The primary care medical home resides in the medical neighborhood, but the medical neighborhood consists of much more than just medical homes and includes the secondary, tertiary, community, and related services needed by different patients at different times to meet their comprehensive health care needs. High-performing health care requires both excellent medical homes and excellent medical neighborhoods (Rittenhouse et al, 2009). The distinguishing feature of a hospitable medical neighborhood is care that is functionally integrated, but not necessarily structurally integrated along the lines of traditional HMOs. According to one definition, \"Integrated health care starts with good primary care and refers to the delivery of comprehensive health care services that are well coordinated with good communication among providers; includes informed and involved patients; and leads to high-quality, cost-effective care. At the center of integrated health care delivery is a high-performing primary care provider who can serve as a medical home for patients\" (Aetna Foundation, 2010).\n\nOrganizations that are structurally integrated have an advantage in being able to provide care that is functionally integrated. These organizations have assets such as multispecialty groups, a unified electronic medical record, interdisciplinary health care teams, and a quality improvement infrastructure equipped to promote care coordination and the free flow of information among all providers involved in a patient's care. One of the ongoing challenges in the United States is whether organizations that are less structurally integrated than traditional prepaid group practice HMOs will be able to achieve the degree of functional integration needed to deliver more effective and efficient care and overcome what we cited in Chapter 5 as the \"fragmentation, chaos, and disarray\" that has long plagued the US health system.\n\nDespite the admonitions of the dissenting _JAMA_ editorialists in 1932 who warned physicians not to be \"misled by utopian fantasies\" of group practice, it appears that in the early part of the twenty-first century a tipping point has occurred in the United States and the health care cottage industry is rapidly giving way to larger organizations for delivering care. From 2002 to 2008, the percentage of medical practices that are doctor-owned fell from 70% to 48% while the percentage owned by hospitals grew from 24% to 50% (Figure 6\u20134). Most new residency graduates are eschewing the tradition of becoming autonomous proprietors of their own private practices and seeking employed positions, seeking what the _New York Times_ has described as \"regular paychecks instead of shopkeeper risks\" (Harris, 2011). Hospitals are merging with one another and with physician organizations and creating large, regional delivery systems.\n\n**Figure 6\u20134.** Ownership of medical practices. (Harris G. More doctors giving up private practices. _New York Times_ , March 25, 2010.)\n\nWill the rapid organizational changes occurring in health care in the United States result in a higher-quality, more affordable health system? Will patients be cared for at the proper level of care\u2014primary, secondary, and tertiary? Will the flow of patients among these levels be constructed in an orderly way within each geographic region\u2014a regionalized structure? Will a sufficient number of primary care providers\u2014generalist physicians, physician assistants, and nurse practitioners\u2014be available so that everyone in the United States can have a regular source of primary care that allows for continuity and coordination of care? Will HMOs, ACOs, and other organizations require their physicians to take responsibility for the health of their enrollee population, or will physicians be content to care only for whoever walks in the door? What is an ideal health delivery system? Different people would have different answers. One vision is a system in which people choose their own primary care clinicians in modest-sized, decentralized, prepaid group practices that would be linked to community hospitals, including specialists' offices providing secondary care. Difficult cases could be referred to the academic tertiary care center in the region. In the primary care practices, teams of health caregivers would endeavor to provide medical care to those people seeking attention, and would also concern themselves with the health status of the entire population served by the practice.\n\n### **REFERENCES**\n\nAetna Foundation. Program Areas: Specifics, 2010. <http:\/\/www.aetna.com\/about-aetna-insurance\/aetna-foundation\/aetna-grants\/program-area-specifics.html>.\n\nBodenheimer T. Selective chaos. _Health Aff (Millwood)_. 2000;19(4):200.\n\nThe Committee on the Costs of Medical Care. Editorial. _JAMA._ 1932;99:1950.\n\nDye NS. Mary Breckinridge, the Frontier Nursing Service and the introduction of nurse-midwifery in the United States. _Bull Hist Med_. 1983;57:485.\n\nEllwood PM et al. Health maintenance strategy. _Med Care._ 1971;9:291.\n\nFisher ES. Building a medical neighborhood for the medical home. _N Engl J Med._ 2008;359:1202.\n\nGarfield SR. The delivery of medical care. _Sci Am_. 1970;222:15.\n\nGeiger HJ. Community health centers: Health care as an instrument of social change. In: Sidel VW, Sidel R, eds. _Reforming Medicine._ New York: Pantheon Books; 1984.\n\nHarris G. More Doctors Giving up Private Practice, and Family Physicians Can't Give Away Solo Practice. _New York Times_. March 25 and April 22, 2011.\n\nHealth Policy Brief: Accountable care organizations. _Health Affairs._ July 27, 2010.\n\nHimmelstein DU et al. Quality of care in investor-owned vs not-for-profit HMOs. _JAMA_. 1999;282:159.\n\nKaiser Commission on Medicaid and the Uninsured. Issue Brief. _Community Health Centers: Opportunities and Challenges of Health Reform_. Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; 2010. <http:\/\/www.kff.org\/uninsured\/upload\/8098.pdf>.\n\nKaiser Family Foundation. Total HMO Enrollment, July 2009. State Health Facts, 2011. http:\/\/www.statehealthfacts.org\/comparetable.jsp?ind=348&cat=7&sub=85&yr=194&typ=1&sort=a.\n\nKepford AE. The Greater Community Association at Creston, Iowa. _Mod Hosp_. 1919;12:342.\n\nMechanic D. _The Growth of Bureaucratic Medicine._ New York: John Wiley & Sons; 1976.\n\nMehrotra A et al. Do integrated medical groups provide higher-quality medical care than individual practice associations? _Ann Intern Med._ 2006;145:826.\n\nRittenhouse DR et al. Physician organization and care management in California: From cottage to Kaiser. _Health Aff (Millwood)_. 2004;23(6):51.\n\nRittenhouse DR et al. Measuring the medical home infrastructure in large medical groups. _Health Aff (Millwood)._ 2008;27:1246.\n\nRittenhouse DR et al. Primary care and accountable care\u2014two essential elements of delivery-system reform. _N Engl J Med._ 2009;361:2301.\n\nRobinson JC, Casalino LP. Vertical integration and organizational networks in health care. _Health Aff (Millwood)_. 1996;15:7.\n\nRothman SM. _Woman's Proper Place: A History of Changing Ideals and Practices._ New York: Basic Books; 1978.\n\nRubin HR et al. Patients' ratings of outpatient visits in different practice settings. _JAMA_. 1993;270:835.\n\nShortell SM et al. How the Center for Medicare and Medicaid innovation should test accountable care organizations. _Health Aff (Millwood)_. 2010;29:1293.\n\nStarr P. _The Social Transformation of American Medicine._ New York: Basic Books; 1982.\n\nSteiner BD et al. Community care of North Carolina: Improving care through community health networks. _Ann Fam Med_. 2008;6:361.\n\nStevens R. _In Sickness and in Wealth: American Hospitals in the Twentieth Century._ New York: Basic Books; 1989.\n\nStoeckle JD, Candib LM. The neighborhood health center: Reform ideas of yesterday and today. _N Engl J Med_. 1969;280:1385.\n\n## **7 The Health Care Workforce and the Education of Health Professionals**\n\nA health care system is only as good as the people working in it. The most valuable resource in health care is not the latest technology or the most state-of-the-art facility, but the health care professionals and other workers who are the human resources of the health care system.\n\nIn this chapter, we discuss the nation's three largest health professions\u2014nurses, physicians, and pharmacists, as well as a closely linked profession, physician assistants (Table 7\u20131). What are the educational pathways and licensing processes that produce the nation's practicing physicians, nurses (including nurse practitioners), pharmacists, and physician assistants? How many of these health care professionals are working in the United States, and where do they practice? Do we have the right number? Too many? Too few? How would we know if we had too many or too few? Are more women becoming physicians? Are more men becoming nurses? Is the growing racial and ethnic diversity of the nation's population mirrored in the racial and ethnic composition of the health professions? To answer these questions, we begin by providing an overview of each of these professions, describing the overall supply and educational pathways. We then discuss several cross-cutting issues pertinent to all these professions.\n\n**Table 7\u20131.** Number of active practitioners in selected health professions in the United States, by profession and year\n\n### **PHYSICIANS**\n\n_Susan Gasser entered medical school in 1997. During college, she had worked in the laboratory of an anesthesiologist, which made her seriously consider a career in that specialty. During her first year of medical school, the buzz among the fourth-year students was that practice opportunities were drying up fast in anesthesiology. Health maintenance organizations (HMOs) wanted more primary care physicians, not more specialists. Almost none of the fourth-year students applied to anesthesiology residency programs that year. Susan started to think more about becoming a primary care physician. In her third year of school, she had a gratifying experience during her family practice rotation working in a community health center and started to plan to apply for family practice residencies._\n\n_At the beginning of her fourth year of school, Susan spent a month in the office of a suburban family physician, Dr. Woe. Dr. Woe frequently remarked to Susan about the pressures he felt to see more patients and about how his income had fallen because of low reimbursement and higher practice expenses. He mentioned that the local anesthesiology group was having difficulty finding a new anesthesiologist to join the group to help keep up with all the surgery being performed in the area. The group was guaranteeing a first-year salary that was twice what Dr. Woe earned as an experienced family physician. Susan quickly began to reconsider applying to anesthesiology residency programs._\n\nApproximately 873,000 physicians are professionally active in the United States. One-third are in primary care fields, and two-thirds in non\u2013primary care fields. Of physicians who have completed residency training, more than 90% have patient care as their principal activity, with the remainder primarily active in teaching, research, or administration (US Department of Health and Human Services, 2008a). Licensing of all types of health care professionals, including physicians, is a state jurisdiction. State medical boards require that physicians applying for licen-sure document a passing grade on national licensing examinations, certification of graduation from medical school, and (in most states) completion of at least one year of residency training after medical school.\n\n#### **Medical Education**\n\nThe University of Pennsylvania opened the first medical school in the colonies in 1765, promoting a curriculum that emphasized the therapeutic powers of blood letting and intestinal purging. Many other medical sects coexisted in this era, including the botanics, \"natural bonesetters,\" midwives, and homeopaths, without any one group winning dominance. Few regulations impeded entry into a medical career; physicians were as likely to have completed informal apprenticeships as to have graduated from medical schools. Most medical schools operated as small, proprietary establishments profiting their physician owner rather than as university-centered academic institutions (Starr, 1982).\n\nThe modern era of the US medical profession dates to the 1890\u20131910 period. In 1893, the opening of the Johns Hopkins University School of Medicine ushered in a new tradition of medical education. Johns Hopkins University implemented many features that remain the standard of medical education in the United States: a 4-year course of study at the graduate school level, competitive selection of students, emphasis on the scientific paradigms of clinical and laboratory science, close linkage between a medical school and a medical center hospital, and cultivation of academically renowned faculty.\n\nThe second key event in the creation of a reformed twentieth-century medical profession was the publication of the Flexner Report in 1910. At the behest of the American Medical Association, the Carnegie Foundation for the Advancement in Teaching commissioned Abraham Flexner to perform an evaluation of medical education in the United States. Flexner's report indicted conventional medical education as conducted by most proprietary, nonuniversity medical schools. Flexner held up the example of Johns Hopkins as the standard by which the nation's institutions of medical education should be judged. Flexner's report was extremely influential. More than 30 medical schools closed in the decades following the Flexner Report, and academic standards at the surviving schools became much more stringent (Starr, 1982). More vigorous regulatory activities in respect to credentialing of medical schools and licensure for medical practice soon enforced the standards promoted in the Flexner Report, and only schools meeting the standards of the Licensing Council on Medical Education (LCME) were allowed to award MD degrees. Unlike the state boards licensing practice entry, which are government agencies, the LCME was a private agency operating under the authority of medical professional organizations. LCME-accredited schools became known as \"allopathic\" medical schools to distinguish themselves from homeopathic schools and practitioners. Although homeopaths still practice in the United States (there is now a resurgence of homeopathic practitioners), homeopaths are not officially sanctioned as \"physicians\" by licensing agencies in the United States. However, one alternative medical tradition has survived in the United States that carries the official imprimatur of the physician rank\u2014osteopathy. Osteopathy originated as a medical practice developed by a Missouri physician, Andrew Still, in the 1890s, emphasizing mechanical manipulation of the body as a therapeutic maneuver (Starr, 1982). Schools of osteopathy award DO degrees and have their own accrediting organization. Much of the educational content of modern-day osteopathic medical schools has converged with that of allopathic schools. Most state licensing boards grant physicians with MD and DO degrees equivalent scopes of practice, such as prescriptive authority. By the middle of the twentieth century, regulatory restrictions on practice entry, institutionalization of a rigorous standard of academic training, and the rapid growth of medical science and technology solidified the prestige and authority of licensed physicians in the United States.\n\nIn 2010, allopathic schools had 16,838 graduates, and osteopathic schools 3631. The annual number of allopathic school graduates changed little between 1980 and 2008, and only started to increase in 2009 in response to a new surge of medical school expansion starting in the first decade of the twenty-first century. In contrast, the annual number of osteopathic graduates has grown steadily over past decades, increasing threefold between 1980 and 2010.\n\n#### **Postdoctoral Education**\n\nAt least one year of formal education after medical school is required for licensure in most states, and most physicians complete additional training to become certified in a particular specialty. Traditionally, the first year of postdoctoral training was referred to as an \"internship,\" with subsequent years referred to as \"residency.\" Before the advent of specialization, many physicians completed only a single year of a general \"rotating\" internship. Physicians aspiring to full specialty training became residents (with trainees often literally \"residing\" in the hospital because of endless hours of on-call duty). Now, almost all physicians in the United States complete a full residency training experience.\n\nResidency training is much more decentralized than medical school education. Although some residency training programs are integrated into the same large academic medical centers that are home to the nation's allopathic medical schools, many smaller community hospitals sponsor residency-training programs, often in only one or two specialties. The Accreditation Council for Graduate Medical Education (ACGME), a private agency, accredits allopathic residency training programs. Residency training ranges from 3 years for generalist fields, such as family medicine and pediatrics, through 4 to 5 years for specialty training in fields such as surgery and obstetrics\u2013gynecology, to 6 years or longer for physicians pursuing highly subspecialized training. Some osteopathic schools sponsor osteopathic residency programs.\n\nOnce physicians have completed residency training, another private consortium, the American Board of Medical Specialties, certifies physicians for board certification in their particular specialty field. Criteria for board certification usually consist of completion of training in an ACGME-accredited program and passing of an examination administered by the specific specialty board (eg, the American Board of Pediatrics). Board certification is not required for state licensure. Physicians may advertise to patients their status as specialty board-certified to promote their expertise and qualifications, and board certification may be a factor considered by hospitals when deciding whether to allow a physician to have \"privileges\" to care for patients in the hospital or for managed care organizations deciding whether to include a physician in the organization's physician network. Many specialty boards now require periodic reexamination to maintain certification.\n\nEach year, approximately 25% more physicians enter ACGME residency programs than the number of students graduating from US allopathic medical schools. Who fills these extra residency positions? Approximately 7% are filled by graduates of schools of osteopathy; half of DO graduates enter allopathic residencies rather than residency programs sponsored by schools of osteopathy. The remainder of the ACGME residency positions are filled by physicians who graduated from medical schools outside the United States. A complex regulatory structure exists to govern which international medical graduates are eligible to enter residency training in the United States, involving state licensing board sanctioning of the graduate's foreign medical school and graduates completing US medical licensing examinations. There is almost no opportunity for international graduates to become licensed to practice in the United States without first undergoing residency training in the United States, even if the physician has been fully trained abroad and has years of practice experience. Some international medical graduates are US citizens who decided to train abroad, often because they were not admitted to a US medical school. However, the majority are not US residents, and most of these physicians come from India, the Philippines, sub-Saharan Africa, and other developing nations (Mullan, 2005). International medical graduates who are not US citizens receive only a temporary educational visa while in residency training, and in principle there is an expectation that these individuals will return to their nations of origin once they have completed training. However, various visa-waiver programs exist to allow these physicians to remain in the United States after completing training, usually linked to a period of service in a US community with a physician shortage. Controversy exists about this reliance on international medical graduates to meet US physician workforce needs, with critics arguing that the United States fosters a \"brain drain,\" depleting developing nations of vital human resources (Mullan, 2005).\n\n#### **Financing Medical Education**\n\nWho pays the cost of medical education in the United States? Unlike the case in most developed nations, where medical schools levy no or only nominal tuition, students pay high amounts of tuition and fees to attend US medical schools. Approximately half of US medical schools are public state institutions, with state tax revenues helping to subsidize medical school education. The Federal Government plays a minor role in financing medical student education, but is a major source of funds to support residency training. Medicare allocates \"graduate medical education\" funding to hospitals that sponsor residency programs. These funds are considerable, amounting to $9.5 billion annually, and include \"direct\" education payments for resident stipends and faculty salaries plus indirect education payments to defray other costs associated with being a teaching hospital. The joint federal\u2013state Medicaid programs contribute an additional $3 billion annually to residency education (Iglehart, 2010). Although in 1997, Medicare capped the number of residency program slots it would pay for, Medicare gives hospitals considerable latitude in how to spend their Medicare medical education dollars. Hospitals can decide which specialties, and how many slots in each specialty, they wish to sponsor for residency training, and can qualify for Medicare education payments as long as the positions are ACGME accredited. Hospitals may also invest non-Medicare revenues in their residency education programs and are not beholden to a prescriptive national workforce planning policy. Hospitals have tended to preferentially add new residency positions in non\u2013primary care fields, guided more by the value of residents as low-cost labor to staff hospital-based specialty services than by an assessment of regional physician workforce needs and priorities. Between 2002 and 2007, hospitals added nearly 8000 new residency positions despite the cap on Medicare-funded positions, with virtually all the gains occurring in specialist positions and family medicine residency positions losing ground during the same period (Salsberg et al, 2008).\n\n### **PHYSICIAN ASSISTANTS**\n\n_Jillian Boca was a speech therapist at a community hospital. She liked her work but wanted to advance in her career. She was talking to some of her colleagues who were physical therapists and x-ray technicians; they were thinking of going back to school to become physician assistants. One of the registered nurses at the hospital was also planning to go back to school to become a nurse practitioner. A local medical school sponsored a program with physician assistant and nurse practitioner students receiving their training together. Jillian and two of her colleagues were admitted to the program._\n\nAs the name suggests, physician assistants (PAs) are closely linked with physicians. The profession of PA originated in the United States in 1965 with the establishment of the first PA training program at Duke University School of Medicine. The PA profession developed to fill the niche of a broadly skilled clinician who could be trained without the many years of medical school and residency education required to produce a physician, and who would work in close collaboration with physicians to augment the effective medical workforce, especially in primary care fields and under-served communities. The first wave of PAs trained in the United States included many veterans who had acquired considerable clinical skills working as medical corpsmen in the Vietnam War. PA training programs served as an efficient means to allow these veterans to \"retool\" their skills for civilian practice.\n\nThe American Academy of Physician Assistants defines PAs as \"health professionals licensed to practice medicine with physician supervision\" (Jones, 2007). PAs are usually licensed by the same state boards that license physicians, with the requirement that PAs work under the delegated authority of a physician. In practical terms, \"delegated authority\" means that PAs are permitted to perform many of the tasks performed by physicians as long as the tasks are performed under physician supervision. Studies of PAs in primary care settings have found that their scope overlaps with approximately 80% of the scope of work of primary care physicians. To be eligible for licensure in most states, PAs must have graduated from an accredited training program and pass the Physician Assistant National Certifying Examination, administered by the National Commission on Certification of Physician Assistants. Approximately 60,000 PAs are professionally active in the United States. Traditionally, the majority of PAs worked in primary care fields. However, currently only one-third of PAs now practice in primary care, with many finding employment opportunities in surgical and medical specialty fields (Jones, 2007). PAs work in diverse settings, including private physician offices, community clinics, HMOs, and hospitals.\n\n#### **Physician Assistant Education**\n\nPA training has been described as a \"condensed version of medical school\" (Jones, 2007). The duration of training ranges from 20 to 36 months, with an average of 27 months (Hooker, 2006). Many of the initial training programs did not award degrees and accepted applicants with varying levels of prior formal education. Currently, of the 136 accredited PA training programs in the United States, 79% award a master's degree and require applicants to have attained a baccalaureate degree (Jones, 2007). Approximately half of PA training programs are based at academic health centers and are directly affiliated with medical schools. Several PA programs have established postgraduate training programs, typically one year in duration and focused on subspecialty training.\n\nPA programs produce about 5,600 graduates annually, compared with the 20,500 graduates of allopathic and osteopathic medical schools. Enrollment in PA programs has grown steadily over the past decades, with the number of PA graduates more than doubling between 1990 and 2010.\n\n### **REGISTERED NURSES**\n\n_Felicia Comfort has worked for 20 years as a registered nurse on hospital medical\u2013surgical wards. Although the work has always been hard, Felicia has found it gratifying to care for patients when they are acutely ill and need the clinical skills and compassion of a good nurse. But lately the work seems even more difficult. The pressure to get patients in and out of the hospital as soon as possible has meant that the only patients occupying hospital beds are those who are severely ill and require a tremendous amount of nursing care. At age 45, Felicia finds that her back has problems tolerating the physical labor of moving patients around in bed. Making matters worse, the hospital recently decided to \"re-engineer\" its staffing as a cost containment strategy and has hired more nursing aides and fewer registered nurses, adding to Felicia's work responsibilities. Felicia decides that it is time for a change. She takes a job as a visiting nurse with a home health care agency, providing services to patients after their discharge from a hospital. She likes the pace of her new job and finds the greater clinical independence refreshing after her years of dealing with rigid hospital regimentation of nurses and physicians._\n\nRegistered nurses represent the single largest health profession in the United States. In 2008, approximately 3,000,000 registered nurses were licensed in the United States (US Department of Health and Human Services, 2010). Approximately 80% of licensed registered nurses are actively employed in nursing jobs, with most of these nurses working full-time. In 2008, hospitals were the primary employment setting for 62% of nurses. Approximately 25% work in ambulatory care or other community-based settings, and 5% in long-term care facilities. The national licensing examination for registered nurses is administered by the National Council of State Boards of Nursing, a nonprofit organization comprising representatives of each of the state boards of nursing.\n\n#### **Registered Nurse Education**\n\nHistorically, many nurses received their education in vocational programs administered by hospitals not integrated into colleges and universities. These programs awarded diplomas of nursing rather than college degrees and tended to have the least demanding curricula. Over time, nursing education shifted into academic institutions. Most nurses are now educated either in 2- to 3-year associate degree programs administered by community colleges, or in baccalaureate programs administered by 4-year colleges. Of nurses active in 2008, 20% received their basic nursing training in diploma programs, 45% in associate degree programs, and 34% in baccalaureate degree programs (US Department of Health and Human Services, 2010). Many nursing leaders have called for nursing education to move almost completely to baccalaureate-level programs. At least one study has found that patient outcomes are better when hospitals are staffed with baccalaureate, trained nurses (Aiken et al, 2003). Of the nurses sitting for the national licensing examination in 2005, only 4% attended diploma programs. However, associate degree programs have remained a more affordable and accessible option than baccalaureate programs for many students, with nearly twice as many new registered nurses coming from community college programs as from baccalaureate programs.\n\nEnrollment in registered nurse training programs has had a cyclical pattern over recent decades, corresponding to perceptions of surpluses and shortages in the labor market for nurses. The number of US-educated nurses taking the national licensing examination for the first time (a proxy for new nurse graduates) increased by approximately 50% between 1990 and 1995, reaching 96,610 in 1995, and then fell back to 1990 levels by 2000 (National Council of State Boards of Nursing, 2006). Graduation numbers have recently rebounded in response to aggressive advertising campaigns promoting nursing as a career, such as the Campaign for Nursing's Future led by the Johnson & Johnson Company, and large increases in starting salaries for nurses. In 2006, nearly 110,000 nurses graduated from US programs (National Council of State Boards of Nursing, 2006).\n\nHistorically, most registered nurses in the United States were educated at US schools. However, as the numbers of US nursing graduates decreased in the late 1990s and hospital demand for nurse labor increased, growing numbers of foreign-educated nurses began entering the US health workforce. Unlike the situation for physicians, international nursing school graduates do not have to undergo training in the United States to become eligible for licensure. They may sit for the US registered nurse licensing examination, and upon passing the examination may apply for an occupational visa to work as a nurse. According to Dr. Linda Aiken, the United States has now become the \"world's largest importer of nurses,\" with approximately 15,000 internationally trained nurses passing the US licensing examination in 2005 (Aiken, 2007). Approximately one-third of internationally educated nurses in the United States immigrated from a single nation, the Philippines. This recent upswing in nurse immigration has raised the same concerns about a brain drain from developing nations that has been voiced about physician immigration.\n\n### **NURSE PRACTITIONERS**\n\n_Felicia Comfort has now been working as a home care nurse for 2 years. She has taken on growing responsibility as a case manager for many home care patients with chronic, debilitating illnesses, coordinating services among the physicians, physical therapists, social workers, and other personnel involved in caring for each patient. She decides that she would like to become the primary caregiver for these types of patients, and applies to a nurse practitioner training program in her area. After completing her 2 years of nurse practitioner education, she finds a job as a primary care clinician at a geriatric clinic._\n\nEight percent of registered nurses in the United States have obtained advanced practice education in addition to their basic nursing training (US Department of Health and Human Services, 2010). Advanced practice nurses include clinical nurse specialists, nurse anesthetists, clinical nurse midwives, and nurse practitioners. The approximately 140,000 professionally active nurse practitioners represent the largest single group of advanced practice nurses.\n\nNurse practitioner education typically involves a 2-year master's degree program for individuals who previously attained a baccalaureate degree in nursing. Education emphasizes primary care, prevention, and health promotion, preparing nurse practitioners for a broad scope of clinical practice, although some training programs also prepare nurse practitioners for work in non\u2013primary care fields. Approximately 50% to 60% of nurse practitioners work in primary care settings.\n\nMany nurse practitioner programs were established in the 1970s with federal funding as part of the same national effort to boost the number of primary care clinicians that gave rise to PA training programs. Enrollment in nurse practitioner programs grew slowly in the 1980s and exploded in the 1990s, with the number of nurse practitioner training programs more than doubling between 1992 and 1997. Whereas 1500 nurse practitioners graduated in 1992, more than 8000 graduated in 1997 (Hooker and Berlin, 2002). Unlike the trend for PAs, the number of annual nurse practitioner graduates has decreased in recent years, falling to approximately 6500 graduates in 2005 (Hooker, 2006); the number of graduates is projected to decrease further to 4000 annually by 2015 (Robert Graham Center, 2005). The causes of this decrease are multifactorial, including an initial pent-up demand for advanced practice training among the existing pool of registered nurses that was met by the expansion of programs in the 1990s, leaving a lower \"steady state\" demand once the initial demand was met, and increases in salaries for registered nurses that has lessened the additional earnings that may be gained by advanced practice training.\n\nLicensing and related regulations for nurse practitioners are less uniform across states than those for physicians, physician assistants, and registered nurses. Slightly more than half of state nursing boards require nurse practitioners to have attained a master's degree, but other states accept less extensive training (Christian et al, 2007). Rather than a single national licensing examination for all nurse practitioners, certification examinations are administered by different organizations and are specialty-specific, akin to medical specialty board certification. State boards of nursing also vary in the scope of practice they allow nurse practitioners. Most states require that nurse practitioners work in collaboration with a physician, usually with written practice protocols in place. Eleven states have more liberal regulations permitting nurse practitioners to practice with complete independence from physicians, while at the other extreme, 10 states require physicians to directly supervise nurse practitioners (Christian et al, 2007).\n\nSimilar to physician assistants, nurse practitioners working in primary care settings typically perform approximately 80% of the types of tasks performed by physicians. Two meta-analyses provide evidence that nurse practitioners can deliver care of equivalent quality to that delivered by primary care physicians (Brown and Grimes, 1995; Horrocks et al, 2002), with the caveat that most studies reviewed included small numbers of clinicians and few examined long-term outcomes for patients with chronic illness or complex conditions.\n\nMuch of the initial impetus for developing training programs for both nurse practitioners and PAs in the 1960s was to create substitutes for physicians in an era when there was a perceived shortage of physicians, especially in primary care fields. As concerns about a physician shortage waned in subsequent decades and the era of cost containment arrived, substitution came to mean less a matter of filling shortages than of finding a less expensive type of clinician to substitute for physician labor. A different view of nurse practitioners and PAs sees them less as physician substitutes than as complements in a health care team that includes a variety of personnel. In this view, each profession brings its own unique training and skills to create a health care team in which the whole is more than the sum of its parts (Wagner, 2000). For example, care of patients with chronic diseases such as diabetes is enhanced by multidisciplinary teams (Grumbach and Bodenheimer, 2004). In these types of teams, nurse practitioners often play a leading role by providing care management, health promotion, and instruction in patient self-care, while physicians focus more on medication management and treatment of acute complications.\n\nThe boldest effort to promote advance practice nurses as substitutes for physicians comes from proponents of doctoral-level professional degrees for nurses, known as doctor of nursing practice (DrNP) degrees. A few DrNP training programs have been established in the United States, involving a 4-year graduate education experience following the initial baccalaureate nursing training. Leaders of these programs have articulated the vision of producing nursing graduates carrying the title of \"doctor\" who will be able to practice autonomously with a scope equivalent to that of physicians, including independent practice in acute care hospital settings. Whether there will be ample numbers of registered nurses interested in pursuing this level of training, along with sufficient liberalization of state scope of practice regulations, to actualize this vision for DrNPs in the health workforce in the United States remains to be determined.\n\n### **PHARMACISTS**\n\n_Rex Hall has worked for 5 years as a pharmacist at a chain drug store. He is not sure that his extensive professional education and skills as a pharmacist are being fully utilized in his current job. Some of his time is spent discussing possible drug interactions with physicians and suggesting alternative drug regimens, as well as counseling patients about side effects and proper use of their medications. But too much of his time is taken up answering calls from physicians and patients who are ordering prescription refills, counting out pills, filling pill bottles, and figuring out which medications are covered by which health plan. He sees a job posting for a new pharmacist position at a local hospital. The job description states that the pharmacist will review drug use in the hospital and develop strategies to work with physicians, nurses, and other staff to minimize drug errors and inappropriate prescribing practices. Rex decides to apply for the job._\n\nPharmacists constitute the nation's third largest health care profession. About 250,000 pharmacists were actively practicing in 2010 (US Department of Health and Human Services, 2008b). Although historically most pharmacists were educated in baccalaureate degree programs, in 2004 all programs were required to extend the training period by 1 to 2 years and award Doctorate of Pharmacy degrees. Pharmacy education is in a period of expansion, with the number of accredited schools increasing from 82 in 2000 to 119 in 2011, and the number of graduates growing from 7300 in 2000 to 11,500 in 2010 (US Department of Health and Human Services, 2008b). Approximately 60% of pharmacists work in retail pharmacies, mostly as employees rather than as owners. Over the past decades, drug store chains such as Walgreens and Longs have largely displaced the independently owned pharmacy. Hospitals are the second largest employer of pharmacists, with HMOs and other managed care organizations, long-term care facilities, and clinics also offering practice settings for pharmacists. The content of pharmacists' work is changing, as noted in the vignette above and in a further discussion later in this chapter.\n\n### **SOCIAL WORKERS**\n\nSocial work is a growing profession, with the number of social workers projected to increase from 642,000 in 2008 to 745,000 in 2018; 43% of social workers are dedicated to health care, with about half of these in the fields of mental health and substance abuse. Social workers are trained in assessment skills, diagnostic impressions, psychosocial support to patients and families; and assistance with navigation of the health and social service systems including transitions between hospital, extended care facilities, and home. Some specific tasks carried out by social workers include assessing patients' personal, behavioral, and family\/home\/job situation for the health care team, connecting patients to durable medical equipment and in-home services, finding placements for hospital in-patients unable to go home, helping patients to get health insurance and other community services, investigating possible neglect or abuse, and counseling patients on healthy behavior change (Kitchen and Brook, 2005).\n\nThe minimum educational requirement is a bachelor's degree, but most social work positions in the health care field require a masters in social work plus state licensure. Licensed clinical social workers (LCSWs) must have at least a master's degree plus 2 years of academic and practical experience in the field, during which they serve as members of care teams in hospital, primary care, and behavioral health settings. LCSWs may be generalists or be specialized in the management of geriatric patients, children, or persons with developmental disabilities, mental health, and substance abuse diagnoses.\n\n### **SUPPLY, DEMAND, AND NEED**\n\n_Justin Case began his premed studies in college in 1993. He was taken aback one morning to read an article in the newspaper reporting that a prestigious national commission had just issued a report declaring that the United States was training too many physicians and that medical schools should reduce their enrollment by 25%. Nonetheless, hepressed on in his studies, medical schools did not decrease the number of first-year positions, and Justin succeeded in gaining admission to medical school. By the time he finished his residency training in internal medicine in 2004, he was hearing reports that the United States was facing a shortage of physicians and he received many offers to join medical practices as a primary care internist. However, he opted to do a fellowship in cardiology at a prominent cardiac center in Miami, FL. One of his classmates warned him that Miami already had more cardiologists than most cities of comparable size. Justin told his friend, \"I'm not worried about finding a good job in Miami when I finish my fellowship. Everyone tells me that there will always be more than enough work for interventional cardiologists in Florida.\"_\n\nThe supply of health workers in all the professions discussed in this chapter has been growing over past decades (Figures 7\u20131 to 7\u20133). Between 1975 and 2005, the number of active registered nurses per capita in the United States nearly doubled, the number of physicians per capita grew by approximately 75%, and the number of pharmacists per capita increased by approximately 50%. Increases in the supply of PAs and nurse practitioners have been even more dramatic. For physicians, virtually all the growth in supply is accounted for by increasing numbers of non\u2013primary care specialists. Interestingly, although supply has steadily increased during these years, health workforce analysts have alternated between sounding alarms about shortages and surpluses of physicians and nurses. For example, in the 1980s and 1990s, several commissions warned of a surplus of physicians in the United States (Graduate Medical Education National Advisory Committee, 1981; Pew Health Professions Commission, 1995; Council on Graduate Medical Education, 1996). By the early years of the twenty-first century, some policy analysts were declaring a physician shortage (Council on Graduate Medical Education, 2005). Similarly, concerns about an oversupply of nurses in the mid-1990s were supplanted in 1998 by declarations of a nursing shortage (Buerhaus et al, 2000).\n\n**Figure 7\u20131.** Supply of practicing physicians in the United States. Note: Includes patient care physicians who have completed training, and excludes physicians employed by the federal government (Council on Graduate Medical Education (COGME). _Patient Care Physician Supply and Requirements: Testing COGME Recommendations_. US Department of Health and Human Services; 1996 [HRSA-P-DM 95\u20133].)\n\n**Figure 7\u20132.** Supply of active registered nurses per 100,000 population in the United States. (Peter I. Buerhaus, PhD, RN, FAAN, Douglas O. Staiger, PhD, and David I. Auerbach, PhD, _The Future of the Nursing Workforce in the United States: Data, Trends and Implications,_ 2009: Jones & Bartlett Publishers, Sudbury, MA. www.jbpub.com. Reprinted with permission.)\n\n**Figure 7\u20133.** Supply of active pharmacists per 100,000 population in the United States. (Bureau of Health Professions. _The Pharmacist Workforce. A Study of the Supply and Demand for Pharmacists_. Rockville, MD: Health Resources and Services Administration; 2000.)\n\nWhat explains why perceptions turned from surplus to shortage when supply was continuing to increase? One concern was that overall supply trends might present a misleading picture of the actual labor participation of health care professionals. For example, female physicians work on average fewer hours per week than male physicians. Women constitute a growing share of the physician workforce, and therefore head counts of the number of practicing physicians may overstate the full-time equivalent supply of physicians. In nursing, concerns were voiced that overly stressful working conditions on hospital wards were driving licensed nurses out of the workforce. This concern was magnified by the fear that the sudden plummeting of enrollment in nursing schools portended a major downturn in entry of newly trained nurses into the workforce.\n\nHowever, the supply of health care professionals is only one part of the equation for determining the adequacy of the workforce. The other part of the equation is a judgment about how many physicians, nurses, or pharmacists are actually required. Even when the supply of health care professionals per capita is growing, there may be a perception of a workforce shortage if the requirements for these workers are judged to be increasing more rapidly than supply. There are two general schools of thought about how to define health workforce requirements (Grumbach, 2002). One view considers market demand as the arbiter of workforce requirements. According to this view, if there is unmet market demand for, let us say, nurses, as indicated by many vacant nursing positions at hospitals, then a shortage exists. Or, to the contrary, if many nurses are unemployed or underemployed, a surplus exists. An alternative approach defines workforce requirements on the basis of population need rather than market demand. For example, a need-based approach for nursing would attempt to evaluate whether a certain level of nursing supply optimizes patient outcomes, such as by determining whether higher registered nurse staffing levels for a given volume and acuity of hospital inpatients result in fewer medication errors and hospital-acquired infections and better overall patient outcomes.\n\nIn the case of registered nursing, both demand and need perspectives converged to conclude that a shortage existed in the late 1990s (Bureau of Health Professions, 2002). As the intensity of hospital care increased and hospitals sought more highly trained registered nurses to staff their facilities, vacancy rates increased for hospital nurses. In response, hospitals began to increase wages to attract nurses into the workforce. Researchers around this time also began to produce evidence that lower levels of registered nurse staffing in hospitals were associated with worse clinical outcomes for hospitalized patients (Aiken et al, 2002; Needleman et al, 2002), suggesting a true medical need for more registered nurses in hospitals. One state, California, proceeded to codify a need-based approach to nurse supply by enacting legislation requiring a minimum nurse staffing level per occupied hospital bed (Spetz, 2004). In response to concerns about a nurse shortage, comprehensive strategies have been implemented that appear to be succeeding in attracting more applicants to nursing programs, increasing enrollment in these programs, and increasing the proportion of licensed nurses who are working as nurses. These strategies include actions by private entities, such as hospitals increasing wages for nurses and the Johnson & Johnson\u2013sponsored advertising campaign mentioned above, and actions by government agencies, such as appropriating more funds for expansion of community and state college nursing program capacity.\n\nThe case of the physician workforce has been less straightforward. While most nurses work as employees of hospitals or other employers, most physicians are self-employed or part-owners of a medical group that acts as their employer, making vacancy rates or other typical labor market metrics less reliable indicators of the demand for physicians. Moreover, physicians' authority and influence over medical care give them considerable market power and create opportunities for supplier-induced demand (see Chapter 9), particularly when costs are covered by third-party payers. In a health care environment like that in the United States, in which demand for physician labor may be almost limitless, physicians tend to keep busy even as supply continues to rise. Dr. Richard Cooper has been the most vocal advocate of the position that the United States currently faces a physician shortage, based on his view that the public's demand for physician services is increasing rapidly because of an aging population and the expanding national economy, while growth in physician supply per capita in the United States is beginning to level off (Cooper et al, 2002). Countering this view has been research that raises questions about whether the public really needs and benefits from more physicians, particularly more specialists. Studies comparing patient outcomes across regions in the United States have found that while a very low supply of physicians is associated with higher mortality, once supply is even modestly greater, patients derive little further survival benefit (Goodman and Grumbach, 2008). For example, mortality rates for high-risk newborns are worse in regions with a very low supply of neonatologists than in regions with a somewhat greater supply, but above that level, further increases in the supply of neonatologists are not associated with better clinical outcomes for newborns (Goodman et al, 2002). At the other age extreme, Medicare beneficiaries residing in areas with high physician supply do not report better access to physicians or higher satisfaction with care and do not receive better quality of care (Goodman and Grumbach, 2008). One exception to these patterns is when studies focus on primary care physician supply, rather than on overall physician supply or the supply of specialists. These studies tend to find that patient outcomes and quality of care are better in regions with a more primary care-oriented physician workforce (Baicker and Chandra, 2004; Starfield et al, 2005). Proponents of a need-based approach to physician workforce planning argue that because much of physician training is supported by tax dollars, and because there is little true market restraint on demand for medical care, society should plan physician supply based on considerations of quality, affordability, and prioritization of health care services informed by the type of research evidence cited above (Grumbach, 2002).\n\nIn assessing the adequacy of health care professional supply, it is important not just to count the number of workers, but to examine how these workers are deployed. The quest for effective deployment of the workforce has been characterized using the following analogy: \"Before adding another spoonful of sugar to your tea, first stir up the sugar already in your tea cup.\" In other words, does the health system make the most of its existing supply of highly trained health care professionals? The case of the pharmacist workforce highlights this issue. As has been the case for nurses and physicians, concerns have recently been raised about a shortage of pharmacists. One of the factors cited is the steep rise in the prescribing of medications, which may be considered an indicator of the demand for pharmacists. Approximately 3.6 billion prescriptions were dispensed in 2005, 70% more than in 1994 (US Health and Human Services, 2008b). The estimated number of prescriptions filled per pharmacist in retail pharmacies grew from 17,400 in 1992 to 22,900 in 1999 (Bureau of Health Professions, 2000). In response, pharmacies sought to hire more pharmacists, and between 1998 and 2000, the number of unfilled pharmacist positions in chain store pharmacies more than doubled (Bureau of Health Professions, 2000; Cooksey et al, 2002). Partly in response to increased output from pharmacy schools, the percentage of pharmacist employment positions unfilled dropped from 9% to 5% between 2000 and 2004 (US Department of Health and Human Services, 2008b).\n\nAlthough these trends would suggest a shortage of pharmacists based on a traditional demand model, some observers have questioned whether the existing supply of pharmacists is optimally deployed. Many pharmacists still spend a great deal of time performing the basic \"pill counting\" tasks of drug dispensing. Should pharmacists continue to perform most dispensing functions, or would their extensive training be better utilized in more clinically challenging activities\u2014especially now that all newly graduated pharmacists in the United States are required to have doctoral-level training? The occupation of pharmacy technician has been developed in the United States to assist pharmacists with drug dispensing (Cooksey et al, 2002). An estimated 69% of pharmacists' time is spent on activities that properly trained technicians could perform\u2014counting, packaging, and labeling prescriptions, and resolving third-party insurance issues. Greater use of properly supervised pharmacy technicians might increase the productivity of the existing pharmacists. In addition, innovations in automation of pill dispensing could reduce pharmacist workload. Delegating more tasks to pharmacy assistants and automated systems would allow pharmacists to optimize their clinical training and skills for patient counseling about medications, collaborating on patient safety programs to reduce the epidemic of medication errors, monitoring drug use for chronic disease management programs, and participating in multidisciplinary clinical teams in both hospitals and ambulatory settings. These same types of concerns have been raised about whether other health care professionals are being deployed with maximum efficiency and productivity and working at their highest level of skill. For example, new models of primary care are emphasizing that many preventive and chronic care tasks traditionally performed by physicians could be delegated to medical assistants and assisted by electronic technologies (Bodenheimer and Grumbach, 2007), allowing more productive use of the work effort of primary care clinicians.\n\n### **WOMEN IN THE HEALTH PROFESSIONS**\n\n_Dr. Jenny Wong works as a general internist for the Suburbia Medical Group. She never has to check her schedule in advance, because she knows that every appointment is always booked, not to mention the last minute add-ons. As one of only two women in a group of eleven primary care physicians, she is in demand. In particular, female patients in the practice have sought her out to become their primary care physician. While gratified to be responding to this demand, Dr. Wong also finds it a bit daunting. She senses that her patients expect her to spend more time with them to explain diagnoses and treatments and discuss their overall well-being. But Dr. Wong has the same 15-minute appointment times as every other physician in the practice and continually finds herself falling behind in her schedule. Today Dr. Wong is feeling especially stressed. She is scheduled to meet at lunchtime with the director of Suburbia Medical Group to discuss plans for her impending maternity leave. She knows he will not take kindly to her intention of taking 4 months off after the birth of her child._\n\nHistorically, most physicians and pharmacists in the United States have been men, and most nurses women. For physicians and pharmacists, this demographic pattern is in the midst of a dramatic change. In 1970, 13% of pharmacists were women, but by 2010, more than half of pharmacists were women. The proportion of women among physicians increased from 8% in 1970 to more than 30% in 2010 (Figure 7\u20134). The figures are even more dramatic when examining the makeup of current students in training: women constituted 47% of medical students and 61% of pharmacy students in 2010. In contrast, nursing has long been a profession mainly comprising women, and this is changing very slowly. In 2008, only 10% of registered nurses were men, up slightly from 5% in 1996.\n\n**Figure 7\u20134.** Women as a percentage of physicians, nurses, and pharmacists in the United States. (US Department of Health and Human Services. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. Health Resources and Services Administration, Bureau of Health Professions, 2008a. US Department of Health and Human Services. The Adequacy of Pharmacist Supply, 2004\u20132030. Health Resources and Services Administration, Bureau of Health Professions, 2008b. US Department of Health and Human Services. The Registered Nurse Population. Findings from the 2008 National Sample Survey of Registered Nurses. Health Resources and Services Administration, Bureau of Health Professions, 2010.)\n\nAs noted above, women, on average, work fewer hours per week than men and are more likely to work on a part-time basis. However, the practices of male and female health care professionals differ in ways other than simply the number of hours worked. Female physicians attract more female patients, in part because female patients highly value more time spent and clearer explanations from their physicians than do male patients, and female physicians spend more time with their patients than do male physicians. Several studies have shown that female physicians deliver more preventive services than male physicians, especially for their female patients (Lurie et al, 1993). Female physicians appear to communicate differently with their patients, with both adults and children, being more likely to discuss lifestyle and social concerns, and to give more information and explanations during a visit (Elderkin-Thompson and Waitzkin, 1999; Roter et al, 2002). Female physicians are more likely to involve patients in medical decision-making than male physicians (Cooper-Patrick et al, 1999).\n\n### **UNDERREPRESENTED MINORITIES IN THE HEALTH PROFESSIONS**\n\n_Cynthia Cuidado is the first person in her family to go to college, much less the first to become a health professional. A large contingent of her extended family celebrates her graduation from her master's degree family nurse practitioner training program. Although HMOs in the city where Cynthia trained had several open positions for nurse practitioners, she has decided to take a job at a migrant farm worker clinic in a rural community near where she grew up._\n\nThe United States is a nation of growing racial and ethnic diversity. According to the 2010 US census, African Americans, Latinos, and Native Americans now account for nearly one-third of the population, yet the health professions fail to reflect the rich racial and ethnic diversity of the US population. Only about 10% of pharmacists, 9% of physicians, 8% of physician assistants, 10% of nurses, and 5% of dentists are from these three underrepresented racial and ethnic groups (Grumbach and Mendoza, 2008).\n\nHealth professions have made efforts to increase the number of underrepresented minorities enrolling in their training programs. In nursing, these efforts appear to be paying dividends (Figure 7\u20135). Underrepresented minorities as a proportion of students in baccalaureate nursing programs increased from 12.2% in 1991 to 18.1% in 2005. Medical schools have experienced a different trend. Underrepresented minorities as a percentage of medical students increased in the early 1990s, from 12.2% in 1991 to 15.5% in 1997. However, the percentage of underrepresented minority medical students dropped after 1997, falling to 13.9% in 2005. The decrease in underrepresented minority student enrollment in medical schools beginning in the mid-1990s coincided with the onset of a wave of antiaffirmative action policies, such as Proposition 209 in California and the Hopwood vs. Texas federal court ruling that curtailed the ability of university admissions committees to give special consideration to applicants' race and ethnicity (Grumbach and Mendoza, 2008). Pharmacy schools also showed little net increase in underrepresented minority enrollment, with 11% of pharmacy students in 1990 and 2010 being from underrepresented minority groups.\n\nThe problem of underrepresented minorities in the health professions is an especially compelling policy concern. As discussed in Chapter 3, minority communities experience poorer health and access to health care compared with communities populated primarily by non-Latino whites. Minority health care professionals are more likely to practice in underserved minority communities and serve disadvantaged patients, such as the uninsured and those covered by Medicaid (Moy and Bartman, 1995; Cantor et al, 1996; Komaromy et al, 1996; Mertz and Grumbach, 2001). Research has also found salutary effects of ethnically concordant relationships between minority patients and health care professionals on the use of preventive services, patient satisfaction, and ratings of the physician's participatory decision-making style (Saha et al, 2000; Cooper et al, 2003; US Department of Health and Human Services, 2006). Some studies focusing specifically on language concordance when patients have limited English proficiency have also found that access to language concordant clinicians is associated with better patient experiences and outcomes such as reductions in patient reports of medication errors (Wilson et al, 2005). Thus, the underrepresentation of minorities is not just a matter of equality of opportunity; it has profound implications for racial and ethnic disparities in access to care and in health status.\n\n**Figure 7\u20135.** Underrepresented minorities as a percentage of students in selected health professions in the United States. Note: Medical schools include only allopathic schools. (American Association of Colleges of Nursing, Enrollment and Graduations in Baccalaureate & Graduate Programs in Nursing; Association of American Medical Colleges, Data Warehouse. _Applicant Matriculant File_. Association of Colleges of Pharmacy, Profile of Pharmacy Students Application Trends; 2007.)\n\n### **CONCLUSION**\n\nAn intricate array of educational pathways, accreditation of teaching institutions, and credentialing of individuals to legally practice a healing profession defines the composition of the health workforce. Access, cost, and quality\u2014the three overriding issues in health care\u2014are all inextricably linked to trends in the health care workforce. An inadequate supply of health care professionals may impede patients' access to care or compromise the quality of care. But increases in the supply of health care professionals may fuel intolerable escalation of health care costs. It is not surprising, then, to find disagreement about whether a health system has enough, too few, or too many of a particular class of health care professionals. The recent consensus in the United States about a shortage of registered nurses is one of the rare instances in which analyses based on demand models and on need models arrived at similar conclusions. The current debate over the adequacy of the physician workforce in the United States is more typical of the challenges in coming to agreement about the adequacy of supply, revealing how different frames of reference for judging the nation's requirement for health care professionals lead to different policy conclusions. In addition to the overall supply of health professionals, the demographic composition of the workforce in terms of gender and race\u2013ethnicity also has important policy implications.\n\nAlthough making definitive determinations about the \"right\" number of health care professionals often proves elusive, two conclusions may be made with more confidence. First, all health systems should deploy their workers in a manner that makes the best use of their training and skills, creating practice structures that allow each health care professional to operate at his or her highest level of capability and ensuring that those patients most in need benefit from the clinical expertise of the health care professionals working in the system. Most systems fall short of this goal and have not fully \"stirred the sugar in the cup of tea,\" failing to continually reassess and adapt the roles and responsibilities of the members of the health care team to the changing needs of modern-day health systems. Second, all systems need to ensure that their health professionals are highly qualified and embrace a culture of continuous quality improvement (discussed in Chapter 10). To echo the opening of this chapter, a health care system is only as good as the people working in it.\n\n### **REFERENCES**\n\nAiken LH. U.S. nurse labor market dynamics are key to global nurse sufficiency. _Health Serv Res_. 2007;42:1299.\n\nAiken LH et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. _JAMA_. 2002;288:1987.\n\nAiken LH et al. Educational levels of hospital nurses and surgical patient mortality. _JAMA_. 2003;290:1617.\n\nBaicker K, Chandra A. 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Rockville, MD: Health Resources and Services Administration; 2002.\n\nCantor JC et al. Physician service to the underserved: Implications for affirmative action in medical education. _Inquiry_. 1996;33:167.\n\nChristian S et al. _Overview of Nurse Practitioner Scopes of Practice in the United States_. University of California, San Francisco, Center for the Health Professions; 2007. <http:\/\/www.acnpweb.org\/files\/public\/UCSF_Discussion_2007.pdf>. Accessed November 14, 2011.\n\nCooksey JA et al. Challenges to the pharmacist profession from escalating pharmaceutical demand. _Health Aff (Millwood)_. 2002;21(5):182.\n\nCooper RA et al. Economic and demographic trends signal an impending physician shortage. _Health Aff (Millwood)_. 2002;21:140.\n\nCooper LA et al. Patient-centered communication, ratings of care and concordance of patient and physician race. _Ann Intern Med_. 2003:139:907.\n\nCooper-Patrick L et al. Race, gender and partnership in the patient-physician relationship. _JAMA_. 1999;282:583.\n\nCouncil on Graduate Medical Education (COGME). _Eighth Report: Patient Care Physician Supply and Requirements: Testing COGME Recommendations_. Rockville, MD: Council on Graduate Medical Education; 1996.\n\nCouncil on Graduate Medical Education (COGME). _Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000\u20132020_. Rockville, MD: Council on Graduate Medical Education; 2005.\n\nElderkin-Thompson B, Waitzkin H. Differences in clinical communication by gender. _J Gen Intern Med_. 1999;14:112.\n\nGoodman D et al. The relation between the availability of neonatal intensive care and neonatal mortality. _N Engl J Med_. 2002;346:1538\u20131544.\n\nGoodman D, Grumbach K. Does having more physicians lead to better health system performance? _JAMA_. 2008;299:335.\n\nGraduate Medical Education National Advisory Committee. _Summary Report_. DHHS Pub. No. (HRA) 81\u2013651. Washington, DC; 1981.\n\nGrumbach K. Fighting hand to hand over physician workforce policy. _Health Aff (Millwood)_. 2002;21(5):13.\n\nGrumbach K, Bodenheimer T. Can health care teams improve primary care practice? _JAMA_. 2004;291:1246.\n\nGrumbach K, Mendoza R. Disparities in human resources: Addressing the lack of diversity in the health professions. _Health Aff (Millwood)_. 2008;27(2):413.\n\nHooker RS. Physician assistants and nurse practitioners: the United States experience. _Med J Aust_. 2006;185:4.\n\nHooker RS, Berlin LE. Trends in the supply of physician assistants and nurse practitioners in the United States. _Health Aff (Millwood)_. 2002;21(5):174.\n\nHorrocks S et al. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. _BMJ_. 2002;324:819.\n\nIglehart J. Health reform, primary care, and graduate medical education. _N Engl J Med_ 2010;363:584.\n\nJones PE. Physician assistant education in the United States. _Acad Med_. 2007;82:882.\n\nKitchen A, Brook J. Social work at the heart of the medical team. _Soc Work Health Care._ 2005;40:1\n\nKomaromy M et al. The role of black and Hispanic physicians in providing health care for underserved populations. _N Engl J Med_. 1996;334:1305.\n\nLurie N et al. Preventive care for women: Does the sex of the physician matter? _N Engl J Med_. 1993;329:478.\n\nMertz EA, Grumbach K. Identifying communities with low dentist supply in California. _J Public Health Dent_. 2001;61:172.\n\nMoy E, Bartman BA. Physician race and care of minority and medically indigent patients. _JAMA_. 1995;273:1515.\n\nMullan F. The metrics of the physician brain drain. _N Engl J Med_. 2005;353:1850.\n\nNational Council of State Boards of Nursing. _Nurse Licensure and NLCEX Examination Statistics_. 2006. <https:\/\/www.ncsbn.org\/1236.htm>.\n\nNeedleman J et al. Nurse-staffing levels and the quality of care in hospitals. _N Engl J Med_. 2002;346:1715.\n\nPew Health Professions Commission. _Critical Challenges. Revitalizing the Health Professions for the Twenty-First Century._ San Francisco: UCSF Center for the Health Professions; December 1995.\n\nRobert Graham Center Policy Studies in Family Medicine and Primary Care. _Physician Assistant and Nurse Practitioner Workforce Trends_. One-pagers, 37, 2005. <http:\/\/www.aafp.org\/afp\/2005\/1001\/p1176.html>. Accessed November 14, 2011.\n\nRoter D et al. Physician gender effects in medical communication: a meta-analytic review. _JAMA_. 2002;288:756.\n\nSalsberg E et al. US residency training before and after the 1997 Balanced Budget Act. _JAMA._ 2008;300:1174.\n\nSaha S et al. Do patients choose physicians of their own race? _Health Aff (Millwood)._ 2000;19(4):76.\n\nSpetz J. California's minimum nurse-to-patient ratios: The first few months. _J Nurs Adm_. 2004;34:571.\n\nStarfield B et al. The effects of specialist supply on populations' health: assessing the evidence. _Health Aff Web Exclusives_. 2005;(suppl):W5-97\u2013W5-107.\n\nStarr P. _The Social Transformation of American Medicine._ New York: Basic Books; 1982.\n\nUS Department of Health and Human Services. The Rationale for Diversity in the Health Professions: A Review of the Evidence. Health Resources and Services Administration; 2006. <http:\/\/bhpr.hrsa.gov\/healthworkforce\/reports\/diversityreviewevidence.pdf>.\n\nUS Department of Health and Human Services. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. Health Resources and Services Administration, Bureau of Health Professions, 2008a. <http:\/\/bhpr.hrsa.gov\/healthworkforce\/reports\/physwfissues.pdf>\n\nUS Department of Health and Human Services. The Adequacy of Pharmacist Supply, 2004\u20132030. Health Resources and Services Administration, Bureau of Health Professions, 2008b. <http:\/\/bhpr.hrsa.gov\/healthworkforce\/reports\/pharmsupply20042030.pdf>\n\nUS Department of Health and Human Services. The Registered Nurse Population. Findings From the 2008 National Sample Survey of Registered Nurses. Health Resources and Services Administration, Bureau of Health Professions, 2010. <http:\/\/bhpr.hrsa.gov\/healthworkforce\/rnsurveys\/rnsurveyfinal.pdf>\n\nWagner EH. The role of patient care teams in chronic disease management. _Br Med J._ 2000;320:569.\n\nWilson E et al. Effects of limited English proficiency and physician language on health care comprehension. _J Gen Intern Med_. 2005;20(9):800-806.\n\n## **8 Painful Versus Painless Cost Control**\n\n_Dr. Joshua Worthy is chief of neurology at a large staff model health maintenance organization (HMO) and serves as the physician representative to the HMO's executive committee. A national health plan has just been enacted that imposes mandatory cost controls. The HMO's budget for the coming year will be frozen at the current year's level. In past years, the annual growth in the HMO's budget has averaged 12%._\n\n_The health plan CEO begins the committee meeting by groaning, \"These cuts are draconian! To meet these new budget limits we'll have to cut staff and ration life-saving technologies. Patients will suffer.\" A consumer member responds, \"We all know there's fat in the system. Why, in the newspaper just the other day there was an article about how rates of back surgery in our city are twice the national average. And if we're going to talk about cuts, maybe we should start by looking at your salary and the number of administrators working here. I'm not so sure patients have to suffer just because we're adopting the kind of reasonable spending limits that they have in most countries.\"_\n\n_Dr. Worthy remains silent for much of the meeting. He wonders to himself, \"Is the CEO right? Is cost containment inevitably a painful process that will deprive our patients of valuable health services? Or, could we be doing a better job with the resources we're already spending? Is there a way that our HMO could implement these cost controls in a relatively painless fashion as far as our patients' health is concerned?\" Interpreting Dr. Worthy's silence as an indication of great wisdom and judgment, the committee assigns him to chair the HMO's task force charged with developing a cost control strategy to meet the new budgetary realities._\n\nConcerns about the rise of health care costs dominate the health policy agenda in the United States. Another pressing health policy concern\u2014lack of adequate insurance and access to care for tens of millions of people\u2014is in part attributable to the problem of rising costs. Health care inflation has made health insurance and health services unaffordable to many families and employers.\n\nPrivate and public payers in the United States have taken aim at health care inflation and discharged volleys of innovative strategies attempting to curb expenditure growth, such as creating new approaches to utilization review, encouraging HMO enrollment, making patients pay more out-of-pocket for care, and a multitude of other measures. These approaches had little noticeable impact on the rate of growth of health care costs in the United States. National health expenditures per capita increased over sevenfold between 1980 and 2009, rising from $1110 to $8086 per capita (Figure 8\u20131). Viewed as a percentage of gross domestic product (GDP), US health expenditures increased from 9.2% in 1980 to 17.6% in 2009 (Figure 8\u20132). Health expenditures as a percentage of GDP are projected to rise to 19.6% by 2019 (Sisko et al, 2010).\n\n**Figure 8\u20131.** US per capita health care expenditures. (Martin A et al. Recession contributes to slowest annual rate of increase in health spending in five decades. _Health Aff (Millwood)_. 2011;30:11.)\n\n**Figure 8\u20132.** US health care expenditures as a percentage of the gross domestic product. (Martin A et al. Recession contributes to slowest annual rate of increase in health spending in five decades. _Health Aff (Millwood)_. 2011;30:11.)\n\nHealth care providers are discovering that they have to adjust to the prospect of practicing in an era of finite resources. Like Dr. Worthy, physicians and other health caregivers need to deliberate about how constraints on expenditure growth may affect patients' health. Must cost control necessarily be painful, leading to rationing of beneficial services? Or, is there a painless route to containing costs, reached by eliminating unnecessary medical treatments and administrative expenses?\n\nIn this chapter, the painful\u2013painless cost control debate will be explored. First a model will be constructed describing the relationship between health care costs and benefits in terms of improved health outcomes. Then different general approaches to cost containment and their potential for achieving painless cost control will be discussed. Chapter 9 will describe specific cost control measures in more detail.\n\n### **HEALTH CARE COSTS AND HEALTH OUTCOMES**\n\n_Before entering medical school, Dr. Worthy worked in the Peace Corps in a remote area in Central America. At the time he first arrived in the region, the infant mortality rate was quite high, withmany deaths due to infectious gastroenteritis. Dr. Worthy participated in the creation of a sewage treatment system and clean well-water sources for the region, as well as a program for implementing oral rehydration techniques for infants. By the end of Dr. Worthy's 2-year stay, the infant mortality rate had dropped by nearly 25%. The cost for the entire program amounted to 15 cents per capita, paid for by the World Health Organization._\n\n_Conditions have been very different for Dr. Worthy as a practicing neurologist in the United States. In the past 5 years, over a dozen new magnetic resonance imaging (MRI) scanners have been installed in the city in which his HMO is located, an urban area with a population of 800,000. Dr. Worthy has found that MRI scans provide images that are better than those of computed tomography (CT) scans, allowing him to more accurately diagnose conditions such as multiple sclerosis in earlier stages. He is less certain about the extent to which these superior images allow superior health care for his patients._\n\nFrom society's point of view, the value of health care expenditures lies in purchasing better health for the population. The concept of \"better health\" is a broad one, encompassing improved longevity and quality of life, reduced mortality and morbidity rates from specific diseases, relief of pain and suffering, enhanced ability to function independently for those with chronic illnesses, and reduction in fear of illness and death. Thus, it is important to know whether investing more resources in health care buys improved health outcomes for society, and if so, what magnitude of the improvement in outcomes may be relative to the amount of resources invested.\n\nFigure 8\u20133, drawn from the work of Robert Evans (1984), illustrates a theoretic relationship between health care resource input and health care outcomes. Initially, as health care resources increase, these outcomes improve, but above a certain level, the slope of the curve diminishes, signifying that increasing investments in health care yield more marginal benefits. In terms of Dr. Worthy's experiences, the Central American region in which he worked lay on the steep slope of this cost\u2013benefit curve: A small investment of resources to create more sanitary water supplies and to administer inexpensive rehydration therapy yielded dramatic improvements in health. On the other hand, purchasing MRI scanners to supplement CT scanners represents a health care system operating on the flatter portion of the curve: Large investments of resources in new technologies may produce more marginal and difficult-to-measure improvements in the overall health of a population.\n\n**Figure 8\u20133.** A theoretic model of costs and health outcomes. Moving from point A to point B on the curve is associated with both higher costs and better health outcomes.\n\nNaturally, different medical interventions lie on steeper (eg, childhood immunizations) or on flatter (eg, the costly prolongation of life for an anencephalic infant) portions of the curve. The curve in Figure 8\u20133 may be viewed as an aggregate cost\u2013benefit curve for the functioning of a health care system as a whole. The system may be an entire nation or a smaller entity such as an HMO, with its defined population of enrollees.\n\nOverall, the US health care system currently operates somewhere along the flatter portion of the curve. Let us assume that Dr. Worthy's HMO system lies at point A on the curve in Figure 8\u20133, with average total health care expenditures per HMO enrollee being the same as the average overall per capita health care cost in the United States (roughly $8000 in 2009). If stringent new cost containment policies forced the HMO to virtually freeze spending at point A rather than increasing annual expenditures at their usual clip to move to point B, then Figure 8\u20133 implies that the HMO would sacrifice improving the health of its enrollees by an amount equal to the distance between points A and B on the vertical axis.\n\nSuch an analysis would confirm the opinion of those who argue that cost containment requires painful choices that affect the health of the population. Among the most forceful proponents of this view are Aaron and Schwartz (1984 and 1990), who have described cost containment as a \"painful prescription\" requiring rationing of beneficial care. In Figure 8\u20133, the distance between points A and B on the _y_ axis measures how much health \"pain\" accompanies the decision to limit spending at point A instead of advancing to point B. Some degree of pain is inherent in the curve. As Evans (1984) observes, \"if its slope is everywhere positive, then in a world of finite resources, unmet needs are inevitable.\" No matter where we sit on the curve, it will always be true that if we spent more we could do a little better.\n\nIn Figure 8\u20133, the distance between points A and B on the y axis is small, given the relatively flat slope of the curve at these points. But reassurances about relatively mild cost containment pain bring to mind the physician, scalpel in hand, hovering over a patient and declaring that \"it will only hurt a little bit.\" A little pain, necessary as it may be, is not the same as no pain; or as Fuchs (1993) puts it, \"'low yield' medicine is not 'no yield' medicine.\"\n\nBefore allowing ourselves (and Dr. Worthy) to become overly chagrined at the inevitable painfulness of cost containment, let us add the new dimension of efficiency. We can picture a point C (Figure 8\u20134) at which spending is the same as that at point A, but outcomes improve. How does the model account for point C, a point off the curve?\n\n**Figure 8\u20134.** Moving off the curve. Point C represents achievement of better health outcome without increased costs.\n\nThe move to point C requires a shifting of the curve (Figure 8\u20135), signifying a new, more efficient (or productive) relationship between costs and health outcomes (Donabedian, 1988). There are numerous possible routes to greater efficiency. For example, diagnostic radiographic imaging services are a rapidly inflating expenditure in the United States. Research has concluded that 20% to 40% of imaging studies are not clinically necessary, and that radiation exposure from diagnostic x-rays carries a risk of inducing malignant cancers (Brenner and Hricak, 2010). Eliminating unnecessary diagnostic radiographic procedures, such as head CT scans for patients with uncomplicated tension headaches, could simultaneously decrease health care costs and improve health. In the remainder of this chapter, we will examine in greater detail the various possible methods that Dr. Worthy's cost control task force could consider to achieve more health \"bang\" for the health care \"buck.\" Before turning to this discussion, however, it is necessary to make explicit three assumptions about this model of costs and outcomes.\n\n**Figure 8\u20135.** Shifting the curve. The shift of the curve represents moving to a more efficient relationship between costs and health outcomes.\n\n1. Implicit in the model is the notion that the relevant outcome of interest is the overall health of a population rather than of any one individual patient. A number of authors have emphasized the need for physicians to broaden their perspective to encompass the health of a general population, as well as their narrower traditional focus on providing the best possible care for each patient (Eddy, 1991; Greenlick, 1992). The population-oriented model of costs and outcomes depicted in Figures 8\u20133, 8\u20134, and 8\u20135 may not fit easily with many physicians' experiences of caring for a particular patient. At the level of the individual patient, the outcome may be all or nothing (eg, the patient will almost certainly live if he or she receives an operation and die without it) and not easily thought about in terms of curves and slopes. Rather than focusing on any one particular intervention or patient, the curve attempts to represent the overall functioning of a health care system in the aggregate for the population under its care. (The ethical issues of the population health perspective are discussed in Chapter 13.)\n\n2. The model assumes that it is possible to quantify health at a population level. Traditionally, health status at this level has been measured relatively crudely, using vital statistics such as life expectancy and infant mortality rates. While an index such as infant mortality rates may be a sensitive, meaningful way of evaluating the impact of health care and public health programs in rural Central America, many analysts have questioned whether such crude indicators accurately gauge the impact of health care services in wealthier industrialized nations. In these latter nations, much of health care focuses on \"softer\" health outcomes such as enhancement of functional status and quality of life in individuals with chronic diseases\u2014aspects more difficult to monitor at the population level than death rates and related vital statistics. In other words, it may be difficult to conceptualize a scale on the _y_ axis of Figures 8\u20133, 8\u20134, and 8\u20135 that can register both the effects of managing gastroenteritis in a poor nation and the addition of MRI scanners in a US city.\n\n3. When evaluating population health, it is difficult to disentangle the effects of health care on health from the effects of such basic social factors as poverty, education, lifestyle, and social cohesiveness (see Chapter 3). For the purpose of our discussion of cost control, we view the curves depicted in Figures 8\u20133, 8\u20134, and 8\u20135 as representing the workings of the health care system (including public health) per se rather than of the broader economic and social milieu. We therefore use the term _health outcomes_ to describe the _y_ axis, a term intended to suggest that we are evaluating those aspects of health status directly under the influence of health care. The _x_ axis correspondingly represents expenditures for formal health care services.\n\n#### **Prices and Quantities**\n\nWe have shown that painless cost control is theoretically possible. But can efficiency be improved in the real world? What strategies could Dr. Worthy's task force propose to move the HMO from point A to point C on the curve? An answer to these questions requires further scrutiny of resource costs in the health care sector.\n\nCosts may be described by the equation\n\n_Price_ refers to such items as the hospital daily room charge or the physician fee for a routine office visit. _Quantity_ represents the volume and intensity of health service use (eg, the length of stay in an intensive care unit, or the number and types of major diagnostic tests performed during a hospitalization). Lomas and colleagues (1989), noting this distinction between prices (Ps) and quantities (Qs), refer to cost containment as \"minding the Ps and Qs\" of health care costs.\n\nLet us look at an example of the   equation:\n\n_Blue Shield pays Dr. Morton $600 for 10 office visits at a fee of $60 per visit. The next year, the insurer pays Dr. Morton $720 for 10 visits at $72 per visit._\n\n_Prudential pays Dr. Norton $600 for 10 office visits, and the next year pays $720 for 12 visits at the same $60 fee. An identical cost increase is a price rise for Dr. Morton but an increase in quantity of care for Dr. Norton._\n\nChanges in prices and quantities have different implications for patients and providers (Reinhardt, 1987). In the preceding example, both physicians increase their income (and both insurance plans increase their expenditures) by $120, though in the case of the price increase, the additional income does not require a higher volume of work. To the patient, however, only the additional $120 spent on a greater number of visits purchases more health care services. (For simplicity's sake, we assume that all visits are identical and that the price rise does not reflect increased quality of service, but simply a higher price for the same product.) A cost increase that merely represents higher prices without additional quantities of health care is an inefficient use of resources from the patient's point of view. Returning to the diagrams in Figures 8\u20133 and 8\u20134, if real costs in a health care system were rising only because medical price inflation was exceeding general price inflation while the quantity of care per capita remained static, then increased health costs would not bring about improved health outcomes, and the overall curve would become absolutely flat.\n\n### **COST CONTROL STRATEGIES**\n\n#### **Controlling Price Inflation**\n\n_After intense deliberation, Dr. Worthy's task force submits a plan for \"painless cost containment\" to the HMO executive committee. The first proposal calls for the HMO to aggressively seek discounts on the prices paid for supplies, equipment, and pharmaceuticals by having the HMO selectively contract with suppliers for bulk purchases and stock a more limited variety of product lines and drugs within the same therapeutic class. The proposal also calls for a 10% reduction in salaries for all HMO employees earning over $150,000 per year, as well as a 10% reduction in the capitation fee paid to the HMO's physician group. The executive committee never gets beyond this part of the plan, as furious argument erupts over the proposed income cuts._\n\nPrice inflation has been a major contributor to the rise of health care costs in recent decades. Between 1947 and 1987, US health care costs rose 2.5% per year faster than the growth in the overall economy. Two-thirds of this higher growth rate, or 1.6%, was due to health care prices rising more rapidly than prices in the overall economy. The remaining 0.9% differential was due to differences in the rate of increase of quantities of health care relative to increases in the overall quantity of goods and services (Fuchs, 1990).\n\nThe rapid rise of health care prices manifests itself in such ways as prices for prescription drugs in the United States often being over 50% higher than prices for the same products sold in other nations. Also, specialist physician incomes have increased rapidly. Higher prices explain much of the higher costs of health care in the United States compared with the costs in other industrialized nations (Peterson and Burton, 2007). Limiting this type of price inflation is one way to restrain expenditures without inflicting \"pain\" on the public's health (Table 8\u20131).\n\n**Table 8\u20131.** Examples of painless cost control\n\n#### **Eliminating Ineffective and Inappropriate Care**\n\n_After a brief hiatus to let the furor subside, the HMO executive committee reconvenes. Dr. Worthy introduces his task force's second recommendation\u2014developing appropriateness of care guidelines\u2014by recounting one of his own clinical experiences. WhenDr. Worthy first came to the HMO, the neurologists were keeping their stroke patients at bed rest for 1 week before initiating physical therapy. Dr. Worthy, in contrast, began physical therapy and discharge planning for stroke patients the moment their neurologic status was stable. The average length of stay in the acute hospital for his stroke patients was 3 days, compared with 9 days for other neurologists. Dr. Worthy gave a grand rounds presentation demonstrating that 4 days of exercise are required to regain the strength lost from each day of bed rest, meaning that stroke patients would have better outcomes and use fewer resources\u2014shorter acute hospital stays and less rehabilitation\u2014under his care than under the care of his colleagues. Dr. Worthy cites this as just one example of how the HMO may be devoting resources to ineffective, or even harmful, care._\n\nIf controlling prices is one approach to painless cost control, are there also ways to contain the \"Q\" (quantity) factor in a manner that does not sacrifice beneficial care? Earlier, we cited unnecessary diagnostic imaging studies as an example of a source of inefficient resource use in terms of quantities of services that add to costs without, in many cases, adding health benefits. A number of researchers have found convincing evidence of substantial amounts of unnecessary care in the United States (Brook and Lohr, 1986; Leape, 1992; Brownlee, 2007; Kilo and Larsen, 2009). Physicians in the United States perform large numbers of inappropriate procedures (Schuster et al, 1998; Deyo et al, 2009), and physicians may inappropriately and harmfully accept new technologies as a result of industry influence rather than proven efficacy (Grimes, 1993; Avorn, 2007).\n\nPersuasive evidence comes from the work of Fisher, Wennberg and colleagues, who found that per capita Medicare costs are over twice as high in some cities (eg, Miami) than in other metropolitan areas (eg, Minneapolis). This difference is explained not by prices or degree of illness but is related to the quantity of services provided, which in turn is associated with the predominance of specialists in the higher-cost areas (Fisher et al, 2003). Moreover, residents of areas with a greater per capita supply of hospital beds are up to 30% more likely to be hospitalized than those in areas with fewer beds, after controlling for socioeconomic characteristics and disease burden (Fisher et al, 2000). As for the value of this spending, quality of care and health outcomes are, if anything, worse in the highest spending regions than in areas with less intensive use of services. These findings suggest that a great deal of unnecessary care is taking place in the high-cost areas.\n\nThe slope of the cost\u2013benefit curve would become more favorable if a system could eliminate those components of rising expenditures that have flat slopes (no medical benefit) or negative slopes (harm exceeding benefit, as in the case of inappropriate surgical procedures or prolonged bed rest after strokes). However, inducing physicians and patients to selectively eliminate unnecessary care is no easy matter.\n\n#### **Administrative Waste**\n\n_The third item on Dr. Worthy's painless cost containment plan targets the HMO's administrative costs. The task force proposes eliminating the HMO's TV and radio advertising budget, laying off 25% of all HMO administrative personnel, and reassigning 25 of the 50 staff members in the department that handles contracts with employers to a new department designed to develop a program to ensure that the HMO provides up-to-date child immunizations and adult preventive care services for 100% of plan enrollees. The HMO's marketing director patiently explains to Dr. Worthy that although he, in principle, agrees with these recommendations, he does not consider it in the HMO's best interest to cut costs in a way that jeopardizes the plan's ability to maintain its market share of enrollees._\n\nNot all quantities in the health care cost equation are clinical in nature. The tremendous administrative overhead of the US health care system has come under increasing scrutiny in recent years as a source of inefficiency in health care expenditures. Woolhandler and colleagues (2003) have estimated that as many as 31 cents of every dollar of US health care spending goes for such quantities of administrative services as insurance marketing, billing and claims processing, and utilization review, rather than for actual clinical services. US administrative costs are over twice as high proportionately as those in nations such as Canada and have been rising more rapidly than the rate of overall national health care inflation. While some level of administrative service is necessary for health care finance management and related activities such as quality assurance, few argue that the burgeoning administrative and marketing activities translate into meaningful improvement in patient health. Reducing administrative services is another route to painless cost containment.\n\nEliminating purely wasteful quantities of health care services, be they ineffective clinical services or unnecessary administrative activities, is a relatively straightforward approach to painless cost control. The motto of this approach is: Stop doing things of no clinical benefit. More complicated are approaches to efficiency that involve not simply ceasing completely unproductive activities, but doing things differently. Examples of this latter approach include innovations that substitute less costly care of equal benefit, preventive care, and redistribution of resources from services with some benefit to services with greater benefit relative to cost. Let us examine each of these examples in turn.\n\n#### **Innovation and Cost Savings**\n\nMuch of the process of innovation in health care involves the search for less costly ways of producing the same or better health outcomes. A new drug is developed that is less expensive but is equally efficacious and well tolerated as a conventional medication. Services provided by highly paid physicians can often be delivered with the same quality by nurses, nurse practitioners, or physician assistants. A clinical trial documents that infusion of chemotherapy for many cancer treatments may be done safely on an outpatient basis, averting the expense of hospitalization. Often new technologies are introduced in hopes that they will ultimately prove to be less costly than existing treatment methods.\n\nHowever, new technologies often fail to live up to cost-saving expectations (Bodenheimer, 2005). A case in point is that of laparoscopic cholecystectomy. Through the use of fiberoptic technology, the gallbladder may be surgically removed using a much smaller abdominal incision than that required for traditional open cholecystectomy, thereby significantly shortening the time required for postoperative recuperation in the hospital. The shorter length of hospital stay reduces the overall cost of the operation, with improved outcomes due to less postoperative pain and disability\u2014seemingly a classic case of \"efficient substitution\" that lowers costs and improves health outcomes. There's a catch, however. The necessity of gallbladder surgery is not always clear-cut for patients with gallstones. Many patients have only occasional, mild symptoms, and prefer to tolerate these symptoms rather than undergo an operation. Rates of cholecystectomy increased dramatically following the advent of the laparoscopic technique, apparently because more patients with milder symptoms were undergoing gallbladder surgery. In one HMO, the cholecystectomy rate increased by 59% between 1988 and 1992 after the introduction of the laparoscopic technique. Even though the average cost per cholecystectomy declined by 25%, the total cost for all cholecystectomies in the HMO rose by 11% because of the increased number of procedures done (Legorreta et al, 1993).\n\n#### **Ounces of Prevention**\n\nIf an ounce of prevention is worth a pound of cure, then replacement of expensive end-stage treatment with low-cost prevention would appear to be an ideal candidate for the \"painless cost controller award.\" Investing in prevention sometimes generates this type of efficiency in health care spending (eg, many childhood vaccinations cost less than caring for children with infections) (Armstrong, 2007). However, the prevention story is not always so simple. In many cases, the cost of implementing a widespread prevention program may exceed the cost of caring for the illness it aims to prevent. For example, screening the general population for elevated blood pressure and providing long-term treatment for those with mild-to-moderate hypertension to prevent strokes and other cardiovascular complications has been found to cost more than the expense of treating the eventual complications themselves (Russell, 2009). For some diseases, this is the case because the complications are rapidly and inexpensively fatal, while successful prevention leads to a long life with high medical costs, perhaps for a different illness, required at some point. Similarly a program of routine mammography screening and biopsy following abnormal test results costs more than it saves by detecting breast cancers at earlier stages. Blood pressure and breast cancer screening programs result in the improved health of the population but require a net investment in additional resources.\n\n#### **Prioritization and Analysis of Cost Effectiveness**\n\n_A fourth recommendation of Dr. Worthy's task force involves the diagnosis and treatment of colon cancer. Many HMO physicians suggest screening colonoscopy for their patients over age 50 for early detection of colon cancer. All the HMO's oncologists strongly recommend chemotherapy for patients who develop metastatic colon cancer. Analysis of cost-effectiveness has demonstrated that screening colonoscopy saves many more years of life per dollar spent than chemotherapy for metastatic colon cancer. Yet chemotherapy allows some patients with metastatic disease to enjoy an extra 6\u201312 months of life. The task force takes the position that the HMO's physicians should do screening colonosco-pies, but that the HMO insurance plan should not cover chemotherapy for metastatic colon cancer._\n\nThe most controversial strategy for making health care more efficient is the redistribution of resources from services with some benefit to services with greater benefit relative to cost. This approach is commonly guided by cost-effectiveness analysis, which as defined by Eisenberg (1989).\n\n_... measures the net cost of providing a service (expenditures minus savings) as well as the outcomes obtained. Outcomes are reported in a single unit of measurement, either a conventional clinical outcome (eg, years of life saved) or a measure that combines several outcomes on a common scale. (Eisenberg, 1989)_\n\nAn example is a cost-effectiveness analysis of different strategies to prevent heart disease, showing that the cost per year of life saved (in 1984 dollars) was approximately $1000 for brief advice about smoking cessation during a routine office visit, $24,000 for treating mild hypertension, and nearly $100,000 for treating elevated cholesterol levels with drugs (Cummings et al, 1989). In order to get the most \"bang\" for the health care \"buck,\" this analysis suggests that a system operating under limited resources would do better by maximizing resources for smoking cessation before investing in cholesterol screening and treatment.\n\nCost-effectiveness analysis must be used with caution. If the data used are inaccurate, the conclusions may be incorrect. Moreover, cost-effectiveness analysis may discriminate against people with disabilities. Researchers are likely to assign less worth to a year of life of a disabled person than does the person himself or herself; thus, analyses using \"quality-adjusted life years\" may have a built-in bias against persons with less capacity to function independently (Menzel, 1992).\n\nDr. David Eddy (1991, 1992, 1993), in a series of provocative articles in the _Journal of the American Medical Association,_ has discussed the practical and ethical challenges of applying cost-effectiveness analysis to medical practice. Two of the essays involve the case of an HMO trying to decide whether to adopt routine use of low-osmolar contrast agents, a type of dye for special x-ray studies that carries a lower risk of provoking allergic reactions than the cheaper conventional dye. With the use of this agent for all x-ray dye studies, 40 nonfatal allergic reactions would be avoided annually and the cost to the HMO would be $3.5 million more per year, compared with costs for use of the older agent in routine cases and use of the low-osmolar dye only for patients at high risk of allergy. The same $3.5 million dollars invested in an expanded cervical cancer screening program in the HMO would prevent approximately 100 deaths from cervical cancer per year.\n\nIn discussing how best to deploy these resources, Eddy highlights several points of particular relevance to clinicians:\n\n1. It must be agreed upon that resources are truly limited. Although the cost-effectiveness of low-osmolar contrast dye and cervical cancer screening is quite different, both programs offer some benefit (ie, they are not flat-of-the-curve medicine). If no constraints on resources existed, the best policy would be to invest in both services.\n\n2. If resources are limited and trade-offs based on cost-effectiveness considerations are to be made, these trade-offs will have professional legitimacy only if it is clear that resources saved from denying services of low cost-effectiveness will be reinvested in services with greater cost-effectiveness, rather than siphoned off for ineffective care or higher profits.\n\n3. Ethical tensions exist between maximizing health outcomes for a group or population as opposed to the individual patient. The radiologist experiences the trauma of patients having severe allergic reactions to the injection of contrast dye. Preventing future deaths from cervical cancer in an unspecified group of patients not directly under the radiologist's care seems an abstract and remote benefit from his or her perspective\u2014one that may be perceived as conflicting with the radiologist's obligation to provide the best care possible to his or her patients.\n\nMany analysts, including those who question the methods of cost-effectiveness analysis, share Eddy's conclusion: Physicians must broaden their perspective to balance the needs of individual patients directly under their care with the overall needs of the population served by the health care system, whether the system is an HMO or the nation's health care system as a whole (see Chapter 13). Professional ethics will have to incorporate social accountability for resource use and population health, as well as clinical responsibility for the care of individual patients (Greenlick, 1992; Hiatt, 1975).\n\n_The final recommendation of Dr. Worthy's task force is for the HMO to hire a consultant to advise the HMO on the relative cost-effectiveness of different services offered by the HMO, in order to prioritize the most cost-effective activities. While waiting for the consultant's report, the task force suggests that the HMO begin implementing this strategy by allocating an extra 5 minutes to every routine medical appointment for patients who smoke, so that the physician, nurse practitioner, or physician assistant has time to counsel patients on smoking cessation, as well as by setting up two dozen new community-based group classes in smoking cessation for HMO members. The costs of these new activities are to be funded from the HMO's existing budget for coronary artery stenting, and the number of these stent procedures is to be restricted to 30 fewer than the number performed during the current year. The day following the executive committee meeting, the HMO's health education director buys Dr. Worthy lunch and compliments him on his \"enlightened\" views. On the way back from lunch, the chief of cardiology accosts Dr. Worthy in the corridor and says, \"Why don't you just take a few dozen of my patients with severe coronary artery disease out and shoot them? Get it over with quickly, instead of denying them the life-saving stents they need.\"_\n\n### **CONCLUSION**\n\nThe relationship between health outcomes and health care costs is not a simple one. The cost\u2013benefit curve has a diminishing slope as increasing investment of resources yields more marginal improvements in the health of the population. The curve itself may shift up or down, depending on the efficiency with which a given level of resources is deployed.\n\nThe ideal cost containment method is one that achieves progress in overall health outcomes through the \"painless\" route of making more efficient use of an existing level of resources. Examples of this approach include restricting price increases, reducing administrative waste, and eliminating inappropriate and ineffective services. \"Painful\" cost containment represents the other extreme, when controls on expenditures are accomplished only by sacrificing quantities of medically beneficial services. Making trade-offs in services based on relative cost-effectiveness may be felt as painless or painful, depending on one's point of view; some individuals may experience the pain of being denied potentially beneficial services, but at a net gain in health for the overall population through more efficient use of the resources at hand.\n\nCost containment in the real world tends to fall somewhere between the entirely painless paragon and the completely painful pariah (Ginzberg, 1983). As the experiences of Dr. Worthy reveal, putting painless cost control into practice may be impeded by political, organizational, and technical obstacles. Price controls may make economic sense but risk intense opposition from providers. Administrative savings may be largely beyond the control of any single HMO or group of providers and require an overhaul of the entire health care system. Identifying and modifying inappropriate clinical practices is a daunting task, as is prioritizing services on the basis of cost-effectiveness. But while painless cost control may be difficult to achieve, few would argue that the US health care system currently operates anywhere near a maximum level of efficiency. Regions in the nation with higher health care spending do not have better health outcomes (Fisher et al, 2003). The nation's lackluster performance on indices such as infant mortality and life expectancy rates suggests that the prolific degree of spending on health care in the United States has not been matched by a commensurate level of excellence in the health of the population (Davis et al, 2010). Making better use of existing resources must be the priority of cost control strategies in the United States.\n\n### **REFERENCES**\n\nAaron H, Schwartz WB. Rationing health care: The choice before us. _Science_. 1990;247:418.\n\nAaron H, Schwartz WB. _The Painful Prescription: Rationing Hospital Care_. Washington, DC: Brookings Institution; 1984.\n\nArmstrong EP. Economic benefits and costs associated with target vaccinations. _J Manag Care Pharm_. 2007;13(Suppl S-b):S12.\n\nAvorn J. Keeping science on top in drug evaluation. _N Engl J Med_. 2007;357:633.\n\nBodenheimer T. High and rising health care costs. Part 2: technologic innovation. _Ann Intern Med_. 2005;142:932.\n\nBrenner DJ, Hricak H. Radiation exposure from medical imaging. _JAMA_. 2010;304:208.\n\nBrook RH, Lohr KN. Will we need to ration effective health care? _Issues Sci Technol_. 1986;3:68.\n\nBrownlee S. _Overtreated_. New York: Bloomsbury; 2007.\n\nCummings SR et al. The cost-effectiveness of counseling smokers to quit. _JAMA_. 1989;261:75.\n\nDavis K et al. _Mirror, Mirror on the Wall_. New York: Commonwealth Fund; 2010.\n\nDeyo RA et al. Overtreating chronic back pain: Time to back off. _J Am Board Fam Med._ 2009;22:62.\n\nDonabedian A. Quality and cost: Choices and responsibilities. _Inquiry_. 1988;25:90.\n\nEddy DM. Applying cost-effectiveness analysis. _JAMA._ 1992;268:2575.\n\nEddy DM. Broadening the responsibilities of practitioners. _JAMA._ 1993;269:1849.\n\nEddy DM. The individual vs. society: Is there a conflict? _JAMA._ 1991;265:1446.\n\nEisenberg JM. Clinical economics. _JAMA._ 1989;262:2879.\n\nEvans RG. _Strained Mercy: The Economics of Canadian Health Care._ Toronto, Ontario, Canada: Butterworths; 1984.\n\nFisher ES et al. The implications of regional variation in medicare spending. _Ann Intern Med._ 2003;138:273.\n\nFisher ES et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. _Health Serv Res._ 2000;34:1351.\n\nFuchs VR. No pain, no gain: Perspectives on cost containment. _JAMA._ 1993;269:631.\n\nFuchs VR. The health sector's share of the gross national product. _Science._ 1990;247:534.\n\nGinzberg E. Cost-containment: Imaginary and real. _N Engl J Med._ 1983;308:1220.\n\nGreenlick MR. Educating physicians for population-based clinical practice. _JAMA._ 1992;267:1645.\n\nGrimes DA. Technology follies: The uncritical acceptance of medical innovation. _JAMA._ 1993;269:3030.\n\nHiatt HH. Protecting the medical commons: Who is responsible? _N Engl J Med._ 1975;293:235.\n\nKilo CM, Larsen EB. Exploring the harmful effects of health care. _JAMA._ 2009;302:89.\n\nLeape LL. Unnecessary surgery. _Annu Rev Public Health._ 1992;13:363.\n\nLegorreta AP et al. Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. _JAMA._ 1993;270:1429.\n\nLomas J et al. Paying physicians in Canada: Minding our Ps and Qs. _Health Aff (Millwood)._ 1989;8(1):80.\n\nMartin A et al. Recession contributes to slowest annual rate of increase in health spending in five decades. _Health Aff (Millwood)._ 2011;30:11.\n\nMenzel PT. Oregon's denial: Disabilities and the quality of life. _Hastings Cent Rep_. 1992;22:21.\n\nPeterson CL, Burton R. _U.S. Health Care Spending: Comparison with Other OECD Countries_ (RL34175) [Electronic copy]. Washington, DC: Congressional Research Service; 2007. <http:\/\/digitalcommons.ilr.cornell.edu\/key_work-place\/311\/>. Accessed November 14, 2011.\n\nReinhardt UE. Resource allocation in health care: The allocation of lifestyles to providers. _Milbank Mem Fund Q_. 1987;65:153.\n\nRussell LB. Preventing chronic disease: An important investment, but don't count on cost savings. _Health Aff (Millwood)_. 2009;28:42.\n\nSchuster M et al. How good is the quality of health care in the United States? _Milbank Q_. 1998;76:517.\n\nSisko AM et al. National health spending projections: The estimated impact of reform through 2019. _Health Aff (Millwood)_. 2010;29:1933.\n\nWoolhandler S et al. Costs of health care administration in the United States and Canada. _N Engl J Med_. 2003;349:768.\n\n## **9 Mechanisms for Controlling Costs**\n\nIn Chapter 8, we discussed the general relationship between costs and health outcomes and explored the tension between painful and painless approaches to cost containment. In this chapter, we examine specific methods for controlling costs. Our emphasis is on distinguishing among the different types of cost control mechanisms and understanding their intent and rationale. We briefly cite evidence about how these mechanisms may affect cost and health outcomes.\n\nFinancial transactions under private or public health insurance (see Chapter 2, Figures 2\u20132, 2\u20133, and 2\u20134) may be divided into two components:\n\n1. _Financing,_ the flow of dollars (premiums or taxes) from individuals and employers to the health insurance plan (private health insurance or government programs), and\n\n2. _Reimbursement,_ the flow of dollars from insurance plans to physicians, hospitals, and other providers.\n\nCost-control strategies can be divided into those that target the financing side versus those that impact the reimbursement side of the funding stream (Figure 9\u20131 and Table 9\u20131).\n\n**Figure 9\u20131.** Cost-control mechanisms may be applied to both the financing and reimbursement components of health care spending under a system of health insurance.\n\n**Table 9\u20131.** Categories of cost controls\n\n### **FINANCING CONTROLS**\n\nCost controls aimed at the financing of health insurance attempt to limit the flow of funds into health insurance plans, with the expectation that the plans will then be forced to modify the outflow of reimbursement. Financing controls come in two basic flavors\u2014regulatory and competitive.\n\n#### **Regulatory Strategies**\n\n_Dieter Arbeiter, a carpenter in Berlin, Germany, is enrolled in one of his nation's health insurance plans, the \"sick fund\" operated by the Carpenter's Guild. Each month, Dieter pays 7.5% of his wages to the sick fund and his employer contributes an equal 7.5%. The German federal government regulates these payroll tax rates. When the government proposes raising the rate to 8.5%, Dieter and his coworkers march to the parliament building to protest the increase. The government backs down, and the rate remains at 7.5%. As a result, physician fees do not increase that year._\n\nIn nations with tax-financed health insurance, government regulation of taxes serves as a control over public expenditures for health care. This regulatory control is most evident when certain tax funds are earmarked for health insurance, as in the case of the German health insurance plans (see Chapter 14) or Medicare Part A in the United States. Under these types of social insurance systems, an increase in expenditures for health care requires explicit legislation to raise the rate of earmarked health insurance taxes. Public antipathy to tax hikes may serve as a political anchor against health care inflation.\n\nA somewhat different model of financing regulation was offered by President Clinton's 1994 health care proposal (which never passed). This proposal called for government regulation of premiums paid to private health insurance plans.\n\n#### **Competitive Strategies**\n\nAn alternative US proposal for containing health costs attempts to control the financing flow through a competitive strategy rather than through regulation. The basic premise of competitive financing strategies is to make employers, employees, and individuals more cost-conscious in their health insurance purchasing decisions. Health insurance plans would be encouraged to compete on the basis of price, with lower-cost plans being rewarded with a greater number of enrollees. Instead of having a government agency regulate financing, the competitive market would pressure plans to restrain their premium prices and overall costs.\n\n_Giovanni Costa works for General Auto (GA). It is 1985, and he and his family have Blue Cross health insurance that covers most services provided by the health care provider of his choice, with no deductible. Giovanni does not know how much his health plan costs, because GA pays the total premium. Once Giovanni asked his friend in the employee benefits department whether the company was worried about the costs of health insurance. \"It's a problem,\" Giovanni was told, \"but it's not too bad because our health insurance premiums are tax deductible for the company. Also, if we gave you higher wages you'd have to pay taxes on those wages, but if we give you better health care coverage, you don't pay taxes on the value of that coverage. So we're both better off by providing generous health care benefits. When it comes right down to it, the government's paying a portion of those premiums.\"_\n\nWhen considering competitive strategies that attempt to make purchasers more price sensitive, it is important to consider who the purchaser of health insurance really is. For employment-based health insurance, is the purchaser the employer selecting which health plans to offer employees, or is it the individual employee deciding to enroll in a specific plan? As in the case of Giovanni Costa and GA, the answer is often both: GA selects which plans to offer employees and what portion of the premium to subsidize, and Giovanni chooses a particular plan from those offered by GA.\n\nHistorically, several factors have blunted both employers' and employees' consideration of price in the purchase of health insurance (Enthoven, 1993). For employees, the fact that employers who provide health benefits usually pay a large share of the premium for their employees' private health insurance has insulated insured employees from the costs of insurance. Employees view health insurance premiums as an expense to the employer rather than as a cost borne by themselves. In fact, many employees might receive higher wages if the costs of health insurance were lower, but employees do not generally perceive health insurance benefits as foregone wages.\n\nMoreover, the federal policy of treating health care benefits as nontaxable to both employee and employer makes it in the employee's financial interest to receive generous health care benefits and reduces the burden to the employer of paying for such benefits. A dollar contributed directly by the employer to a health plan goes farther toward the purchase of health insurance than a dollar in wages that is first taxed as income and then spent by the employee for health insurance. This dynamic, which cost the federal government about $260 billion in 2010 (Gruber, 2010), has shielded employees from the real price of health insurance and given employees less incentive to be cost-conscious consumers when selecting an insurance plan.\n\nFor employers, inflation of health insurance premiums in the 1950s and 1960s was an acceptable part of doing business when the economy was booming and health insurance costs consumed only a small portion of overall business expenses. However, as health insurance costs continued to spiral upward and economic growth slowed in recent decades, employers became more active in their approach to health insurance costs (see Chapter 16).\n\n_It is 2010, and GA now offers Giovanni Costa three choices of health insurance plans: The health maintenance organization (HMO) plan costs $1000 per month for family coverage, with GA paying 70% and Giovanni paying 30%; the preferred provider organization (PPO) plan is worth $1200 per month; and the fee-for-service plan runs $1400 a month. If Giovanni chooses the HMO plan, GA pays $700 (70%) and Giovanni pays $300 (30%). If Giovanni signs up for the $1200 PPO plan, GA still pays $700 (70% of the lowest-cost plan) and Giovanni must pay the rest\u2014$500. If Giovanni wants to choose the fee-for-service plan, GA pays $700 and Giovanni pays $700. GA negotiated with all three of its health plans that premium levels would be frozen at their 2008 rates for the next 3 years. A fourth plan previously offered by GA refused to agree to this stipulation, and GA dropped this plan from its portfolio of employee benefits. After 2011, however, the three health plans can demand yearly premium increases, increasing health insurance costs for both GA and Giovanni._\n\nThe competitive approach to health insurance financing encourages price-sensitive purchasing by both employer and employee. For employers, the competitive strategy calls for businesses to be more aggressive in their negotiations with health plans over premium rates. Employers bargain actively with health plans and offer employees only plans that keep their rates below a certain level. Moreover, employers make employees more cost-aware when selecting a health plan by limiting the amount of the insurance premium that the employer will pay. Rather than paying all or most of the premium, many employers offer a fixed amount of insurance subsidy\u2014often indexed to the cost of the cheapest health plan\u2014and compel employees selecting more costly plans to pay the extra amount. Economist Alain Enthoven, one of the chief proponents of the competitive approach, has called this strategy \"managed competition\" (Enthoven, 2003). The strategy is also known as the \"defined contribution\" approach.\n\nIs the evolving competitive approach succeeding at controlling costs? From 2000 to 2010, employer-sponsored health insurance premiums rose by 114%, a major cost-control failure (Claxton et al, 2010). However, competition has never been truly instituted in the United States; 94% of metropolitan markets are controlled by one or two large commercial insurance companies that can extract increasing premiums from employers (Arnst, 2009). Moreover, insurance plans find it easier to compete by \"gaming\" the market through selection of low-cost enrollees rather than by disciplining providers to deliver a lower-cost, higher-quality product. Studies have shown that competing Medicare HMOs have utilized precisely that strategy (Mehrotra et al, 2006).\n\nIf competition could succeed at containing costs, would the outcome be painful or painless cost control? A fundamental concern about market-oriented reforms is that whatever pain may be produced would be experienced most acutely by individuals with lower incomes. Under competition, individuals with higher incomes would be the ones most likely to pay the extra premium costs to enroll in more expensive health plans, while individuals of lesser means could not afford the extra premiums and would be relegated to the lower-cost plans. If the differential in premium prices across plans were large, enrollees in low-cost plans might experience inferior quality of care and health outcomes.\n\n#### **The Weaknesses of Financing Controls**\n\nFor cost controls\u2014whether regulatory or competitive\u2014on the financing side of the health care equation to be successful, these strategies ultimately must produce reductions in the flow of funds on the reimbursement side. A government may try to limit the level of taxes earmarked for health care. However, if payments to physicians, hospitals, and other providers continue to grow at a rapid clip, the imbalance between the level of financing and level of reimbursement will produce budget deficits and ultimately force the government to raise taxes. Similarly, under competition, health insurers will attempt to hold down premium increases in order to gain more customers, but if these health plans cannot successfully control what they pay to hospitals, physicians, pharmacies, and other providers, then insurers will be forced to raise their premiums, and competitive relief from health care inflation will prove elusive. It is on the reimbursement side of the equation that the rubber meets the road in health care cost containment. Governments in nations with publicly financed insurance programs do not simply regulate health care financing, but are actively involved in controlling provider reimbursement. Competition would place the onus on private health insurance plans\u2014rather than a public agency\u2014to regulate reimbursement costs. We now turn to an examination of the options available to private insurers or government for controlling the flow of funds in the reimbursement transaction.\n\n### **REIMBURSEMENT CONTROLS**\n\nIn Chapter 8, we distinguished between the \"Ps\" and \"Qs\" of health care costs: prices and quantities. Cost equals price multiplied by quantity\n\nStrategies to control costs on the reimbursement side can primarily target either prices or quantities (see Table 9\u20131).\n\n#### **Price Controls**\n\n_Under California's fee-for-service Medicaid program, Dr. Vincent Lo's reimbursement for a routine office visit has remained below $25 for the past 8 years._\n\n_The Medicare program reduced Dr. Ernesto Ojo's fee for cataract surgery from $1600 to $900._\n\n_Instead of paying all hospitals in the area the going rate for magnetic resonance imaging (MRI) brain scans ($1200), Apple a Day HMO contracts only with those hospitals who agree to perform scans for $800, and will not allow its patients to receive MRIs at any other hospital._\n\n_Metropolitan Hospital wants a contract with Apple a Day HMO at a per diem rate of $1750. Because Apple a Day can hospitalize its patients at Cross-town Hospital for $1400 a day, Metropolitan has no choice but to reduce its per diem rate to Apple a Day to $1400 in order to get the contract. In turn, to make up the $350 per day shortfall, Metropolitan increases its charges to several other private insurers._\n\nIn Canada and most European nations, a public or quasipublic agency regulates a uniform fee schedule for physician and hospital payments. Often, negotiations occur between the payers (payer is a general term that includes both purchasers and insurers\u2014see Chapter 16) and professional organizations in establishing these fee schedules. In the United States, as discussed in Chapter 4, Medicare, Medicaid, and many private insurance plans have replaced \"usual, customary, and reasonable\" physician payment with predetermined prices for particular services. Competitive approaches to controlling prices have also been attempted in the United States. In the 1980s, California initiated competitive bidding among hospitals for Medicaid contracts, with contracts awarded to hospitals offering lower per diem charges. Private insurance plans have also used competitive bidding to bargain for reductions in physician and hospital fees.\n\nControlling prices has produced some limited success at restraining the growth of overall health care expenditures. However, two major problems limit the potency of price controls for containing overall costs, particularly when prices are regulated at the fee-for-service level.\n\n1. The first problem occurs when price controls are implemented in a piecemeal fashion by different payers. Providers, like Metropolitan Hospital, often respond to price controls imposed by one payer by increasing charges to other payers with less restrictive policies on fees\u2014a phenomenon known as _cost shifting._ The cost-shifting problem may be avoided when a uniform fee schedule is used by all payers (as in Germany) or by a single payer (as in Canada).\n\n2. The quantity of services provided often surges when prices are strictly controlled, leading analysts to conclude that providers respond to fee controls by inducing higher use of services in order to maintain earnings (Bodenheimer, 2005).\n\nPrice controls have the appeal of being a relatively painless form of cost control insofar as they do not limit the quantity of services provided. However, variations in fee schedules may compromise access to care for certain populations; Medicaid fee-for-service rates to physicians are far below private insurance rates in most states, making it difficult for Medicaid patients to find private physicians who will accept Medicaid payment. In nations with uniform fee schedules, concerns have been voiced that ratcheting down of fees may result in \"patient churning\" (high volumes of brief visits), with a deterioration in quality of care and patient satisfaction.\n\n#### **Utilization (Quantity) Controls**\n\nBecause the effectiveness of price controls may be limited by increases in quantity, payers need to consider methods for containing the actual use of services. As indicated in Table 9\u20131, there are a variety of methods for attempting to control use. We begin by examining one strategy, changing the unit of payment, that we introduced in Chapter 4. We then describe additional mechanisms that attempt to restrain the quantity of services.\n\n##### **Changing the Unit of Payment**\n\n_Dr. John Wiley is upset when the PPO reduces his fee from $75 to $60 per visit. In order to maintain his income, Dr. Wiley lengthens his day by half an hour so he can schedule more patient visits._\n\n_Dr. Jane Stuckey is angry when the HMO reduces her capitation payment from $20 to $15 per patient per month. She is unable to maintain her income by providing more visits because more patient visits do not bring her more money. She hopes that more HMO patients will enroll in her practice so that she can receive more capitation payments._\n\nOne simple way to get a handle on the quantity factor is by redefining the unit of payment. In Chapter 4, we discussed how services may be bundled into more aggregate units of payment, such as capitated physician payment and diagnosis-related group (DRG) episode-of-care hospital payment. The more bundled the unit of payment, the more predictable the quantity tends to be. For example, in the case of Dr. Wiley receiving fee-for-service payment, there is a great potential for costs to rise due to increases in the number of physician visits, surgical procedures, and diagnostic tests. When the unit of payment is capitation, as in the case of Dr. Stuckey, the quantity factor is not the number of visits but rather the number of individuals enrolled in a practice or plan. From a health plan's perspective, the   formula still applies when paying physicians by capitation, but now the P is the capitation fee and the Q is the number of individuals covered. Other than by raising birth rates, physicians have little discretion in inducing a higher volume of \"quantities\" at the capitation level for the health care system as a whole. Similarly, under global budgeting of hospitals, P represents the average global budget per hospital and Q is the number of hospitals.\n\nShifting payment to a more aggregated unit has obvious appeal as a way for payers to counter cost inflation due to the quantity factor. Life is never so simple, however. In Chapter 4, we discussed how more aggregate units of payment shift financial risk to providers of care. Another way of describing this shifting of risk is that one person's solution to the quantity problem becomes another person's new quantity problem. A hospital paid by global budget instead of by fee-for-service now must monitor its own internal quantities of service lest these quantities drive hospital operating costs over budget. To the extent that providers are unsuccessful in managing resources under more global forms of payment, pressures mount to raise the prices paid at these more aggregated payment units.\n\nChanges in policies for units of payment rarely occur independent of other reforms in cost-control strategies, making it difficult to isolate the specific effects of changing the unit of payment. For example, physician capitation usually occurs in the context of other organizational and cost-control features within a managed care plan. For example, group- and staff-model HMOs receiving capitation payments from employers and paying physicians by salary have been shown to reduce costs by reducing the quantity of services provided, in particular by reducing rates of hospitalization (Hellinger, 1996; Bodenheimer, 2005).\n\nFor hospitals, changing Medicare payments from a fee-for-service to an episode-of-care unit under the DRG-based system in 1983 resulted in a modest slowing of the rate of increase in Medicare Part A expenditures. However, hospitals were able to shift costs to private payers to make up for lower DRG revenues, and national health expenditures as a whole were not affected by Medicare's new payment mechanism (Rice, 1996). Global hospital budgeting in Canada has been a key element of that nation's relative success at containing hospital costs (Rice, 1996).\n\nThe health care system in Germany and in some Canadian provinces has countered the open-ended dynamic of fee-for-service payment by introducing global budgeting, called expenditure caps, for physician payment (Bodenheimer, 2005). Under Canadian expenditure caps, a budget is established for all physician services in a province. Although individual physicians continue to bill the provincial health plan on a fee-for-service basis, if increases in the use of services cause overall physician costs to exceed the budget, fees are reduced (or fee increases for the following year are sacrificed) to stay within the expenditure cap. Evidence from Canada suggests that implementation of expenditure caps was associated with stabilization of physician costs in the mid-1990s (Barer et al, 1996). In the United States, the Medicare program adopted a less-stringent version of an expenditure cap for physician fees, known as the \"sustainable growth rate\" (Vladeck, 2010). Expenditure caps for physician payments allow the payer to focus on the aggregate C part of the equation\u2014in this case, the total physician budget. The shared savings program proposed under the new Medicare Accountable Care Organization initiative, discussed in Chapter 6, is a related strategy attempting to provide a global expenditure feedback loop to modulate fee-for-service payments.\n\n##### **Patient Cost Sharing**\n\n_Randy Payton has an insurance policy with a $2000 deductible and 20% copayment for all services; if he incurs medical expenses of $6000, he pays the first $2000 plus 20% of $4000, for a total of $2800._\n\n_Joseph Mednick's health plan requires that he pay $20 each time he fills a prescription for a medication, with the health plan paying the cost above $20; because he suffers from diabetes, hypertension, and coronary artery disease, the copayments for his multiple medications cost him $1200 per year._\n\nCost sharing refers to making patients pay directly out of pocket for some portion of their health care. In managed competition, cost sharing occurs as part of the financing transaction _at the point of purchasing a health insurance plan_. In this section, we discuss the more traditional notion of cost sharing\u2014using deductibles, copayments, and uncovered services as part of the reimbursement transaction to make patients pay a share of costs _at the point of receiving health care services_.\n\nThe primary intent of cost sharing at the point of service is to discourage patient demand for services. (Cost-sharing also shifts some of the overall bill for health care from third party payers to individuals in the form of greater out-of-pocket expenses.) As discussed in Chapter 3, when individuals have insurance coverage, they are more likely to use services than when they have no insurance. While protection against individual financial risk is one of the essential benefits of insurance, insurance coverage removes the market restraint on costs that occurs in a system of out-of-pocket payment.\n\nCost sharing at the point of service has been one of the few cost-containment devices subjected to the rigorous evaluation of a randomized controlled experiment. In the Rand Health Insurance Experiment, individuals were randomly assigned to health insurance plans with varying degrees of cost sharing. Individuals with cost-sharing plans made about one-third fewer visits and were hospitalized one-third less often than individuals randomized to the plan with no cost sharing (Newhouse et al, 1981).\n\nAlthough the randomized controlled trial provides an excellent laboratory for scrutinizing the effect of a single cost-containment mechanism, some observers have cautioned that analyses based on controlled research designs may produce results that cannot be generalized to the real world of health policy. For example, the United States has a greater level of cost sharing than many industrialized nations, but also the highest overall costs. Studies have found that when cost sharing begins to produce lower use of services for a large population of patients rather than for a small number of patients in an experiment, physicians may increase the volume of services provided to patients with better insurance coverage (Beck and Horne, 1980; Fahs, 1992). Moreover, 70% of health care expenditures are incurred by 10% of the population\u2014people who are extremely ill and generate huge costs through lengthy ICU stays and other major expenses. Cost sharing has little influence over this component of care. Compared to the micro-world of one not-very-sick patient deciding whether to spend some money on a physician visit, patient cost sharing in the macro-world may remove only a thin slice from a large, expanding pie (Bodenheimer, 2005).\n\nThe Rand experiment also evaluated the influence of cost sharing on appropriateness of care and health outcomes. Cost sharing did not reduce medically inappropriate use of services selectively, but equally discouraged use of appropriate and inappropriate services. Study patients (especially those with low incomes) with cost sharing received less preventive services and had poorer hypertension control than those without cost sharing (Brook et al, 1983). Patients are less likely to purchase needed medications under cost-sharing policies, for example Medicare Part D's \"donut hole\" (see Chapter 2), leading to worse control of chronic illnesses and more emergency hospitalizations (Hsu et al, 2006; Tamblyn et al, 2001; Goldman et al, 2007; Schneeweiss et al, 2009). These studies suggest that cost sharing is not a painless form of cost control.\n\nCost sharing for emergency department care may reduce inappropriate use of emergency services without adversely affecting appropriate use or patient health outcomes (Goodell et al, 2009). Cost sharing may be a painless form of cost control when used in modest amounts, not applied to low-income patients, and designed to encourage patients to use lower-cost alternative sources of care (eg, clinics instead of emergency departments) rather than to discourage use of services altogether.\n\n##### **Utilization Management**\n\n_Thelma Graves suffers from a severe hyperthyroid condition; she and her physician agree that she will undergo thyroid surgery. Before scheduling the surgery, the physician has to call Ms. Graves' insurance company to obtain preauthorization, without which the insurer will not pay for the surgery._\n\n_Fred Brady is hospitalized for an acute myocardial infarction. The hospital contacts the utilization management firm for Mr. Brady's insurer, which authorizes 5 hospital days. On the fourth day, Mr. Brady develops a heart rate of 36 beats\/min, requiring the insertion of a temporary pacemaker and prolonging the hospital stay for 10 extra days. After the fifth hospital day, Mr. Brady's physician has to call the utilization management (UM) firm every 2 days to justify why the insurer should continue to pay for the hospitalization._\n\n_Derek Jordan has juvenile-onset diabetes and at age 42 becomes eligible for Medicare due to his permanent disability from complications of his diabetes. He is admitted to the hospital for treatment of a gangrenous toe. Under Medicare's DRG method of payment, the hospital receives the same payment for Derek's hospitalization regardless of whether it lasts 2 days or 12 days. Therefore, the hospital wants Derek's physician to discharge Derek as soon as possible. Each day, a hospital UM nurse reviews Derek's chart and suggests to the physician that Derek no longer requires acute hospitalization._\n\nUtilization management involves the surveillance of and intervention in the clinical activities of physicians for the purpose of controlling costs (Grumbach and Bodenheimer, 1990). In contrast to cost sharing, which attempts to restrict health care use by influencing patient behavior, UM seeks to influence physician behavior. The mechanism of influencing physician decisions is simple and direct: denial of payment for services deemed unnecessary.\n\nUM is related to the unit of payment in the following way: Whoever is at financial risk (see Chapter 4) performs UM. Under fee-for-service reimbursement, insurance companies perform UM to reduce their payments to hospitals and physicians. The DRG system induces hospitals, at risk for losing money if their patients stay too long, to perform UM. Under an HMO capitation contract with a primary physician group, the physician group conducts UM so that it does not pay more to physicians than it receives in capitation payments. If an HMO pays a hospital a per diem rate, the HMO may send a UM nurse to the hospital each day to review whether the patient is ready to go home.\n\n_Micromanage, Inc., performs UM for several insurance companies. Each day, Rebecca Hasselbach reviews the charts of each patient hospitalized by these insurers to determine whether the patients might be ready for discharge. In some cases, Ms. Hasselbach discusses the case with her medical director and with the patient's attending physician. Usually, if the attending physician wants the patient to remain in the hospital, his or her opinion is honored. By pushing for early discharges, Ms. Hasselbach, her Micromanage colleagues around the country, and the medical director save their insurers about $1,000,000 each year. The annual cost of the UM operation is $900,000._\n\nAlthough a few case studies of UM have shown some short-term reduction in rates of hospitalization and surgery, there is little evidence that this approach yields substantial savings, particularly when the overhead of administering the UM program itself is taken into account (Wickizer, 1990). If successful at containing costs, UM would appear to be a painless form of cost control because it intends to selectively reduce inappropriate or unnecessary care. However, reviewers often make decisions on a case-by-case basis without explicit guidelines or criteria, with the result that decisions may be inconsistent both between different reviewers for the same case and among the same reviewer for different cases (Light, 1994).\n\nUM has come under fire as a process of micromanagement of clinical decisions that intrudes into the physician\u2013patient relationship and places an unwelcome administrative burden on physicians and other caregivers. Physicians in the United States have been called the most \"second-guessed and paperwork-laden physicians in western industrialized democracies\" (Lee and Etheredge, 1989). Substantial physician time goes into appealing denials and persuading insurers about the appropriateness of services delivered. A physician and public backlash to UM forced many health insurance plans to relax their UM activities in the late 1990s. However, many plans reintroduced UM around 2003 as costs escalated (Mays et al, 2004).\n\nSeveral approaches to UM have been developed that attempt to avoid some of the onerous features of case-by-case utilization review. Practice profiling, rather than focusing on individual cases, uses summary data on practice patterns to identify physicians whose overall use of services significantly deviates from the standards set by other physicians in the community. Physician outliers identified by practice profiling are then subject to various interventions. In Canada and Germany, these interventions consist of educational and monitoring activities performed by regional medical societies. The questionable accuracy of some profile data and the need to account for underlying differences in patients' clinical needs that may in part explain practice variation have limited the utility of practice profiling as a cost-control tool (Bindman, 1999). Perhaps the most blunt form of utilization management is when a health plan simply refuses to cover an entire class of services, such as in vitro fertilization or experimental treatments for cancer. This approach is discussed in more detail in Chapter 13.\n\n##### **Supply Limits**\n\n_Bob is a patient in the Canadian province of Alberta. He develops back pain, and after several visits to his family physician requests an MRI of his spine to rule out disk disease. His physician, who does not suspect a disk herniation, agrees to place him on the waiting list for an MRI, which for non-urgent cases is 5 months long._\n\n_Rob lives in Alberta, and after lifting an 80-pound load at work, experiences severe lower back pain radiating down his right leg. Finding a positivestraight-leg-raising test on the right with loss of the right ankle reflex, his family physician calls the radiologist and obtains an emergency MRI scan within 3 days._\n\nSupply limits are controls on the number of physicians and other caregivers and on material resources such as the number of hospital beds or MRI scanners. Supply limits can take place within an organized delivery system such as an HMO in the United States, or for an entire geographic region such as a Canadian province.\n\nThe number of elective operations and invasive procedures, such as cardiac catheterization, performed per capita increases with the per-capita supply of surgeons and cardiologists, respectively (Bodenheimer, 2005). This phenomenon is sometimes called \"supplier-induced demand\" (Evans, 1984; Rice and Labelle, 1989; Phelps, 2003). Controlling physician supply may reduce the use of physician services and thereby contribute to cost containment.\n\nSupplier-induced demand pertains to material capacity as well as to physician supply. Per-capita spending for fee-for-service Medicare patients is over twice as high in some regions of the United States than in others (Gawande, 2009, www.dartmouthatlas.org). This remarkable cost variation is not explained by differences in demographic characteristics of the population, prices of services, or levels of illness, but is due to the quantity of services provided. Residents of areas with a greater per-capita supply of hospital beds are up to 30% more likely to be hospitalized than those in areas with fewer beds (Fisher et al, 2000). The maxim that \"empty beds tend to become filled\" has been known as Roemer's law (Roemer and Shain, 1959). Conversely, strictly regulating the number of centers allowed to perform heart surgery establishes a limit for the total number of cardiac operations that can be performed. In situations of limited supply, physicians must determine which patients are most in need of the limited supply of services. Ideally, those truly in need gain access to appropriate services, with physicians possessing the wisdom to distinguish those patients truly in need (Rob) from those not requiring the service (Bob).\n\nAlthough there may not always be a directly linear relationship between supply and use of services, there are clear instances in which limitations of capacity restrain use. For example, international comparisons demonstrate large variations in use of coronary revascularization procedures (coronary artery bypass surgery and angioplasty), with a relatively low rate of surgery in the United Kingdom, an intermediate rate in Canada, and the highest rate in the United States. These rates correspond to the degree to which these nations regulate (minimally in the case of the United States) the number of centers performing cardiac surgery. In spite of the large variations in the quantity of care, with the US performing almost four times the number of procedures per capita than the UK, there are minimal differences in heart disease mortality among these countries (OECD, 2009).\n\nA \"natural experiment\" provides an illustration of how restricting the supply of a high cost resource may be implemented in a relatively painless manner for patients' clinical outcomes. A US hospital experiencing a nursing shortage abruptly reduced the number of staffed intensive care unit beds from 18 to 8 (Singer et al, 1983). For patients admitted to the hospital for chest pain, physicians became more selective in admitting to the intensive care unit only those patients who actually suffered heart attacks. Limiting the use of ICU beds did not result in any adverse health outcomes for patients admitted to nonintensive care unit beds, including those few nonintensive care unit patients who actually sustained heart attacks. This study suggests that when faced with supply limits, physicians may be able to prioritize patients on clinical grounds in a manner that selectively reduces unnecessary services. Establishing supply limits that require physicians to prioritize services based on the appropriateness and urgency of patient need represents a very different (and less intrusive) approach to containing costs than UM, which relies on external parties to authorize or deny individual services in a setting of relatively unconstrained capacity.\n\n##### **Controlling the Type of Supply**\n\nA specific form of supply control is regulation of the _types_ (rather than the total number) of providers. Chapter 5 explored the balance between the number of generalist and specialist physicians in a health care system. Increasing the proportion of generalists may yield savings for two reasons. First, generalists earn lower incomes than specialists. Second, and of greater impact for overall costs, generalists appear to practice a less resource-intensive style of medicine and generate lower overall health care expenditures, including less use of hospital and laboratory services (Bodenheimer and Grumbach, 2007).\n\n### **CONCLUSION**\n\nIn the real world, cost containment strategies are applied not as isolated phenomena in a static system, but as an array of policies concerned with modes of financing, organization of health care delivery, and cost control all mixed together. Managed care is a strategy that utilizes mixture of cost control mechanisms: changing the unit of payment, utilization management, price discounts, and in some cases supply controls. The Canadian health care system (see Chapter 14) also relies on regulation of prices, global budgets and supply controls.\n\nThere is no perfect mechanism for controlling health care costs. Strategies must be judged by their relative success at containing costs and doing so in as painless a manner as possible\u2014without compromising health outcomes. In the view of Dr. John Wennberg, the key to cost control in the United States\n\n_is not in the micromanagement of the doctor-patient relationship but the management of capacity and budgets. The American problem is to find the will to set the supply thermostat somewhere within reason. (Wennberg, 1990)_\n\nAlthough US managed care plans and Canadian provincial health plans are often viewed as diametrically opposed paradigms for health care reform, both the Canadian plans and US group and staff model HMOs base their cost control approaches on what Wennberg terms \"the management of capacity and budgets.\" In Canada, this management is under public control through regulation of physician supply, physician and hospital budgets, and technology. In the United States, private group and staff model HMOs adjust their own \"thermostats\" by setting their own budgets and numbers of physicians, hospital beds, and high-cost equipment.\n\nIf there is a lesson to be learned from attempts to control health care costs in the United States over the past decades, it is that cost-containment policies affecting provider reimbursement need to focus more on macromanagement and less on micromanagement. Trying to manage costs at the level of individual patient encounters (ie, regulating fees for each service, reviewing daily practice decisions, or imposing cost sharing for every prescription and visit to the physician) is a cumbersome and largely ineffectual strategy for containing overall expenditures. Moreover, one payer lowering its costs by shifting expenses to another payer does not produce systemwide cost savings. Those systems that have been most successful in moderating the inexorable increase in health care costs have tended to emphasize global cost containment tools, such as paying by capitation or other aggregate units, limiting the size and specialty mix of the physician workforce, and concentrating high-technology services in regional centers. The future debate over cost containment in the United States will center on whether these cost-containment tools are best wielded by private health care plans operating in a price competitive market or by public regulation of health care providers and suppliers.\n\n### **REFERENCES**\n\nArnst C. In most markets, a few health insurers dominate. _Business Week_. July 23, 2009.\n\nBarer ML et al. Re-minding our Ps and Qs: Cost controls in Canada. _Health Aff (Millwood)_. 1996;15(2):216.\n\nBindman AB. Can physician profiles be trusted? _JAMA_. 1999;281:2142.\n\nBodenheimer T. High and rising health care costs. _Ann Intern Med_. 2005;142:847, 932, 996.\n\nBodenheimer T, Grumbach K. Improving primary care. _Strategies and Tools for a Better Practice_. New York: McGraw-Hill; 2007.\n\nBrook RH et al. Does free care improve adults' health? _N Engl J Med_. 1983;309:1426.\n\nClaxton G et al. Health benefits in 2010. _Health Aff (Millwood)_. 2010;29:1942.\n\nEnthoven AC. Employment-based health insurance is failing: now what? _Health Aff (Millwood)_. 2003;(suppl web exclusives):W3\u2013W237.\n\nEnthoven AC. The history and principles of managed competition. _Health Aff (Millwood)_. 1993;12(suppl): 24\u201348.\n\nEvans RG. _Strained Mercy: The Economics of Canadian Health Care._ Toronto, Ontario, Canada: Butterworths; 1984.\n\nFisher ES et al. Associations among hospital capacity, utilization, and mortality of U.S. Medicare beneficiaries, controlling for sociodemographic factors. _Health Serv Res_. 2000; 34:1351.\n\nGawande A. The cost conundrum. _The New Yorker_. June 1, 2009.\n\nGoldman DP et al. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. _JAMA_. 2007;298:61.\n\nGoodell S et al. _Emergency Department Utilization and Capacity_. Robert Wood Johnson Foundation Policy Brief. No. 17, July 2009. www.rwjf.org\/files\/research\/45929.emergencyutilization.brief.pdf. Accessed November 14, 2011.\n\nGruber J. _The Tax Exclusion for Employer-Sponsored Health Insurance_. National Bureau of Economic Research. February 2010. www.nber.org\/papers\/w15766. Accessed November 14, 2011.\n\nGrumbach K, Bodenheimer T. Reins or fences: A physician's view of cost containment. _Health Aff (Millwood)_. 1990;9(3):120.\n\nHellinger FJ. The impact of financial incentives on physician behavior in managed care plans: A review of the evidence. _Med Care Res Rev_. 1996;53:294.\n\nHsu J et al. Unintended consequences of caps on Medicare drug benefits. _N Engl J Med_. 2006;354:2349.\n\nLee PR, Etheredge L. Clinical freedom: Two lessons for the UK from U.S. experience with privatisation of health care. _Lancet_. 1989;1:263.\n\nLight DW. Life, death, and the insurance companies. _N Engl J Med_. 1994;330:498.\n\nMays GP et al. Managed care rebound? Recent changes in health plans' cost containment strategies. _Health Aff (Millwood)_. 2004;(suppl web exclusive):w4\u2013427\u201336.\n\nMehrotra A et al. The relationship between health plan advertising and market incentives: Evidence of risk-selective behavior. _Health Aff (Millwood)_. 2006;25:759.\n\nNewhouse JP et al. Some interim results from a controlled trial of cost sharing in health insurance. _N Engl J Med_. 1981;305:1501.\n\nOECD. Health at a Glance. Organization for Economic Cooperation and Development, 2009. www.oecd.org\/health.\n\nPhelps CE. _Health Economics._ Boston, MA: Addison Wesley; 2003.\n\nRice TH. Containing health care costs. In: Andersen RM, Rice TH, Kominski GF, eds. _Changing the U.S. Health Care System_. San Francisco, CA: Jossey-Bass; 1996.\n\nRice TH, Labelle RJ. Do physicians induce demand for medical services? _J Health Polit Policy Law_. 1989;14:587.\n\nRoemer MI, Shain M. _Hospital Utilization Under Insurance_. Chicago, IL: American Hospital Association; 1959.\n\nSchneeweiss S et al. The effect of Medicare Part D coverage on drug use and cost sharing among seniors without prior drug benefits. _Health Aff (Millwood)_. 2009;28:w305.\n\nSinger DE et al. Rationing intensive care: Physician responses to a resource shortage. _N Engl J Med_. 1983;309:1155.\n\nVladeck BC. Fixing Medicare's physician payment system. _N Engl J Med_. 2010;362:1955.\n\nWennberg JE. Outcomes research, cost containment, and the fear of health care rationing. _N Engl J Med_. 1990;323:1202.\n\nWickizer TM. The effect of utilization review on hospital use and expenditures: A review of the literature and an update on recent findings. _Med Care Rev_. 1990;47:327.\n\n## **10 Quality of Health Care**\n\nEach year in the United States, millions of people visit hospitals, physicians, and other caregivers and receive medical care of superb quality. But that's not the whole story. Some patients' interactions with the health care system fall short (Institute of Medicine, 1999, 2001).\n\nAt the beginning of the twenty-first century, an estimated 32,000 people died in US hospitals each year as a result of preventable medical errors (Zahn and Miller, 2003). In addition, an estimated 57,000 people in the United States died because they were not receiving appropriate health care\u2014in most cases, because common medical conditions such as high blood pressure or elevated cholesterol are not adequately controlled (National Committee for Quality Assurance, 2010). Hospitals vary greatly in their risk-adjusted mortality rates for Medicare patients; for 2000 to 2002, if hospitals with mortality rates higher than expected reduced deaths to the levels that were expected given their patient mix, 17,000 to 21,000 fewer deaths per year would have occurred (Schoen et al, 2006).\n\nFatal medication errors among outpatients doubled between 1983 and 1993 (Phillips et al, 1998). Prescribing errors occur in 7.6% of outpatient prescriptions (Gandhi et al, 2005), which amounts to 228 million errors in 2004. In 2007, about 25% of elderly patient received high-risk medications (Zhang et al, 2010). Diagnostic error rates are around 10% for a variety of medical conditions (Wachter, 2010). In some primary care practices, patients are not informed about abnormal laboratory results over 20% of the time (Casalino et al, 2009).\n\nForty-five percent of adults do not receive recommended chronic and preventive care, and 30% seeking care for acute problems receive treatment that is contra-indicated (Schuster et al, 1998; McGlynn et al, 2003). Only 50% of people with hypertension are adequately treated (Egan, 2010). Sixty-three percent of people with diabetes are inadequately controlled (Saydah et al, 2004). In many studies, racial and ethnic minority patients experience an inferior quality of care compared with white patients (Agency for Healthcare Research and Quality, 2010). The likelihood of patients being harmed by medical negligence is almost three times as great in hospitals serving largely low-income and minority patients than in hospitals with more affluent populations (Burstin et al, 1993a; Ayanian, 1994; Fiscella et al, 2000). A recent study of multiple quality measures found that the US continues to have serious quality problems and lags behind other developed nations (Schoen et al, 2006).\n\nA prominent Institute of Medicine report (2001) concluded that between what we _know_ and what we _do_ lies not just a gap, but a chasm. Quality problems have been categorized as overuse, underuse, and misuse (Chassin et al, 1998). We will first examine the factors contributing to poor quality and then explore what can be done to elevate all health care to the highest possible level.\n\n### **THE COMPONENTS OF HIGH-QUALITY CARE**\n\nWhat is high-quality health care? It is care that assists healthy people to stay healthy, cures acute illnesses, and allows chronically ill people to live as long and fulfilling a life as possible. What are the components of high-quality health care? (Table 10\u20131)\n\n**Table 10\u20131.** Components of high-quality care\n\n#### **Adequate Access to Care**\n\n_Lydia and Laura were friends at a rural high school; both became pregnant. Lydia's middle-class parents took her to a nearby obstetrician, while Laura, from a family on welfare, could not find a physician who would take Medicaid. Lydia became the mother of a healthy infant, but Laura, going without prenatal care, delivered a low-birth-weight baby with severe lung problems._\n\nTo receive quality care, people must have access to care. People with reduced access to care suffer worse health outcomes in comparison to those enjoying full access\u2014the quality problem of underuse (see Chapter 3). Quality requires equality (Schiff et al, 1994).\n\n#### **Adequate Scientific Knowledge**\n\n_Brigitte Levy, a professor of family law, was started on estrogen replacement in 1960 when she reached menopause. Her physician prescribed the hormone pills for 10 years. In 1979, she was diagnosed with invasive cancer of the uterus, which spread to her entire abdominal cavity in spite of surgical treatment and radiation. She died in 1980 at age 68, at the height of her career._\n\nA body of knowledge must exist that informs physicians what to do for the patient's problem. If clear scientific knowledge fails to distinguish between effective and ineffective or harmful care, quality may be compromised. During the 1960s, medical science taught that estrogen replacement, without the administration of progestins, was safe. Sadly, cases of uterine cancer caused by estrogen replacement did not show up until many years later. Brigitte Levy's physician followed the standard of care for his day, but the medical profession as a whole was relying on inadequate scientific knowledge. A great deal of what physicians do has never been evaluated by rigorous scientific experiment (Eddy, 1993), and many therapies have not been adequately tested for side effects. Treatments of uncertain safety and efficacy may cause harm and cost billions of dollars each year.\n\n#### **Competent Health Care Providers**\n\n_Ceci Yu, age 77, was waking up at night with shortness of breath and wheezing. Her physician told her she had asthma and prescribed albuterol, a bronchodilator. Two days later, Ms. Yu was admitted to the coronary care unit with a heart attack. Writing to the chief of medicine, the cardiologist charged that Ms. Yu's physician had misdiagnosed the wheezing of congestive heart failure and had treated Ms. Yu incorrectly for asthma. The cardiologist charged that the treatment might have precipitated the heart attack._\n\nThe provider must have the skills to diagnose problems and choose appropriate treatments. An inadequate level of competence resulted in poor quality care for Ms. Yu.\n\nThe Harvard Medical Practice study reviewed 30,000 medical records in 51 hospitals in New York State in 1984 (Studdert et al, 2004). The study found that in approximately 4% of hospital admissions, the patient experienced a medical injury (ie, a medical problem caused by the management of a disease rather than by the disease itself); this is the quality problem of misuse. A more recent study placed the percent of hospital patients experiencing a medical injury at 13.8% (Meurer et al, 2006). Medical injuries can be classified as negligent or not negligent.\n\n_Jack was given a prescription for a sulfa drug. When he took the first pill, he turned beet red, began to wheeze, and fell to the floor. His friend called 911, and Jack was treated in the emergency department for anaphylactic shock, a potentially fatal allergic reaction. The emergency medicine physician learned that Jack had developed a rash the last time he took sulfa. Jack's physician had never asked him if he was allergic to sulfa, and Jack did not realize that the prescription contained sulfa._\n\n_Mack was prescribed a sulfa drug, following which he developed anaphylactic shock. Before writingthe prescription, Mack's physician asked whether he had a sulfa allergy. Mack had said \"No.\"_\n\nMedical negligence is defined as failure to meet the standard of practice of an average qualified physician practicing in the same specialty. Jack's drug reaction must be considered negligence, while Mack's was not. Of the medical injuries discovered in the Harvard study, 28% were because of negligence. In those injuries that led to death, 51% involved negligence. The most common injuries were drug reactions (19%) and wound infections (14%). Eight percent of injuries involved failure to diagnose a condition, of which 75% were negligent. Seventy percent of patients suffering all forms of medical injury recovered completely in 6 months or less, but 47% of patients in whom a diagnosis was missed suffered serious disabilities (Brennan et al, 1991; Leape et al, 1991).\n\nNegligence cannot be equated with incompetence. Any good health care professional may have a mental lapse, may be overtired after a long night in the intensive care unit, or may have failed to learn an important new research finding.\n\n#### **Money and Quality of Care**\n\n_Nina Brown, a 56-year-old woman with diabetes, arrived at her primary care physician's office complaining of several bouts of chest pain over the past month. Her physician examined Ms. Brown, performed an electrocardiogram (ECG), which showed no abnormalities, diagnosed musculoskeletal pain, and recommended she take some ibuprofen. Five minutes later in the parking lot, Ms. Brown collapsed of a heart attack. The health plan insuring Ms. Brown had an incentive arrangement with primary care physicians whereby the physicians receive a bonus payment if the physicians reduce use of emergency department and referral services below the community average._\n\n_Completely healthy at age 45, Henry Fung reluctantly submitted to a treadmill exercise test at the local YMCA. The study was possibly abnormal, and Mr. Fung, who had fee-for-service insurance, sought the advice of a cardiologist. The cardiologist knew that treadmill tests are sometimes positive in healthy people. He ordered a coronary angiogram, which was perfectly normal. Three hours after the study, a clot formed in the femoral artery at the site of the catheter insertion, and emergency surgery was required to save Mr. Fung's leg._\n\nNo one can know what motivated the physician to send Ms. Brown home instead of to an emergency department when unstable coronary heart disease was one possible diagnosis (underuse); nor can one guess what led the fee-for-service cardiologist to perform an invasive coronary angiogram of questionable appropriateness on Mr. Fung (overuse). One factor that bears close attention is the impact of financial considerations on the quantity (and thus the quality) of medical care (Relman, 2007). As noted in Chapter 4, fee-for-service reimbursement encourages physicians to perform more services, whereas capitation payment rewards those who perform fewer services.\n\nMore than 40 years ago, Bunker (1970) found that the United States performed twice the number of surgical procedures per capita than Great Britain. He postulated that this difference could be accounted for by the greater number of surgeons per capita in the United States and concluded that \"the method of payment appears to play an important, if unmeasured, part.\" Most surgeons in the United States are compensated by fee-for-service, whereas most in Great Britain are paid a salary. From 8% to 86% of surgeries\u2014depending on the type\u2014have been found to be unnecessary and have caused substantial avoidable death and disability (Leape, 1992). As an example, spinal fusion surgery increased by 77% from 1996 to 2001, though little evidence supports this procedure in many cases. Complications are frequent and rates of reoperation (because of failure to relieve pain or worsening pain) are high. Reimbursement for this procedure is greater than that provided for most other procedures performed by orthopedists and neurosurgeons (Deyo et al, 2004).\n\n_It was a nice dinner, hosted by the hospital radiologist and paid for by the company manufacturing magnetic resonance imaging (MRI) scanners. After the meal came the pitch: \"If you physicians invest money, we can get an MRI scanner near our hospital; if the MRI makes money, you all share in the profits.\" One internist explained later, \"After I put in my $10,000, it was hard to resist ordering MRI scans. With headaches, back pain, and knee problems, the indications for MRIs are kind of fuzzy. You might order one or you might not. Now, I do.\"_\n\nRelman (2007) writes about the commercialization of medicine: \"The introduction of new technology in the hands of specialists, expanded insurance coverage, and unregulated fee-for-service payments all combined to rapidly increase the flow of money into the health care system, and thus sowed the seeds of a new, profit-driven industry.\"\n\nDuring the 1980s, many physicians formed partnerships and joint ventures, giving them part ownership in laboratories, MRI scanners, and outpatient surgicenters. Forty percent of practicing physicians in Florida owned services to which they referred patients. Ninety-three percent of diagnostic imaging facilities, 76% of ambulatory surgery centers, and 60% of clinical laboratories in the state were owned wholly or in part by physicians. The rates of use for MRI and CT scans were higher for physician-owned compared with non-physician-owned facilities (Mitchell and Scott, 1992). In a national study, physicians who received payment for performing x-rays and sonograms within their own offices obtained these examinations four times as often as physicians who referred the examinations to radiologists and received no reimbursement for the studies. The patients in the two groups were similar (Hillman et al, 1990).\n\nAfter 2000, profitable diagnostic, imaging, and surgical procedures have rapidly migrated from the hospital to free-standing physician-owned ambulatory surgery centers, endoscopy centers, and imaging centers (Berenson et al, 2006). For example, the number of CT scans performed for Medicare patients increased by 65% from 2000 to 2005; during those years, the number of MRI scans jumped by 94% (Bodenheimer et al, 2007). The number of CT scans is growing by more than 10% per year, increasing patients' risk of radiation-related cancer (Smith-Bindman, 2010). A significant association exists between surgeon ownership of ambulatory surgery centers and a higher volume of surgeries; surgery volume increases immediately following surgeons' acquisition of the surgicenter (Hollingsworth et al, 2010).\n\nMoving to the other side of the overuse\u2013underuse spectrum, payment by capitation, or salaried employment by a for-profit business, may create a climate hostile to the provision of adequate services. In the 1970s, a series of HMOs called prepaid health plans (PHPs) sprang up to provide care to California Medicaid patients. The quality of care in several PHPs became a major scandal in California. At one PHP, administrators wrote a message to health care providers: \"Do as little as you possibly can for the PHP patient,\" and charts audited by the California Health Department revealed many instances of undertreatment. The PHPs received a lump sum for each patient enrolled, meaning that the lower the cost of the services actually provided, the greater the PHP's profits (US Senate, 1975).\n\nThe quantity and quality of medical care are inextricably interrelated. Too much or too little can be injurious. The research of Fisher et al (2003) has shown that similar populations in different geographic areas have widely varying rates of surgeries and days in the hospital, with no consistent difference in clinical outcomes between those in high-use and low-use areas.\n\n#### **Health Care Systems and Quality of Care**\n\n_The personnel cutbacks were terrible; staffing had diminished from four RNs per shift to two, with only two aides to provide assistance. Shelley Rush, RN, was 2 hours behind in administering medications and had five insulin injections to give, with complicated dosing schedules. A family member rushed to the nursing station saying, \"The lady in my mother's room looks bad.\" Shelley ran in and found the patient unconscious. She quickly checked the blood sugar, which was disastrously low at 20 mg_ \/ _dL. Shelley gave 50% glucose, and the patient woke up. Then it hit her\u2014she had injected the insulin into the wrong patient._\n\nHealth care institutions must be well organized, with an adequate, competent staff. Shelley Rush was a superb nurse, but understaffing caused her to make a serious error. The book _Curing Health Care_ by Berwick et al (1990) opens with a heartbreaking case:\n\n_She died, but she didn't have to. The senior resident was sitting, near tears, in the drab office behind the nurses' station in the intensive care unit. It was 2:00 AM, and he had been battling for thirty-two hours to save the life of the 23-year-old graduate student who had just suffered her final cardiac arrest._\n\n_The resident slid a large manila envelope across the desk top. \"Take a look at this,\" he said. \"Routine screening chest x-ray, taken 10 months ago. The tumor is right there, and it was curable\u2014then. Bythe time the second film was taken 8 months later, because she was complaining of pain, it was too late. The tumor had spread everywhere, and the odds were hopelessly against her. Everything we've done since then has really just been wishful thinking. We missed our chance. She missed her chance.\" Exhausted, the resident put his head in his hands and cried._\n\n_Two months later, the Quality Assurance Committee completed its investigation.... \"We find the inpatient care commendable in this tragic case,\" concluded the brief report, \"although the failure to recognize the tumor in a potentially curable stage 10 months earlier was unfortunate....\" Nowhere in this report was it written explicitly why the results of the first chest x-ray had not been translated into action. No one knew._\n\n_One year later.... it was 2:00 AM, and the night custodian was cleaning the radiologist's office. As he moved a filing cabinet aside to sweep behind it, he glimpsed a dusty tan envelope that had been stuck between the cabinet and the wall. The envelope contained a yellow radiology report slip, and the date on the report\u2014nearly two years earlier\u2014convinced the custodian that this was, indeed, garbage... He tossed it in with the other trash, and 4 hours later it was incinerated along with other useless things. (Berwick et al, 1990)_\n\nThis patient may have had perfect access to care for an illness whose treatment is scientifically proved; she may have seen a physician who knew how to make the diagnosis and deliver the appropriate treatment; and yet the quality of her care was disastrously deficient. Dozens of people and hundreds of processes influence the care of one person with one illness. In her case, one person\u2014perhaps a file clerk with a near-perfect record in handling thousands of radiology reports\u2014lost control of one report, and the physician's office had no system to monitor whether or not x-ray reports had been received. The result was the most tragic of quality failures\u2014the unnecessary death of a young person.\n\nHow health care systems and institutions are organized has a major impact on health care outcomes. For example, large multispecialty group practices in 22 metropolitan areas have better-quality measures at lower cost than dispersed physician practices in those areas (Weeks et al, 2009). Studies have shown that hospitals with more RN staffing have lower surgical complication rates (Kovner and Gergen, 1998) and lower mortality rates (Aiken et al, 2002).\n\n_Oliver Hart lived in a city with a population of 80,000. He was admitted to Neighborhood Hospital with congestive heart failure caused by a defective mitral valve. He was told he needed semiurgent heart surgery to replace the valve. The cardiologist said \"You can go to University Hospital 30 miles away or have the surgery done here.\" The cardiologist did not say that Neighborhood Hospital performed only seven cardiac surgeries last year. Mr. Hart elected to remain for the procedure. During the surgery, a key piece of equipment failed, and he died on the operating table._\n\nQuality of care must be viewed in the context of regional systems of care (see Chapter 6), not simply within each health care institution. In one study, 27% of deaths related to coronary artery bypass graft (CABG) surgery at low-volume hospitals might have been prevented by referral of those patients to hospitals performing a higher volume of those surgeries (Dudley et al, 2000). Quality improves with the experience of those providing the care (Kizer, 2003; Peterson et al, 2004). Had Mr. Hart been told the relative surgical mortality rates at University Hospital, which performed 500 cardiac surgeries each year, and at Neighborhood Hospital, he would have chosen to be transferred 30 miles down the road. Not only does the volume of surgeries in a hospital matter; equally important is the volume of surgeries performed by the specific surgeon (Birkmeyer et al, 2003).\n\nIn the late 1980s, Dr. Donald Berwick (1989) and others realized that quality of care is not simply a question of whether or not a physician or other caregiver is competent. If poorly organized, the complex systems within and among medical institutions can thwart the best efforts of professionals to deliver high-quality care.\n\n_There are two approaches to the problem of improving quality... [One is] the Theory of Bad Apples, because those who subscribe to it believe that quality is best achieved by discovering bad apples and removing them from the lot.... The Theory of Bad Apples gives rise readily to what can be called the my-apple-is-just-fine-thank-you response... andseeks not understanding, but escape. [The other is] the Theory of Continuous Improvement . . . . Even when people were at the root of defects,... the problem was generally not one of motivation or effort, but rather of poor job design, failure of leadership, or unclear purpose. Quality can be improved much more when people are assumed to be trying hard already, and are not accused of sloth. Fear of the kind engendered by the disciplinary approach poisons improvement in quality, since it inevitably leads to the loss of the chance to learn._\n\n_Real improvement in quality depends... on continuous improvement throughout the organization through constant effort to reduce waste, rework, and complexity. When one is clear and constant in one's purpose, when fear does not control the atmosphere (and thus the data), when learning is guided by accurate information... and when the hearts and talents of all workers are enlisted in the pursuit of better ways, the potential for improvement in quality is nearly boundless . . . . A test result lost, a specialist who cannot be reached, a missing requisition, a misinterpreted order, duplicate paperwork, a vanished record, a long wait for the CT scan, an unreliable on-call system\u2014these are all-too-familiar examples of waste, rework, complexity, and error in the physician's daily life . . . . For the average physician, quality fails when systems fail. (Berwick et al, 1989)_\n\n#### **The Components of Quality: Summary**\n\nGood-quality care can be compromised at a number of steps along the way.\n\n_Angie Roth has coronary heart disease and may need CABG surgery. (1) If she is uninsured and cannot get to a physician, high-quality care is impossible to obtain. (2) If clear evidence-based guidelines do not exist regarding who benefits from CABG and who does not, Ms. Roth's physician may make the wrong choice. (3) Even if clear guidelines exist, if Angie Roth's physician fails to evaluate her illness correctly or sends her to a surgeon with poor operative skills, quality may suffer. (4) If indications for surgery are not clear in Ms. Roth's case but the surgeon will benefit economically from the procedure, the surgery may be inappropriately performed. (5) Even if the surgery is appropriate and performed by an excellent surgeon, faulty equipment in the operating room or poor teamwork among the operating room surgeons, anesthesiologists, and nurses may lead to a poor outcome._\n\nThe Institute of Medicine, in its influential 2001 report _Crossing the Quality Chasm_ , conceptualized six core dimensions of quality: safe, effective, patient-centered, timely, efficient, and equitable. These dimensions, defined in greater detail in Table 10\u20132, are consistent with the components of quality discussed earlier.\n\n**Table 10\u20132.** Quality aims as defined by the Institute of Medicine\n\n### **PROPOSALS FOR IMPROVING QUALITY**\n\n_Several infants at a hospital received epinephrine in error and suffered serious medical consequences. An analysis revealed that several pharmacists had made the same mistake; the problem was caused by the identical appearance of vitamin E and epinephrine bottles in the pharmacy. This was a system error._\n\n_An epidemic of unexpected deaths on the cardiac ward was investigated. The times of the deaths were correlated with personnel schedules, leading to the conclusion that one nurse was responsible. Itturned out that she was administering lethal doses of digoxin to patients. This was not a system error._\n\nQuality issues must be investigated to determine if they are system errors or problems with a particular caregiver. Traditionally, quality assurance has focused on individual caregivers and institutions in a \"bad apple\" approach that relies heavily on sanctions. More recently, quality has been viewed through the lens of the continuous quality improvement (CQI) model that seeks to enhance the clinical performance of all systems of care, not just the outliers with flagrantly poor quality of care. The move to a CQI model has required development of more formalized standards of care that can be used as benchmarks for measuring quality, and more systematic collection of data to measure overall performance and not just performance in isolated cases (Tables 10\u20132).\n\n#### **Traditional Quality Assurance: Licensure, Accreditation, and Peer Review**\n\nTraditionally, the health care system has placed great reliance on educational institutions and licensing and accrediting agencies to ensure the competence of individuals and institutions in health care. Health care professionals undergo rigorous training and pass special licensing examinations intended to ensure that caregivers have at least a basic level of knowledge and competence. However, not all individuals who have successfully completed their education and passed licensing examinations are competent clinicians. In some cases, this reflects a failure of the educational and licensing systems. In other cases, clinicians may have been competent practitioners at the time they took their examinations, but their skills lapsed or they developed impairment from alcohol or drug use, depression, or other conditions (Leape and Fromson, 2006).\n\nLicensing agencies in the United States do not require periodic reexaminations. In most cases, licensing boards only respond to patient or health care professional complaints about negligent or unprofessional behavior. Many organizations that confer specialty board certification require physicians to pass examinations on a periodic basis to maintain active specialty certification. Some specialties also require physicians to perform and document systematic quality reviews of their own clinical practices for maintenance of certification. However, while some hospitals may require active specialty certification for a physician to be granted privileges to practice in the hospital, certification is not required for medical licensure, diluting some of the consequences of not participating in specialty recertification.\n\nThe traditional approach to quality assurance has also relied heavily on peer pressure within hospitals, HMOs, and the medical community at large. Peer review is the evaluation by health care practitioners of the appropriateness and quality of services performed by other practitioners, usually in the same specialty. Peer review has been a part of medicine for decades (eg, tissue committees study surgical specimens to determine whether appendectomies and hysterectomies have actually removed diseased organs; credentials committees review the qualifications of physicians for hospital staff privileges). But peer review moved to center stage with the passage of the law enacting Medicare in 1965.\n\nMedicare anointed the Joint Commission on Accreditation of Hospitals (now named simply the Joint Commission) with the authority to terminate hospitals from the Medicare program if quality of care was found to be deficient. The Joint Commission requires hospital medical staff to set up peer review committees for the purpose of maintaining quality of care.\n\nThe Joint Commission uses criteria of structure, process, and outcome to assess quality of care. Structural criteria include such factors as whether the emergency department defibrillator works properly. Criteria of process include whether medical records are dictated and signed in a timely manner, or if the credentials committee keeps minutes of its meetings. Outcomes include such measures as mortality rates for surgical procedures, proportions of deaths that are preventable, and rates of adverse drug reactions and wound infections. Medicare also contracts with quality improvement organizations (QIOs) in each state to promote better quality of care among physicians caring for Medicare beneficiaries.\n\n_Angela Lopez, age 57, suffered from metastatic ovarian cancer but was feeling well and prayed she would live 9 months more. Her son was the first family member ever to attend college, and she hoped to see him graduate. It was decided to infuse chemotherapy directly into her peritoneal cavity.As the solution poured into her abdomen, she felt increasing pressure. She asked the nurse to stop the fluid. The nurse called the physician, who said not to worry. Two hours later, Ms. Lopez became short of breath and demanded that the fluid be stopped. The nurse again called the physician, but an hour later Ms. Lopez died. Her abdomen was tense with fluid, which pushed on her lungs and stopped circulation through her inferior vena cava. The quality assurance committee reviewed the case as a preventable death and criticized the physician for giving too much fluid and failing to respond adequately to the nurse's call. The physician replied that he was not at fault; the nurse had not told him how sick the patient was. The case was closed._\n\nThe traditional quality assurance strategies of licensing and peer review have not been particularly effective tools for improving quality. Peer review often adheres to the theory of bad apples, attempting to discipline physicians (to remove them from the apple barrel) for mistakes rather than to improve their practice through education. The physician who caused Ms. Lopez's preventable death responded to peer criticism by blaming the nurse rather than learning from the mistake. With the hundreds of decisions physicians make each day, often in time-constrained situations, serious errors are relatively common in medical practice. Yet 42% of physicians recently surveyed had never disclosed a serious error to a patient (Gallagher et al, 2006). Hiding mistakes rather than correcting them is the legacy of a punitive quality assurance apparatus (Leape, 1994).\n\nEven if sanctions against the truly bad apples had more teeth, these measures would not solve the quality problem. Removing the incontrovertibly bad apples from the barrel does not address all the quality problems that emanate from competent caregivers who are not performing optimally. Health care systems do need to ensure basic clinical competence and to forcefully sanction caregivers who, despite efforts at remediation, cannot operate at a basic standard of acceptable practice. But measures are also needed to \"shift the curve\" of overall clinical practice to a higher level of quality, not just to trim off the poor-quality outliers.\n\nPeer reviewers frequently disagree as to whether the quality of care in particular cases is adequate or not (Laffel and Berwick, 1993). Because of these limitations, efforts are underway to formalize standards of care using clinical practice guidelines and to move from individual case review to more systematic monitoring of overall practice patterns (Table 10\u20133).\n\n**Table 10\u20133.** Proposals for improving quality\n\n#### **Clinical Practice Guidelines**\n\n_Dr. Benjamin Waters was frustrated by patients who came in with urinary incontinence. He never learned about the problem in medical school, so he simply referred these patients to a urologist. In his managed care plan, Dr. Waters was known to over-refer, so he felt stuck. He could not handle the problem, yet he did not want to refer patients elsewhere. He solved his dilemma by prescribing incontinence pads and diapers, but did not feel good about it._\n\n_Dr. Denise Drier learned about urinary incontinence in family medicine residency but did not feel secure about caring for the problem. On the web, she found \"Urinary Incontinence in Adults: Clinical Practice Guideline Update.\" She studied the material and applied it to her incontinence patients. After a few successes, she and the patients were feeling better about themselves._\n\nFor many conditions, there is a better and a worse way to make a diagnosis and prescribe treatment. Physicians may not be aware of the better way because of gaps in training, limited experience, or insufficient time or motivation to learn new techniques. For these problems, clinical practice guidelines can be helpful in improving quality of care. In 1989, Congress established the Agency for Health Care Policy and Research, now called the Agency for Healthcare Research and Quality (AHRQ), to develop practice guidelines, among other tasks. Produced by panels of experts, practice guidelines make specific recommendations to physicians on how to treat clinical conditions such as diabetes, osteoporosis, urinary incontinence, or cataracts. However, some powerful physician interests, displeased by AHRQ practice guidelines that recommended against surgical treatment for most cases of back pain, pressured Congress to reduce AHRQ's budget and bar AHRQ from issuing its own guidelines.\n\nMore than 2000 guidelines exist; written by dozens of organizations, they vary in scientific reliability. Most are developed by societies of medical specialists (Steinbrook, 2007). Ideally, practice guidelines are based on a rigorous and objective review of scientific evidence, with explicit ratings of the quality of the evidence. However, 87% of clinical practice guideline authors in one survey had ties to the pharmaceutical industry, a bias often not disclosed to readers of the guidelines (Shaneyfelt and Centor, 2009). For example, eight of nine authors of widely used guidelines recommending broad use of cholesterol-lowering statin drugs had financial ties to companies making or selling statins (Abramson and Starfield, 2005). Moreover, clinical practice guidelines developed based on research on a narrowly defined population, such as nonelderly patients with a single chronic condition, may not be applicable to different patient populations, such as elderly patients with multiple diseases (Boyd et al, 2005).\n\nPractice guidelines are not appropriate for many clinical situations. Uncertainty pervades clinical medicine, and practice guidelines are applicable only for those cases in which we enjoy \"islands of knowledge in our seas of ignorance.\" Practice guidelines can assist but not replace clinical judgment in the quest for high-quality care.\n\n_Pedro Urrutia, age 59, noticed mild nocturia and urinary frequency. His friend had prostate cancer, and he became concerned. The urologist said that his prostate was only slightly enlarged, his prostate-specific antigen (blood test) was normal, and surgery was not needed. Mr. Urrutia wanted surgery and found another urologist to do it._\n\n_At age 82, James Chin noted nocturia and urinary hesitancy. He had two glasses of wine on his wife's birthday and later that night was unable to urinate. He went to the emergency department, was found to have a large prostate without nodules, and was catheterized. The urologist strongly recommended a transurethral resection of the prostate. Mr. Chin refused, thinking that the urinary retention was caused by the alcohol. Five years later, he was in good health with his prostate intact._\n\nThe difficulty with creating a set of indications for surgery, for example surgery for benign enlargement of the prostate gland, is that patient preferences vary markedly. Some, like Mr. Urrutia, want prostate surgery, even though it is not clearly needed; others, like Mr. Chin, have strong reasons for surgery but do not want it. Practice guidelines must take into account not only scientific data, but also patient preferences (O'Connor et al, 2007).\n\nDo practice guidelines in themselves improve quality of care? Studies reveal that by themselves they are unsuccessful in influencing physicians' practices (Cabana et al, 1999). However, guidelines can be an important foundation for more comprehensive quality improvement strategies, such as computer systems to remind physicians when patients are in need of certain services according to a guideline (eg, a reminder system about women due for a mammogram) or having trusted colleagues (\"opinion leaders\") or visiting experts (\"academic detailing\") conduct small group sessions with clinicians to review and reinforce practice guidelines (Bodenheimer and Grumbach, 2007).\n\n#### **Measuring Practice Patterns**\n\nOne of the central tenets of the CQI approach is the need to systematically monitor how well individual caregivers, institutions, and organizations are performing. There are two basic types of indicators that are used to evaluate clinical performance: process measures and outcome measures. _Process_ of care refers to the types of services delivered by caregivers. Examples are prescribing aspirin to patients with coronary heart disease, or turning immobile patients in hospital beds on a regular schedule to prevent bed sores. _Outcomes_ are death, symptoms, mental health, physical functioning, and related aspects of health status, and are the gold standard for measuring quality. However, outcomes (particularly those dealing with quality of life) may be difficult to measure. More easily counted outcomes such as mortality may be rare events, and therefore uninformative for evaluating quality of care for many conditions that are not immediately life-threatening. Also, outcomes may be heavily influenced by the underlying severity of illness and related patient characteristics, and not just by the quality of health care that patients received (King and Wheeler, 2007) When measuring patient outcomes, it is necessary to \"risk adjust\" these outcome measurements for differences in the underlying characteristics of different groups of patients. Because of these challenges in using outcomes as measures to monitor quality of care, process measures tend to be more commonly used. For process measures to be valid indicators of quality, there must first be solid research demonstrating that the processes do in fact influence patient outcomes.\n\n_Dr. Susan Cutter felt horrible. It was supposed to have been a routine hysterectomy. Somehow she had inadvertently lacerated the large intestine of the patient, a 45-year-old woman with symptomatic fibroids of the uterus but otherwise in good health prior to surgery. Bacteria from the intestine had leaked into the abdomen, and after a protracted battle in the ICU the patient died of septic shock._\n\n_Dr. Cutter met with the Chief of Surgery at her hospital. The Chief reviewed the case with Dr. Cutter, but also pulled out a report showing the statistics on all of Dr. Cutter's surgical cases over the previous 5 years. The report showed that Dr. Cutter's mortality and complication rates were among the lowest of surgeons on the hospital's staff. However, the Chief did note that another surgeon, Dr. Dehisce, had a complication rate that was much higher than that of all the other staff surgeons. The Chief of Surgery asked Dr. Cutter to serve on a departmental committee to review Dr. Dehisce's cases and to meet with Dr. Dehisce to consider ways to address his poor performance._\n\nThe contemporary approach to quality monitoring moves beyond examining a few isolated cases toward measuring processes or outcomes for a large population of patients. For example, a traditional peer review approach is to review every case of a patient who dies during surgery. Reviewing an individual case may help a surgeon and the operating team understand where errors may have occurred\u2014a process known as \"root cause\" analysis. However, it does not indicate whether the case represented an aberrant bad outcome for a surgeon or team that usually has good surgical outcomes, or whether the case is indicative of more widespread problems. To answer these questions requires examining data on all the patients operated on by the surgeon and the operating team to measure the overall rate of surgical complications, and having some benchmark data that indicate whether this rate is higher than expected for similar types of patients.\n\n_Mel Litus was the nurse in charge of diabetes education for a large medical group. After seeing yet another patient return to clinic after having had a foot amputation or suffering a heart attack, Mel wondered how the clinic team could do a better job in preventing diabetic complications. The medical group had recently implemented a new computerized clinical information system. Mel met with the administrator in charge of the computer system and arranged to have a printout made of all the laboratory findings, referrals, and medications for the diabetic patients in the medical group. When Mel reviewed the printout, he noticed that many of the patients didn't attend appointments very regularly and were not receiving important services like regular ophthalmology visits and medications that protect the kidneys from diabetic damage. Mel met with the medical director for quality improvement to discuss a plan for sharing this information with the clinical staff and creating a system for more closely monitoring the care of diabetic patients._\n\nMany practice organizations, from small groups of office-based physicians to huge, vertically integrated HMOs are starting to monitor patterns of care and provide feedback on this care to physicians and other staff in these organizations. The goal of this feedback is to alert caregivers and health care organizations about patterns of care that are not achieving optimal standards, in order to stimulate efforts to improve processes of care. The response may range from individual clinicians systematically reviewing their care of certain types of patients and clinical conditions, to entire organizations redesigning the system of care. A typical example of this practice profiling is measuring the rate at which diabetic patients receive recommended services, such as annual eye examinations, periodic testing of HbA1c levels, and evaluation of kidney function. Process of care profiles alert individual caregivers to specific diabetic patients who need to be called in for certain tests, and point out patterns of care that suggest that the organization should implement systematic reforms, such as developing case management programs for diabetic patients in poor control (Bodenheimer and Grumbach, 2007).\n\n#### **Continuous Quality Improvement**\n\nMaximizing excellence for individual health care professionals is only one ingredient in the recipe for high-quality health care. Improving institutions is the other, through CQI techniques. CQI involves the identification of concrete problems and the formation of interdisciplinary teams to gather data and propose and implement solutions to the problems.\n\n_In LDS Hospital in Salt Lake City, variation in wound infection rates by different physicians was related to the timing of the administration of prophylactic antibiotics. Patients who received antibiotics 2 hours before surgery had the lowest infection rates. The surgery department adopted a policy that all patients receive antibiotics precisely 2 hours before surgery; the rate of postoperative wound infections dropped from 1.8% to 0.9%. (Burke, 2001)_\n\nSuch successes only dot, but do not yet dominate, the health care quality landscape (Solberg, 2007). The Institute for Healthcare Improvement (IHI) has led efforts to spread CQI efforts by sponsoring \"collaboratives\" to assist institutions and groups of institutions to improve health care outcomes and access while ideally reducing costs. Hundreds of health care organizations have participated in collaboratives concerned with such topics as improving the care of chronic illness, reducing waiting times, improving care at the end of life, and reducing adverse drug events. Collaboratives involve learning sessions during which teams from various institutions meet and discuss the application of a rapid change methodology within institutions. Some of IHI's successes have taken place in the area of chronic disease, with a variety of institutions\u2014from large integrated delivery systems to tiny rural community health centers\u2014implementing the chronic care model to improve outcomes for conditions such as diabetes, asthma, and congestive heart failure (Bodenheimer et al, 2002). Collaboratives that assist institutions to implement the chronic care model have shown modest improvement in patient outcomes compared with controls (Vargas et al, 2007). In the area of patient safety, in 2004, IHI launched the 100,000 Lives Campaign (www.ihi.org) to reduce mortality rates in hospitals, followed by a 5 Million Lives Campaign between 2006 and 2008; more than 4000 hospitals in the United States participated in these campaigns. There is evidence that these campaigns have contributed to reductions in hospital mortality, although there is debate about the magnitude of the impact (Berwick et al, 2006; Wachter and Pronovost, 2006).\n\n#### **Computerized Information Systems**\n\nThe advent of computerized information systems has created opportunities to improve care and to monitor the process and outcomes of care for entire populations. Electronic medical records can create lists of patients who are overdue for services needed for preventive care or the management of chronic illness and can generate reminder prompts for physicians and patients (Baron, 2007). In-hospital medical errors related to drug prescribing are reduced with computerized physician order entry (CPOE), systems requiring physicians to enter hospital orders directly into a computer rather than handwriting them. The computer can alert the physician about inappropriate medication doses or medications to which the patient is known to be allergic (Kaushal et al, 2003). However, hospital-based electronic health records have not yet been proven to significantly improve quality (Eslami et al, 2007; DesRoches et al, 2010). By themselves, computerized information systems are unlikely to improve quality; computerization must be accompanied by changes in the organization of informational processes (Bodenheimer and Grumbach, 2007).\n\n#### **Public Reporting of Quality**\n\nThe CQI approach emphasizes systematic monitoring of care to provide internal feedback to clinicians and health organizations to spur improved processes of care. A different approach to monitoring quality of care is to direct this information to the public. This approach views public release of systematic measurements of quality of care\u2014commonly referred to as health care \"report cards\"\u2014as a tool to empower health care consumers to select higher-quality caregivers and institutions. Advocates of this approach argue that armed with this information, patients and health care purchasers will make more informed decisions and preferentially seek out health care organizations with better report card grades.\n\nAn important experiment in individual physician report cards was initiated by the New York State Department of Health in 1990. The department released data on risk-adjusted mortality rates for coronary bypass surgery performed at each hospital in the state, and in 1992, mortality rates were also published for each cardiac surgeon. Each year's list was big news and highly controversial. However, difficulties in measurement were highlighted by the fact that within 1 year, 46% of the surgeons had moved from one-half of the ranked list to the other half.\n\nSeveral fascinating results came of this project: (1) Patients did not switch from hospitals with high mortality rates to those with lower mortality rates. (2) With the release of each report, one in five bottom quartile surgeons relocated or ceased practicing within two years. (3) In 4 years, overall risk-adjusted coronary artery bypass mortality dropped by 41% in New York State. Mortality for this operation also dropped in states without report cards, but not as much. (4) Some surgeons, worried about the report cards, may have elected not to operate on the most risky patients in order to improve their report card ranking. It is possible that the reduction in surgical mortality in part resulted from withholding surgery for the sickest patients. The New York State experiment had less effect on changing the market decisions of patients and purchasers than on motivating quality improvements in hospitals that had poor surgical outcomes (Marshall et al, 2000; Jha and Epstein, 2006).\n\nIn 2011, the federal Centers for Medicare and Medicaid Services (CMS) launched its Physician Compare website, which will report on quality-of-care measures for specific physicians by 2015 (www.medicare.gov\/find-a-doctor\/provider-search.aspx).\n\nThe most important report card program is the Healthcare Effectiveness Data and Information Set (HEDIS). Developed by the National Committee for Quality Assurance (NCQA), a private organization controlled by large HMOs and large employers, HEDIS for 2010 is a list of 71 performance indicators including the percentage of children immunized; the percentage of enrollees of certain ages who have received Pap smears, colorectal screening, mammograms, and glaucoma screening; the percentage of pregnant women who received prenatal care in the first trimester; the percentage of diabetic patients who received retinal examinations; and the percentage of smokers for whom physicians made efforts at smoking cessation; the appropriateness of treatment for asthma, bronchitis, osteoporosis, depression, and others. NCQA chiefly reports on the performance of health plans; some critics believe that reporting on physicians and hospitals would be more helpful. Another problem is that few employers use quality data when selecting health plans for their employees; cost is the driving factor in most employer decisions (Galvin and Delbanco, 2005).\n\nReport cards are based on a philosophy that says \"if you can't count it, you can't improve it.\" Albert Einstein expressed an alternative philosophy that might illuminate the report card enterprise: \"Not everything that can be counted counts, and not everything that counts can be counted.\" Increasingly, the focus on quality is switching to a focus on value, with value referring to quality divided by cost. Thus an increase in a quality measure associated with a growth in cost may not improve value, where improved quality with a stable or reduced cost increases value (Owens et al, 2011).\n\n#### **Pay for Reporting**\n\nIn 2003, the Medicare program initiated public reporting for hospitals, focusing on risk-adjusted quality of care for heart attacks, heart failure, and pneumonia. More recently, surgical care and other measures have been added. Reports on individual hospitals and an explanation of the program are available at www.hospitalcompare.hhs.gov. The program, the Hospital Quality Initiative, is voluntary but nonparticipating hospitals receive a reduction in their Medicare payments. One might say that the program is in essence no-pay for no-reporting. Hospital quality has improved for some measures that are reported (Chassin et al, 2010), but hospitals focus their quality activities on the specific measures prescribed by the program, at times to the detriment of other quality activities (Pham et al, 2006).\n\nIn 2007, Medicare began the Physician Quality Reporting System, under which physicians who report certain quality measures may receive a 2% increase in their Medicare fees. This is not a full-fledged pay for reporting program because the reports for individual physicians or physician practices are not made public (www.cms.hhs.gov\/pqri\/).\n\n#### **Pay for Performance**\n\nBy 2003, a new concept\u2014\"pay for performance\"\u2014was gaining widespread acceptance in health care (Epstein et al, 2004). Pay for performance (P4P) goes one step beyond pay for reporting; physicians or hospitals receive more money if their quality measures exceed certain benchmarks or if the measures improve from year to year.\n\nOne of the largest P4P programs is the Integrated Healthcare Association (IHA) program in California. IHA, representing employers, health plans, health systems and physician groups, launched the program in 2002 with a set of uniform performance measures. In 2010, seven health plans and 221 physician organizations\u2014involving 35,000 physicians and 10 million patients\u2014participated in the IHA program (www.iha.org).\n\nIn 2010, the health plans paid physician organizations $49 million in performance-based bonuses. The physician organizations receive funds for demonstrating improved clinical care (eg, cancer screening, immunizations, and management of asthma, diabetes, and cardiovascular disease), patient satisfaction, and development of information technology. In 2009, IHI added cost containment measures including inpatient utilization, hospital readmissions, and generic drug prescribing. Physician organizations distribute a substantial amount of the money to individual physicians but keep a portion of the bonus for organizationwide quality-enhancing initiatives. Quality measures have improved modestly since the program began, between 5% and 12%, but patient satisfaction did not. A limitation of the program is that the bonuses are small (about 2% of physician group revenues) and practices must spend money to organize and report their data (Damberg et al, 2009). Moreover, health plans are becoming less enthusiastic about P4P as they are not seeing the return on investment hoped for (Integrated Healthcare Organization, 2009).\n\nThe IHA program is unique for two reasons: All major health plans collaborated in choosing the measures upon which performance bonuses are based, and most physicians in California belong to a large medical group or independent practice association (see Chapter 6). If only one health plan sets up a P4P program with physicians, there may not be enough patients from that health plan to accurately measure the physician's quality; with all health plans participating, a substantial portion of a physician's patient panel is included in the measures. If P4P targets individual physicians rather than larger physician organizations, the small numbers of patients may distort the results. The ability of the California experience to aggregate a large number of patients allows for more accurate performance evaluation.\n\nA P4P program initiated by large employers rather than health plans is Bridges to Excellence. This program involves more than 80 employers, large national health plans, and 3000 physicians in about 15 states. Physicians receive bonus payments for implementing computerized office systems and for improving the care of patients with diabetes, asthma, chronic lung disease, heart disease, back pain, and high blood pressure. Physicians practicing high-quality medicine in these areas receive public recognition and may receive bonuses, with the employers financing the program counting on higher-quality translating into lower costs. Performance is measured only for patients who are employees of the employers participating in the program, a small number for many physicians (www.bridgestoexcellence.org).\n\nIn 2003, Medicare launched a P4P program for 268 hospitals, measuring certain quality indicators for heart attack, heart failure, pneumonia, coronary artery bypass surgery, and hip and knee replacements. High-performing hospitals receive bonuses and the lowest performers may be subject to penalties. Performance on ten measures for heart attack, heart failure, and pneumonia in the P4P hospitals improved more than in control hospitals (Lindenauer, 2007). Another study looked at more than 100,000 heart attack patients treated at P4P and control hospitals; between 2003 and 2006, quality measures for these patients improved equally at P4P and control hospitals (Glickman et al, 2007). From 2003 to 2008, quality scores for participating hospitals improved by 18% (CMS, 2010), which was a 2% to 4% greater improvement than in control hospitals (Mehrotra et al, 2009).\n\nA P4P program described as \"an initiative to improve the quality of primary care that is the boldest such proposal attempted anywhere in the world\" was launched in the United Kingdom in 2004 (Roland, 2004). This program is described in Chapter 14.\n\nSome authors urge caution, pointing out that P4P programs could encourage physicians and hospitals to avoid high-risk patients in order to keep their performance scores up (McMahon et al, 2007). Another difficulty is that many patients see a large number of physicians in a given year, making it impossible to determine which physician should receive a performance bonus (Pham et al, 2007). Moreover, P4P programs could increase disparities in quality by preferentially rewarding physicians and hospitals caring for higher-income patients and having greater resources available to invest in quality improvement, and penalizing those institutions and physicians attending to more vulnerable populations in resource-poor environments (Casalino et al, 2007).\n\n#### **Financially Neutral Clinical Decision Making**\n\nThe quest for quality care encompasses a search for a financial structure that does not reward over- or under-treatment and that separates physicians' personal incomes from their clinical decisions. Balanced incentives (see Chapter 4), combining elements of capitation or salary and fee-for-service, may have the best chance of minimizing the payment\u2013treatment nexus (Robinson, 1999), encouraging physicians to do more of what is truly beneficial for patients while not inducing inappropriate and harmful services. Completely financially neutral decision making will always be an ideal and not a reality.\n\n### **WHERE DOES MALPRACTICE REFORM FIT IN?**\n\n_During a coronary angiogram, emboli traveled to the brain of Ivan Romanov, resulting in a serious stroke, with loss of use of his left arm and leg. The angiogram was appropriate and performed without any technical errors. Mr. Romanov had suffered a medical injury (an injury caused by his medical treatment), but the event was not because of negligence._\n\n_During a dilation and curettage (D &C), Judy Morrison's physician unknowingly perforated her uterus and lacerated her colon. Ms. Morrison reported severe pain but was sent home without further evaluation. She returned 1 hour later to the emergency department with persistent pain and internal bleeding. She required a two-stage surgical repair over the following 4 months. This medical injury was found by the legal system to be because of negligence._\n\nA peculiar set of institutions called the malpractice liability system forms an important part of US health care (Sage and Kersh, 2006). The goals of the malpractice system are twofold: To financially compensate people who in the course of seeking medical care have suffered medical injuries and to prevent physicians and other health care personnel from negligently causing harm to their patients.\n\nThe existing malpractice system scores miserably on both counts. According to the Harvard Medical Practice Study, only 2% of patients who suffer adverse events caused by medical negligence file malpractice claims that would allow them to receive compensation, meaning that the malpractice system fails in its first goal. Moreover, the system does not deal with 98% of negligent acts performed by physicians, making it difficult to attain its second goal. More recent research has confirmed the findings of the Harvard study (Sage and Kersh, 2006).\n\nOn the other hand, as many as 40% of malpractice claims do not involve true medical errors (Studdert et al, 2006), with an even smaller proportion representing actual negligence. Nonetheless, one-quarter of these inappropriate claims result in the patient receiving monetary compensation. Overall, for every dollar in compensation received by patients in malpractice awards, legal costs and fees come to 54 cents (Studdert et al, 2006).\n\nThe malpractice system has serious negative side effects on medical practice (Localio et al, 1991).\n\n1. The system assumes that punishment, which usually involves physicians paying large amounts of money to a malpractice insurer plus enduring the overwhelming stress of a malpractice jury trial, is a reasonable method for improving the quality of medical care. Berwick's analysis of the Theory of Bad Apples suggests that fear of a lawsuit closes physicians' minds to improvement and generates an \"I didn't do it\" response. The entire atmosphere created by malpractice litigation clouds a clear analytic assessment of quality.\n\n2. The system is wasteful, with a huge portion of malpractice insurance premiums spent on lawyers, court costs, and insurance overhead almost as costly as payments to patients (Mello et al, 2010). Many claims have no merit but create enormous waste and wreak an unnecessary stress upon physicians. Patients granted malpractice award payments sometimes experienced no negligent care, and patients subjected to negligent care often receive no malpractice payments (Brennan et al, 1996). Total costs of the malpractice system came to $55.6 billion in 2008, 2.4% of total national health spending (Mello et al, 2010).\n\n3. The system is based on the assumption that trial by jury is the best method of determining whether there has been negligence, a highly questionable assumption.\n\n4. People with lower incomes generally receive smaller awards (because wages lost from a medical injury are lower) and are therefore less attractive to lawyers, who are generally paid as a percentage of the award. Accordingly, low-income patients, who suffer more medical injury, are less likely than wealthier people to file malpractice claims (Burstin et al, 1993b).\n\nIn summary, the malpractice system is burdened with expensive, unfounded litigation that harasses physicians who have done nothing wrong, while failing to discipline or educate most physicians committing actual medical negligence and to compensate most true victims of negligence.\n\n_Mei Tagaloa underwent neurosurgery for compression of his spinal cord by a cervical disk. On awakening from the surgery, Mr. Tagaloa was unable to move his legs or arms at all. After 3 months of rehabilitation, he ended up as a wheelchair-bound paraplegic. He sued the neurosurgeon and his family physician. The physicians' malpractice insurer paid for lawyers to defend them. Mr. Tagaloa's lawyer used the system of contingency fees, whereby he would receive one-third of the settlement if Mr. Tagaloa won the case, but would receive nothing if Mr. Tagaloa lost._\n\n_After 18 months, the case went to trial; the physicians left their practices and sat in the courtroom for 3 weeks. Each physician spent many hours going over records and discussing the case with the lawyers. The family physician, who had nothing to do with the surgery, was so upset with the proceedings that he developed an ulcer. The jury found the family physician innocent and the neurosurgeon guilty of negligence. The family physician lost $8000 in income because of absence from his practice. The neurosurgeon's malpractice insurer paid $900,000 to Mr. Tagaloa, who paid $300,000 to the lawyer._\n\nA number of proposals have been made for malpractice reform (Mello and Gallagher, 2010).\n\n#### **Tort Reform**\n\nMedical malpractice fits into the larger legal field of torts (wrongful acts or injuries done willfully or negligently). The California Medical Injury Compensation Reform Act and the Indiana Medical Malpractice Act are examples of tort reform, placing caps on damages awarded to injured parties and limits on lawyers' contingency fees. Tort reform can help physicians by slowing the growth of malpractice insurance premiums. However, caps on awards can be unfair to patients, limiting payments to those with the worst injuries (Mello et al, 2003; Localio, 2010) (Table 10\u20134).\n\n**Table 10\u20134.** Malpractice reform options\n\n#### **Alternative Dispute Resolution**\n\nThese programs would substitute mediation, arbitration, or private negotiated settlements for jury trials in the case of medical injury. Alternatives to the jury trial could bring more compensation to injured parties by reducing legal costs and might shift the dispute settlement to a more scientific, less emotional theater.\n\n#### **No-Fault Malpractice Reform**\n\nProposals have been made to switch compensation for medical injury from the tort system to a no-fault plan (Studdert and Brennan, 2001; Localio, 2010). Under no-fault malpractice, patients suffering medical injury would receive compensation whether or not the injury was caused by negligence. Without costly lawyers' fees and jury trials, overhead costs would drop from more than 50% to approximately 20%. A no-fault system would compensate far more people and would cost approximately the same as the current tort system (Johnson et al, 1992). In addition, the no-fault approach might allow physicians to be more inclined to identify and openly discuss medical errors for the purpose of correcting them (Studdert et al, 2004).\n\n#### **Enterprise Liability**\n\nA relatively new idea for malpractice reform is to make health care institutions\u2014primarily hospitals and HMOs\u2014responsible for compensating medical injuries (Studdert et al, 2004; Sage and Kersh, 2006; Chan, 2010). As with no-fault proposals, patients suffering medical injury would be compensated whether or not the injury is negligent. Enterprise liability improves upon the no-fault concept by making institutions pay higher insurance premiums if they are the site of more medical injuries (whether caused by system failure or physician error). Hospitals and HMOs would have a financial incentive to improve the quality of care.\n\n### **CONCLUSION**\n\nEach year people in the United States make more than 1 billion visits to physicians' offices and spend more than 100 million days in acute care hospitals. While quality of care provided during most of these encounters is excellent, the goal of the health care system should be to deliver high-quality care every day to every patient. This goal presents an unending challenge to each health caregiver and health care institution. Physicians make hundreds of decisions each day, including which questions to ask in the patient history, which parts of the body to examine in the physical examination, which laboratory tests and x-rays to order and how urgently, which diagnoses to entertain, which treatments to offer, when to have the patient return for follow-up, and whether other physicians need to be consulted. Nurse practitioners, physician assistants, nurses, and other caregivers face similar numbers of decisions. It is humanly impossible to make all of these decisions correctly every day. For health care to be of high quality, mistakes should be minimized, mistakes with serious consequences should be avoided, and systems should be in place that reduce, detect, and correct errors to the greatest extent possible. Even when all decisions are technically accurate, if caregivers are insensitive or fail to provide the patient with a full range of informed choices, quality is impaired.\n\nFor the clinician, each decision that influences quality of care may be simple, but the sum total of all decisions of all caregivers impacting on a patient's illness makes the achievement of high-quality care elusive. To safeguard quality of care, our nation needs laws and regulations, including standards for health care professional education, rules for licensure, boards with the authority to discipline clear violators, and measurement to inform institutions, practitioners, and patients about the quality of their care. Improvement of health care quality cannot solely rely on regulators in Washington, DC, in state capitals, or across town; it must come from within each institution, whether a huge academic center, a community hospital, or a small medical office.\n\n### **REFERENCES**\n\nAbramson J, Starfield B. 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Claims, errors, and compensation payments in medical malpractice litigation. _N Engl J Med._ 2006;354:2024.\n\nUS Senate. Hearings Before the Permanent Subcommittee on Investigations, Committee on Government Operations, March 13 and 14, 1975. Prepaid Health Plans. US Government Printing Office; 1975.\n\nVargas RB et al. Can a chronic care model collaborative reduce heart disease risk in patients with diabetes? _J Gen Intern Med._ 2007;22:215.\n\nWachter RM. Why diagnostic errors don't get any respect\u2014and what can be done about them. _Health Aff (Millwood)_. 2010;29:1605.\n\nWachter RM, Pronovost PJ. The 100,000 Lives Campaign: A scientific and policy review. _Jt Comm J Qual Patient Saf_. 2006;32:621.\n\nWeeks WB et al. Higher health care quality and bigger savings found at large multispecialty medical groups. _Health Aff (Millwood)_. 2009;29:991.\n\nZahn C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. _JAMA._ 2003;290:1868.\n\nZhang Y et al. Geographic variation in the quality of prescribing. _N Engl J Med_. 2010;363:1985.\n\n## **11 Prevention of Illness**\n\n### **WHAT IS PREVENTION?**\n\n_In 2009, the United States spent_ $ _2.5 trillion on health care. Only 3% of this total was dedicated to government public health activities designed to prevent illness._\n\nThe renowned medical historian Henry Sigerist, writing in 1941, listed the main items that must be included in a national health program. The first three items were free education, including health education, for all; the best possible working and living conditions; and the best possible means of rest and recreation. Medical care rated only fourth on his list (Terris, 1992a). For Sigerist (1941), medical care was\n\n_A system of health institutions and medical personnel, available to all, responsible for the people's health, ready and able to advise and help them in the maintenance of health and in its restoration when prevention has broken down. (Sigerist, 1941)_\n\nMany people working in the fields of medical care and public health believe that \"prevention has broken down\" too often; sometimes because modern science has insufficient knowledge to prevent disease, but more often because society has dedicated insufficient resources and commitment to prevention.\n\n_Primary prevention_ seeks to avert the occurrence of a disease or injury (eg, immunization against polio; taxes on the sale of cigarettes to reduce their affordability, and thereby their use). _Secondary prevention_ refers to early detection of a disease process and intervention to reverse or retard the condition from progressing (eg, Pap smears to screen for premalignant and malignant lesions of the cervix, and mammograms for early detection of breast cancer).\n\nThe promotion of good health and the prevention of illness encompass three distinct levels or strategies (Terris, 1986; Table 11\u20131):\n\n**Table 11\u20131.** Strategies of prevention\n\n1. The first and broadest level includes measures to address the fundamental social determinants of illness; as evidence presented in Chapter 3 shows, lower income is associated with higher morbidity and mortality rates. Improvement in the standard of living and social equity (eg, through job creation programs to reduce or eliminate unemployment) may have a greater impact on preventing disease than specific public health programs or medical care services.\n\n2. The second level of prevention involves public health interventions to reduce the incidence of illness in the population as a whole. Examples are water purification systems, the banning of cigarette smoking in the workplace, and public health education on human immunodeficiency virus (HIV) prevention in the schools. These strategies generally consist of primary prevention. The 3% figure cited in the opening paragraph represents these public health activities.\n\n3. The third level of prevention involves individual health care providers performing preventive interventions for individual patients; these activities can be either primary or secondary prevention. The US Preventive Services Task Force and other organizations have established regular schedules for preventive medical care services (US Preventive Services Task Force, 2010).\n\n### **THE FIRST EPIDEMIOLOGIC REVOLUTION**\n\nUntil modern times, the conditions that produced the greatest amount of illness and death in the population were infectious diseases. The initial decline of infectious disease mortality rates took place even before the cause of these illnesses was understood. In the eighteenth and nineteenth centuries, food production increased markedly throughout the Western world. By the early nineteenth century, infectious disease mortality rates were dropping in England, Wales, and Scandinavia, probably as a result of improved nutrition that allowed individuals, particularly children, to resist infectious agents. Thus, the initial success of illness prevention took place through the improvement of overall living conditions rather than from specific public health or medical interventions (McKeown, 1990).\n\nIn the nineteenth century, scientists and public health practitioners discovered many of the agents causing infectious diseases. By comprehending the causes (such as bacteria and viruses) and the risk factors (eg, poverty, overcrowding, poor nutrition, and contaminated water) associated with these illnesses, public health measures (such as water purification, sewage disposal, and pasteurization of milk) were implemented that drastically reduced their incidence. This was the first epidemiologic revolution (Terris, 1985).\n\nFrom 1870 to 1930, the death rate from infectious diseases fell rapidly. Medical interventions, whether immunizations or treatment with antibiotics, were introduced only after much of the decline in infectious disease mortality had taken place. The first effective treatment against tuberculosis, the antibiotic streptomycin, was developed in 1947, but its contribution to the decrease in the tuberculosis death rate since the early nineteenth century has been estimated to be a mere 3%. For whooping cough, measles, scarlet fever, bronchitis, and pneumonia, mortality rates had fallen to similarly low levels before immunization or antibiotic therapy became available. Pasteurization and water purification were probably the main reason for the decline in infant mortality rates (McKeown, 1990).\n\nSome illnesses are exceptions to the rule that infectious disease mortality is influenced more by improved living standards and public health measures than by medical interventions. Immunization for smallpox, polio, and tetanus and antimicrobial therapy for syphilis had a substantial impact on mortality rates from those illnesses. Considering infectious diseases as a group, however, medical measures probably account for less than 5% of the decrease in mortality rates for these conditions over the past century (McKinlay et al, 1989; McKeown, 1990).\n\nAs infectious diseases waned in importance during the first half of the twentieth century and as life expectancy increased, rates of noninfectious chronic illness grew rapidly. Eleven major infectious diseases accounted for 40% of total deaths in the United States in 1900, but less than 10% in 1980. In contrast, heart disease, cancer, and stroke (cerebrovascular disease) caused 16% of total deaths in 1900 but 64% by 1980 (McKinlay et al, 1989).\n\n### **THE SECOND EPIDEMIOLOGIC REVOLUTION**\n\nFifty years ago, epidemiologists did not understand the causes of noninfectious chronic diseases.\n\n_Unable to prevent the occurrence of these diseases, we retreated to a second line of defense, namely, early detection and treatment\u2014so-called secondary prevention. But secondary prevention has\u2014with few exceptions\u2014proved disappointing; it cannot compare in effectiveness with measures for primary prevention. The periodic physical examination, the cancer detection center, multiphasic screening, and ahost of variations on these themes have incurred enormous expenditures for relatively modest benefits... Major exceptions are cancer of the cervix, for which early detection has proved dramatically effective, and, to a lesser extent, cancer of the breast._\n\n_Beginning in 1950, dramatic breakthroughs occurred in the epidemiology of the noninfectious diseases. During the next three decades, our epidemiologists forged powerful weapons to combat most of the major causes of death. In doing so, they initiated a second epidemiologic revolution, which, if we act appropriately, will result in an enormous reduction in premature death and disability. (Terris, 1992b)_\n\nDuring the second epidemiologic revolution, it was learned that the major illnesses in the United States have a few central causes and are in large part preventable. In 2007, 2.4 million people died in the United States (Table 11\u20132). A surprisingly small number of risk factors are implicated in 37% of these deaths. It has been estimated that use of tobacco causes 435,000 fatalities, a high-fat diet and inactivity contributes to 365,000 more, and alcohol is responsible for 85,000 deaths annually in the United States (Heron et al, 2009; Xu et al, 2010). By discovering and educating the population about the risk factors of smoking, rich diet, and lack of exercise, the second epidemiologic revolution has already been very successful. From 1980 to 2006, age-adjusted mortality rates for coronary heart disease (CHD) declined by an astonishing 61%. This decline was associated with reduced rates of tobacco use and lowered mean serum cholesterol levels in the population. As with infectious diseases a century earlier, this decline was in substantial part related to public health interventions regarding smoking and diet (US Department of Health and Human Services, 2009). The unfortunate side of this success story is that those in the poorest socioeconomic position and the least education have considerably higher mortality rates than those with higher socioeconomic status (Loucks, 2009).\n\n**Table 11\u20132.** Causes of death in the United States, 2007 _a_\n\n### **INDIVIDUAL OR POPULATION?**\n\nChronic disease prevention may be viewed from two distinct perspectives: that of the individual and that of the population (Rose, 1985). The medical model seeks to identify high-risk individuals and offer them individual protection, often by counseling on such topics as smoking cessation and low-fat diet. The public health approach seeks to reduce disease in the population as a whole, using such methods as mass education campaigns to counter drinking and driving, the taxation of tobacco to drive up its price, and the labeling of foods to indicate fat and cholesterol content. Both approaches have merits but the medical model suffers from some drawbacks.\n\nThe individual-centered approach of the medical model may produce tunnel vision regarding the causation, and thus the prevention, of disease. Let us take the example of cholesterol.\n\nAncel Keys (1970) performed a famous study comparing CHD in different nations. In east Finland, CHD was common, 20% of diet calories came from saturated fat, and 56% of men aged 40 to 59 years had cholesterol levels greater than 250 mg\/dL. In Japan, CHD was rare, 3% of calories were provided by saturated fat, and only 7% of men aged 40 to 59 years had cholesterol levels above 250 mg\/dL. If we compared two individuals in east Finland who eat the same diet, one with a cholesterol level of 200 mg\/dL and the other with a level of 300 mg\/dL, we might conclude that the variation in cholesterol levels among individuals is caused by genetic or other factors, but not diet. If, on the other hand, we remove our individual blinders and look at entire populations, studying the average cholesterol level and the percentage of fat in the diet in east Finland and in Japan, we will conclude that high-fat diets correlate with high levels of cholesterol and with high rates of CHD.\n\nIndividual variations within each country are often of less importance than variations between one nation and another. The clues to the causes of diseases \"must be sought from differences between populations or from changes within populations over time\" (Rose, 1985).\n\nThe medical model may also target its interventions to the wrong individuals. Let us continue with the cholesterol example. In the United States, most people with high cholesterol levels remain healthy for years, and some people with low levels have heart attacks at an early age. Why is this so? Because the risk of CHD for persons with high cholesterol levels or low cholesterol levels is not so different; even for the low-risk individual, CHD is the most likely cause of death. Everyone in the United States is at risk for this disease. A \"low\" cholesterol level of 180 mg\/dL is low by US standards, but high when compared with levels in poor nations. A large number of people at small risk for a disease may give rise to more cases of the disease than the smaller number of people who are at high risk (Brown et al, 1992). This fact limits the utility of the medical model's \"high-risk\" approach to prevention. A public health approach (eg, mass educational campaigns on the health effects of rich diets and the labeling of foods) strives to reduce the mean population cholesterol level. A 10% reduction in the serum cholesterol distribution of the entire population would do far more to reduce the incidence of heart disease than a 30% reduction in the cholesterol levels of those relatively few individuals with counts greater than 300 mg\/dL.\n\nA coherent ideology underlies the medical model of chronic disease prevention\u2014the concept that in the arena of noninfectious chronic disease, individuals play a major role in causing their own illnesses by such behaviors as smoking, drinking alcohol, and eating high-fat foods. The corollary to this view is that chronic disease mortality rates can be reduced by persuading individuals to change their lifestyles. These statements are true, but they do not tell the whole story.\n\nAn alternative ideology, which fits more closely with the public health approach to chronic disease prevention, argues that modern industrial society, rather than the individuals living in that society, creates the conditions leading to heart disease, cancer, stroke, and other major chronic diseases of the developed world. Tobacco advertising; processed high-fat, high-salt foods in \"supersized\" portions; easy availability of alcoholic beverages; societal stress; an urbanized and suburbanized existence that substitutes automobile travel for exercise; and a markedly unequal distribution of wealth are the substrates upon which the modern epidemic of chronic disease has flourished. Such a worldview leads to an emphasis on societal rather than individual strategies for chronic disease prevention (Fee and Krieger, 1993).\n\nBoth the medical and the public health models (seeing responsibility as both individual and societal) must be joined to further implement the second epidemio-logic revolution; medical caregivers must attempt to change high-risk lifestyles of their individual patients, and society must search for ways to reduce the consumption of tobacco, alcohol, and rich foods. One model that bridges the medical and public health approaches is community-oriented primary care. In this model, primary care clinicians systematically define a target population, determine its health needs, and develop community-based interventions to address these needs (Nutting, 1990). The target population could be as simple as the patients enrolled in a primary care practice, or more ambitiously, an entire neighborhood. For example, a pediatrician might review data on her enrolled patients and find that many children are obese. In addition to counseling individual families in her practice, in the Community Oriented Primary Care model the pediatrician would also work with community members and agencies on broader public health interventions, such as advocating for improved school lunch programs and more time for physical education classes in the local schools, or encouraging the local health department to launch a media campaign promoting consumption of water instead of sweetened beverages.\n\n### **MODELS OF PREVENTION**\n\nTo provide examples of different approaches to preventing illness, we have chosen to discuss two serious health problems in the United States: coronary heart disease and breast cancer.\n\n#### **Coronary Heart Disease**\n\nCoronary heart disease (CHD) is associated with four major risk factors: the eating of a rich diet (the principal cause of the CHD epidemic), elevated levels of serum cholesterol, cigarette smoking, and hypertension (Stamler, 1992a).\n\nPrimary prevention strategies are available for CHD because the causes of the disease are well understood. Primary CHD prevention involves risk factor reduction, including cessation of cigarette smoking, replacement of rich diets by low-fat diets, and control of hypertension. These strategies have been largely responsible for the large decrease in CHD death rates (Figure 11\u20131).\n\n**Figure 11\u20131.** Trends in age-adjusted mortality from coronary heart disease in the United States, 1980\u20132006.\n\n#### **Cigarette Smoking**\n\nTobacco has been called the smallpox virus of chronic disease\u2014a harmful agent whose elimination from the planet would benefit humankind (Fee and Krieger, 1993). Since the 1964 release of the first Surgeon General's Report on the Health Consequences of Smoking, the smoking behavior of the US population has changed dramatically. Between 1965 and 2007, the age-adjusted percentage of adult men who were current smokers dropped from 51% to 22%; for adult women, the decline was from 34% to 18% (Figure 11\u20132). These reductions in smoking prevalence avoided an estimated 3 million deaths between 1964 and 2000\u2014a major public health achievement (Warner, 1989). However, rates of smoking are far higher among people with lower educational levels and smoking continues to be the leading cause of death in the United States (US Department of Health and Human Services, 2009).\n\n**Figure 11\u20132.** Cigarette smoking by persons 18 years and older in the United States in 1965 (light blue bars) and 2007 (dark blue bars). Percentages are age adjusted. (US Department of Health and Human Services. _Health United States_. 2009.)\n\nAntismoking campaigns have been relatively successful for well-educated people, but less so for people with less education, who also tend to be poorer. Between 1974 and 2007, cigarette smoking declined 38% among the least educated persons, while it dropped 67% among the most educated. In 2006, 30% of the least educated persons smoked cigarettes, compared with only 9% of the most educated (US Department of Health and Human Services, 2009).\n\nSince the 1969 ban on radio and television cigarette advertising, the tobacco industry has increased its advertising expenditures dramatically in the print media and through sponsorship of community events. In 2005, tobacco advertising expenditures exceeded $13 billion, almost double the 1999 figure (Bayer et al, 2002; Cokkinides et al, 2009). Tobacco industry documents prove that the principal target group for cigarette advertising is young adults (Ling and Glantz, 2002). The antismoking campaign of the past 30 years has merged the medical and public health models of prevention. Physician counseling can influence smokers to quit. In 2006, however, only 34% of low-income smokers had smoking cessation discussions with their health care provider (Cokkinides et al, 2009) and relapse rates for those who quit after receiving active treatment are 77% at 12 months (Mannino, 2009). Public health measures are more effective, including public education, cigarette taxes, and restriction of smoking in public places. A 10% increase in the price of cigarettes reduces cigarette consumption by 3% to 5%. Yet compared with other developed nations, the United States has relatively low taxes on tobacco (Cokkinides et al, 2009; Schroeder and Warner, 2010).\n\n#### **Rich Diet**\n\nA rich diet is a diet high in fat, saturated fat, cholesterol, salt, and often alcohol, and one with a high caloric intake in relation to the amount of energy expended (Stamler, 1992a). The rich diet produces CHD primarily by causing an increase in low-density-lipoprotein cholesterol. Lowering cholesterol levels has been shown to reduce the risk of heart attacks caused by CHD.\n\nIn the late 1980s, a major national campaign was launched by the National Institutes of Health (NIH) to reduce serum cholesterol levels. This National Cholesterol Education Program is based on the medical model, with health care providers screening individuals for elevated cholesterol and aggressively treating hyperlipidemic patients with diet, cholesterol-lowering medications, or both (Grundy et al, 2004).\n\nPublic health analysts have criticized the NIH strategy as relying too heavily on a medical model of prevention that is expensive and of potentially limited effectiveness. The NIH approach targets more than 100 million people who need dietary changes and recommends drug treatment for many of these individuals.\n\nThe use of statin drugs to treat hyperlipidemia in people with known CHD (secondary prevention) and without CHD (primary prevention) has been shown to reduce deaths from CHD and deaths from all causes (Steinberg and Gotto, 1999). However, the effectiveness of drug treatment is far greater if it is used in secondary rather than primary prevention (Hayward et al, 2010). For primary prevention, 53 patients would have to take a statin drug for 5 years to prevent one patient from experiencing a fatal or nonfatal coronary event. For secondary prevention (patients with known CHD), statin drugs can prevent approximately one nonfatal myocardial infarction or death for every 10 patients treated, at a far lower cost for every year of life saved (Pharoah and Hollingworth, 1996; Lloyd-Jones, 2001).\n\nThe NIH cholesterol reduction strategy highlights the paradox of primary prevention: Prevention within a population of healthy individuals may be better (and less expensively) served by broad public health efforts to reduce risk among the majority of people at moderate risk than by concentrating intensive medical interventions on the smaller number of high-risk persons (Rose, 1985). The traditional orientation of physicians toward individual patients (the medical model) has led the medical profession and the NIH to emphasize identification and treatment of high-risk individuals with elevated cholesterol levels. Pharmaceutical manufacturers also have an interest in promoting a medical model of prevention that relies on prescribing medications. Reducing the mean cholesterol level of the US population rather than reducing the individual cholesterol counts of hyperlipidemic patients may have better long-term results for primary prevention.\n\nCurrently, public health efforts to curb the consumption of rich foods are failing; 74% of adults in the United States were classified as overweight or obese in 2008, compared with 46% in the early 1960s (Ogden and Carroll, 2010). The food industry spends billions of dollars on advertising, a substantial portion of which promotes high-fat fast foods. Proposals have been made to copy the strategy used by tobacco prevention campaigns in reducing the availability of high-fat foods; for example, taxing unhealthy foods, changing school lunch programs to reduce their fat content, restricting food advertising directed at children, and eliminating school-based candy and soft-drink vending machines are primary preventive measures that are gaining public acceptance (Frieden et al, 2010). Growing attention is also being paid to the billions of dollars annually in federal government subsidies to agribusinesses for growing corn, which has contributed to the flooding of the nation with low-cost, high fructose corn sweeteners and other high-calorie processed foods. Public health advocates have called for reforms to the federal farm bill to reduce subsidies for obesogenic foods and to provide more support for sustainable farming of healthful fruits and vegetables (Pollan, 2007; Wallinga, 2010).\n\n#### **Hypertension**\n\nRisk factors for hypertension include high salt intake, low potassium intake, high ratio of dietary sodium to potassium, obesity, and excess alcohol intake; other important risk factors likely exist. Prior to the advent of modern agriculture, intake of sodium was low and intake of potassium high, and high levels of physical exertion prevented persons from being overweight.\n\nCHD risk is associated with increased blood pressure, even at relatively moderate levels of blood pressure elevation. Individuals with systolic blood pressures of 130 to 140 mm Hg have almost twice the cardiovascular risk of those with systolic blood pressures less than 110 mm Hg. One quarter of hypertension-related cardiovascular deaths take place among borderline hypertensives, and in the United States, 90% of men aged 35 to 57 years have blood pressure levels that create excess cardiovascular risk. Thus, it can be said that high blood pressure as a risk factor for CHD is a problem for the entire population and not simply a problem for the 20% to 25% of the population with frank hypertension. Similarly to the cholesterol situation, the greatest impact in reducing hypertension-related CHD mortality rates will come from a reduction in the blood pressure of the large number of borderline hypertensives rather than from focusing solely on people with very high blood pressure (Stamler, 1992b).\n\nPrimary prevention of high blood pressure can be accomplished by a reduction in the daily intake of salt by 3 g per person. Currently, the average man in the United States consumes 10.4 g of salt per day, with women eating 7.3 g. Such a change would reduce the number of new CHD cases by 60,000 per year. This public health approach would be as effective as the use of medical treatment to control the blood pressures of the 65 million people in the United States with hyper-tension (Bibbins-Domingo et al, 2010).\n\nPrevention of hypertension has focused on screening and early treatment of elevated blood pressure. These measures are considered secondary prevention (early diagnosis and intervention) with respect to high blood pressure as a disease but are categorized as primary prevention (averting the occurrence) with respect to CHD. American medicine has a poor record in lowering elevated blood pressures; only 50% of hypertensives are adequately controlled (Egan et al, 2010)\n\n#### **Breast Cancer**\n\nWhereas mortality rates for cardiovascular disease declined since the late 1960s, cancer mortality rates continued to increase through 1990. Between 1990 and 2006, cancer mortality rates dropped by 16%, probably as a result of reductions in cigarette smoking. Breast cancer mortality rates have also decreased during those years, but are considerably higher for African American women than for white women (US Department of Health and Human Services, 2009).\n\nThe designing of effective primary prevention for a disease generally depends on an understanding of the epidemiology of that disease. In the case of lung cancer, the discovery of the link with cigarette smoking allowed a widespread primary prevention program to be developed\u2014the antismoking campaign. But the causes of many cancers are still unclear, meaning that preventive strategies must use secondary rather than primary prevention. Pap smears for early detection of cervical cancer, fecal occult blood testing and colonoscopy for early detection of colorectal cancer, and mammography for early detection of breast cancer are examples of secondary prevention.\n\nMultiple risk factors for breast cancer have been uncovered, including age greater than 65 years, a family history of breast cancer, atypical hyperplasia on breast biopsy, birth in North America or northern Europe, and genetic susceptibility related to the BRCA geno-type. Women with more years of ovulatory menstrual cycles have a greater risk, indicating a hormonal influence on the disease (American Cancer Society, 2011).\n\nHowever, only one-fourth of breast cancer cases can be accounted for by these risk factors. The differences between high and low age-adjusted breast cancer risk in the United States are small compared with the differences between such high-incidence nations as the United States and low-incidence (generally underdeveloped) nations. Perhaps unknown agents related to modern industrialization are the primary causes of breast cancer, while such influences as female hormones are secondary promoters of the disease.\n\nThe age-adjusted incidence (new cases) of breast cancer fell sharply in 2003 compared with 2002 and continued to fall slightly through 2006, a phenomenon temporally related to the drop in the use of hormone replacement therapy by women in the United States, occasioned by the widely publicized report from the Women's Health Initiative providing new data on the risks of hormone replacement therapy (Ravdin et al, 2007). This association suggests that estrogen is an important cause or facilitator of breast cancer.\n\nEvidence linking dietary fat to cancer of the breast is inconsistent and weak, and further research is needed on the role of environmental carcinogens (American Cancer Society, 2011). From the 1940s to the 1980s, industrial production of synthetic organic chemicals rose from 1 billion to 400 billion pounds annually, and the volume of hazardous wastes also increased 400-fold during that period (Epstein, 1990, 1994). One study estimated that toxic chemicals encountered at work-places are responsible for 20% of all human cancers (Landrigan, 1992). Estrogens have been used as additives to poultry and cattle feed, and pesticide residues contain estrogen-like compounds that may contribute to breast cancer causation (Davis and Bradlow, 1995). Some studies have linked breast cancer risk to organo-chlorine insecticides, polycyclic aromatic hydrocarbons, and organic solvents, but research on these environmental causes of breast cancer has been inadequate and inconsistent (Brody and Rudel, 2003).\n\nLack of knowledge has forced modern medicine to retreat to secondary prevention (ie, early diagnosis through breast examinations and mammography) to reduce mortality rates in women with the disease. Thankfully, breast cancer, like cervical cancer, lends itself to secondary prevention techniques. Periodic mammograms can reduce breast cancer mortality rates in women aged above 50 years. Yet many breast cancer activists decry the relatively paltry sums going for basic epidemiologic research to determine the causes of breast cancer.\n\n#### **Summary**\n\nThe examples of CHD and breast cancer illustrate different aspects of illness prevention. Primary prevention has been successful in reducing mortality rates for CHD. Both public health and medical approaches have been used, with far greater emphasis given to the latter strategy. Secondary prevention has had some success in reducing breast cancer mortality rates, but the incidence of the disease remains high and primary prevention is badly needed.\n\n### **DOES PREVENTION REDUCE MEDICAL CARE COSTS?**\n\nThe influence of prevention on medical care costs is a complex one. As a rule, primary prevention using public health measures is far more cost-effective than primary prevention through medical care; public health measures do not require many millions of expensive one-to-one interactions with medical care providers.\n\nIn the arena of individual medical care prevention, some measures save money and some do not. Every dollar invested in measles, mumps, and rubella immunizations saves many more dollars in averted medical care costs. Physician counseling on smoking cessation is a low-cost activity that can reduce the multibillion dollar cost of caring for people with tobacco-related illness. These preventive care activities do reduce health care spending in the long run. In contrast, medical care to reduce cholesterol and high blood pressure are unlikely to result in significant savings to the health care system (Cohen et al, 2008).\n\nPrimary prevention through public health action can be enormously effective in reducing the burden of human suffering and the cost of treating disease. From 1900 to 1940, the nation's public health efforts achieved a 97% reduction in the death rate for typhoid fever; 97% for diphtheria; 92% for infectious diarrhea; 91% for measles, scarlet fever, and whooping cough; and 77% for tuberculosis (Winslow, 1944). The imposition of a $2-per-pack increase in the tobacco tax could substantially reduce the $50-plus billion annual cost of tobacco-related disease, while at the same time yielding tens of billions of dollars per year in tax revenues\u2014an ideal preventive measure that actually earns money. If the three primary preventive methods known to reduce the incidence of coronary heart disease, cancer, and stroke (ie, reduction in smoking, cholesterol levels, and blood pressure) were intensified, the medical care costs of these illnesses could be reduced by 50%. These three illnesses account for 20% of personal health care costs in the United States and reducing their incidence could yield a cost savings of billions of dollars per year. However, these savings are overstated because money saved by preventing disease X will ultimately be spent on the treatment of disease Y or Z, which will strike those people spared from disease X.\n\n### **CONCLUSION**\n\nThe goals of disease prevention are to delay disability and death and to maximize illness-free years of life. Improvements in living standards, public health measures, and preventive medical care have made enormous contributions toward the achievement of these goals. Producing further improvements in the overall health of society will likely depend on reducing the growing gap between the rich and the poor and shifting a greater proportion of the health dollar to disease prevention.\n\n### **REFERENCES**\n\nAmerican Cancer Society. What are the risk factors for breast cancer, 2011. www.cancer.org\/cancer\/breastcancer\/detailedguide\/breast-cancer-risk-factors. Accessed November 15, 2011.\n\nBayer R et al. Tobacco advertising in the United States. _JAMA_. 2002;287:2990.\n\nBibbins-Domingo K et al. Projected effect of dietary salt reductions on future cardiovascular disease. _N Engl J Med._ 2010;362:590.\n\nBrody JG, Rudel RA. Environmental pollutants and breast cancer. _Environ Health Perspect_. 2003;111:1007.\n\nBrown EY, Viscoli CM, Horwitz RI. Preventive health strategies and the policy makers? paradox. _Ann Intern Med_. 1992;116:593.\n\nCohen JT et al. Does preventive care save money? _N Engl J Med_. 2008;358:661.\n\nCokkinides V et al. Tobacco control in the United States: recent progress and opportunities. _CA Cancer J Clin_. 2009;59:352.\n\nDavis DL, Bradlow HL. Can environmental estrogens cause breast cancer? _Sci Am_. 1995;273:167.\n\nEgan BM et al. US trends in prevalence, awareness, treatment, and control of hypertension, 1988\u20132008. _JAMA_. 2010;303:2043.\n\nEpstein SS. Losing the war against cancer: Who's to blame and what to do about it. _Int J Health Serv_. 1990;20:53.\n\nEpstein SS. Environmental and occupational pollutants are avoidable causes of breast cancer. _Int J Health Serv_. 1994;24:145.\n\nFee E, Krieger N. Thinking and rethinking AIDS: Implications for health policy. _Int J Health Serv_. 1993;23:323.\n\nFrieden TR et al. Reducing childhood obesity through policy change. _Health Aff (Millwood)_. 2010;29:357.\n\nGrundy SM et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. _Circulation_. 2004;110:227.\n\nHayward RA et al. Optimizing statin treatment for primary prevention of coronary artery disease. _Ann Intern Med_. 2010;152:69.\n\nHeron MP et al. Deaths: Final data for 2006. _Natl Vital Stat Rep_. 2009;57(14):1\u2013134.\n\nKeys A. Coronary heart disease in seven countries. _Circulation_. 1970;41(suppl 1):11.\n\nLandrigan PJ. Commentary: Environmental disease: A preventable epidemic. _Am J Public Health_. 1992;82:941.\n\nLing PM, Glantz SA. Using tobacco industry marketing research to design more effective tobacco control campaigns. _JAMA_. 2002;287:2983.\n\nLloyd-Jones DM et al. Applicability of cholesterol-lowering primary prevention trials to a general population. _Arch Intern Med_. 2001;161:949.\n\nLoucks EB et al. Life-course socioeconomic position and incidence of coronary heart disease. _Am J Epidemiol_ 2009;169:829.\n\nMannino DM. Why won't our patients stop smoking? _Diabetes Care_. 2009;32(suppl 2):S426.\n\nMcKeown T. Determinants of health. In: Lee PR, Estes CL, eds. _The Nation's Health_. Boston, MA: Jones & Bartlett; 1990.\n\nMcKinlay JB et al. A review of the evidence concerning the impact of medical measures on recent mortality and morbidity in the United States. _Int J Health Serv_. 1989;19:181.\n\nNutting PA, ed. _Community Oriented Primary Care: From Principle to Practice_. Albuquerque, NM: University New Mexico Press; 1990.\n\nOgden CL, Carroll MD. Prevalence of overweight, obesity, and extreme obesity among adults: United States, trends 1976\u20131980 through 2007\u20132008. June 2010. www.cdc.gov.\n\nPharoah PD, Hollingworth W. Cost effectiveness of lowering cholesterol concentration with statins in patients with and without pre-existing coronary heart disease. _Br Med J_. 1996;312:1443.\n\nPollan M. You are what you grow. _N Y Times Mag_. April 22, 2007.\n\nRavdin PM et al. The decrease in breast-cancer incidence in 2003 in the United States. _N Engl J Med_. 2007;356:1670.\n\nRose G. Sick individuals and sick populations. _Int J Epidemiol_. 1985;14:32.\n\nSchroeder SA, Warner KE. Don't forget tobacco. _N Engl J Med_. 2010;363;201.\n\nSigerist HE. _Medicine and Human Welfare._ New Haven, CT: Yale University Press; 1941.\n\nStamler J. Established major coronary risk factors. In: Marmot M, Elliott P, eds. _Coronary Heart Disease Epidemiology_. New York: Oxford University Press; 1992a.\n\nStamler R. The primary prevention of hypertension and the population blood pressure problem. In: Marmot M, Elliott P, eds. _Coronary Heart Disease Epidemiology._ New York: Oxford University Press; 1992b.\n\nSteinberg D, Gotto AM. Preventing coronary artery disease by lowering cholesterol levels. _JAMA_. 1999;282:2043.\n\nTerris M. The changing relationships of epidemiology and society: The Robert Cruikshank Lecture. _J Public Health Policy_. 1985;6:15.\n\nTerris M. What is health promotion? _J Public Health Policy_. 1986;7:147.\n\nTerris M. Concepts of health promotion: Dualities in public health theory. _J Public Health Policy_. 1992a;13:267.\n\nTerris M. Healthy lifestyles: The perspective of epidemiology. _J Public Health Policy_. 1992b;13:186.\n\nUS Department of Health and Human Services. Health United States. 2009. www.cdc.gov.\n\nUS Preventive Services Task Force. _Guide to Clinical Preventive Services_. 2010\u20132011. August 2010. www.ahrq.gov.\n\nWallinga D. Agricultural policy and childhood obesity. _Health Aff (Millwood)._ 2010;29:405.\n\nWarner KE. Smoking and health: A 25-year perspective. _Am J Public Health_. 1989;79:141.\n\nWinslow CEA. Who killed Cock Robin? _Am J Public Health_. 1944;34:658.\n\nXu J et al. Deaths: final data for 2007. _Natl Vital Stat Rep_. 2010;59(19):1\u2013135.\n\n## **12 Long-Term Care**\n\n_Eddie Taylor awoke one morning at his home in California unable to speak or to move the right side of his body, but able to understand other people around him. After 3 terrifying days in a hospital and 3 frustrating weeks in a stroke rehabilitation center, Mr. Taylor failed to improve. Because he no longer required hospital-level care, he became ineligible for Medicare hospital coverage. Since Mrs. Taylor was wheelchair-bound with crippling rheumatoid arthritis and unable to care for him, he was transferred to a nursing home. Medicare did not cover the $220 per day cost. After 2 years, Medicaid began to pick up the nursing home bills. Much of the family's life savings\u2014earned during the 50 years Mr. Taylor worked in a men's clothing store\u2014had been spent to allow Medicaid eligibility. Because Medicaid paid only $140 per day, few recreational activities were offered, and Mr. Taylor spent each day lying in bed next to a demented patient, who screamed for hours at a time. Unable to voice his complaints at the inhuman conditions of his life, he became severely depressed, stopped eating, and within 3 months was dead._\n\n_On high school graduation night, Lyle celebrated with a few drinks and drove to his girlfriend's house. He lost control of the car, hit a tree, and suffered a fractured cervical spine, unable to move his arms or legs. After 9 months in a rehabilitation unit, Lyle remained quadriplegic. He returned home, with a home care agency providing total 24-hour-a-day care at a cost of $300 per day, not covered by insurance. Lyle's father, a businessman, became increasingly angry at his wife, the principal flutist in the city's professional orchestra, because she refused to leave the orchestra to care for Lyle. After 1 year and $110,000 in long-term care expenses, Lyle's parents were close to divorce. One night Lyle's father awoke in a cold sweat; in his dream, he had placed a plastic bag over Lyle's head and suffocated him._\n\nTime and again physicians and other caregivers witness the tragedy of chronic illness compounded by the failure of the nation's health care system to meet the social needs created by the illness. The crisis of long-term care is twofold: Thousands of families each year lose their savings to pay for the chronic illness of a family member, and long-term care often takes place in dehumanizing institutions that rob their occupants of their last remaining vestiges of independence.\n\nLong-term care includes those health, social, housing, transportation, and other supportive services needed by persons with physical, mental, or cognitive limitations sufficient to compromise independent living. The need for long-term care services is usually determined by evaluating a person's impairment of activities of daily living (ADLs; eg, eating, dressing, bathing, toileting, and getting in or out of bed or a chair) and in instrumental activities of daily living (IADLs; eg, laundry, housework, meal preparation, grocery shopping, transportation, financial management, taking medications, and telephoning) (Table 12\u20131). Twelve million people in the United States require assistance with one or more ADLs or IADLs, and can therefore be considered as needing long-term care services (Kaye et al, 2010).\n\n**Table 12\u20131.** Activities requiring assistance in long-term care\n\nProjections of growth for the elderly population in the United States are startling. In 2000, the population 65 years of age and older numbered 35 million; this figure is expected to reach 72 million by the year 2030. The number of people 85 years and older will more than double from 4.2 million in 2000 to 8.7 million in 2030. Those 80 years and older are most likely to need long-term care because 56% have severe disability (Administration on Aging, 2010). As more and more people need long-term care, the answers to two questions become increasingly urgent: How shall the nation finance long-term care? Should most long-term care be delivered through institutions or in people's homes and communities?\n\n### **WHO PAYS FOR LONG-TERM CARE?**\n\n_Phoebe McKinnon was in good health until she fell, broke her hip, and suffered a postoperative joint infection. She was placed on complete bed rest with oral antibiotics for 3 months, after which time she would have another surgery. Widowed, Ms. McKinnon lived alone; her only daughter lived 1500 miles away. Because Ms. McKinnon required 24-hour-a-day help, the social worker, after carefully researching the financial options, reluctantly suggested that Ms. McKinnon spend the 3 months in a nursing home. Ms. McKinnon and her daughter agreed but were shocked when the social worker explained that the cost would be $220 a day, for a total bill of $19,800._\n\nThe United States spent $205 billion on long-term care in 2009, including $137 billion on nursing home care (Martin et al, 2011). In 2006, a 1-year nursing home stay cost an average of $76,000.\n\nIn 2009, direct out-of-pocket payments by patients and their families financed 22% of long-term care services in the United States. A common scenario is that of Eddie Taylor: After a portion of their life savings are spent for long-term care, families finally become eligible for Medicaid long-term care coverage. Medicaid pays for 34% of US long-term care expenditures (Table 12\u20132). Many people expect the Medicare program to pay for nursing home stays, and like Phoebe McKinnon and her daughter, are surprised and shocked when they find that Medicare will not assist them. Only 28% of long-term care costs are financed by Medicare (Martin et al, 2011).\n\n**Table 12\u20132.** Long-term care financing, 2009 _a_\n\nAverage out-of-pocket expenses for health care paid by the Medicare beneficiaries amounted to 20% of family income in 2005. One-fifth of these expenses went to nursing homes (Kaiser Family Foundation, 2009).\n\nWhat are the precise roles of Medicare, Medicaid, and private insurance in the financing of long-term care services?\n\n#### **Medicare Long-Term Coverage**\n\n_Glenn Whitehorse, who was a diabetic, developed gangrene of his right leg requiring above-the-knee amputation. He was transferred from the acute care hospital to the hospital's skilled nursing facility, where he received physical therapy services. Because he was generally frail, he was unable to move from bed to chair without assistance. Mr. Whitehorse's physical and occupational therapists felt he might do better at home, where he could receive home physical therapy and nursing care. All these services were covered by Medicare._\n\n_Mrs. Whitehorse had Parkinson's disease and was unable to assist her husband in bathing, getting out of bed, and going to the bathroom; she was forced to hire someone to assist with these custodial functions, which were not covered by Medicare. When Mr. Whitehorse no longer showed any potential for improvement, Medicare discontinued coverage of his home health services. The situation became too difficult, and he was placed in a nursing home for custodial care. Medicare did not cover the nursing home costs._\n\nWhich services provided in a nursing facility or at home are covered by Medicare? The key distinction is between \"skilled care,\" for which Medicare pays, and \"custodial care,\" which is usually not covered. A related issue is that of postacute versus chronic care. Medicare usually covers services needed for a few weeks or months after an acute hospitalization but often does not pay for care required by a stable chronic condition.\n\nWhat are some examples of skilled care versus custodial services? Registered nurses in a hospital nursing facility, nursing home, or home care agency provide a wide variety of services, such as changing the dressing on a wound, taking blood pressures, listening to the heart and lungs to detect heart failure or pneumonia, reviewing patient compliance with medications, and providing patient education about diabetes, hypertension, heart failure, and other illnesses. Physical and occupational therapists work with stroke, hip fracture, and other patients to help them reach their maximum potential level of functioning. Speech therapists perform the difficult task of teaching stroke patients with speech deficits how to communicate. These are all skilled services, usually covered by Medicare.\n\nCustodial services involve assistance with ADLs and IADLs rather than treatment or rehabilitative care related to a disease process; these are tasks such as cooking, cleaning house, shopping, or helping a patient to the toilet. These services, usually provided by nurses' aides, home health aides, homemakers, or family members, are considered unskilled and are often not covered by Medicare.\n\n#### **Medicaid Long-Term Coverage**\n\n_Willie Robinson, who lived alone, suffered from deforming degenerative arthritis and was unable to do anything more active than sitting in a chair. Because Mr. Robinson had no skilled care medical needs, Medicare would not provide any assistance. Medicaid and the county welfare agency paid for a homemaker to provide 20 hours of help per week, but that was not sufficient. Mr. Robinson had no choice but to enter a nursing home, because that was the only way he could obtain 24-hour-a-day help paid for by Medicaid._\n\nMedicaid differs from Medicare in paying the costs of nursing home care. For home health care, however, Medicaid generally does not cover 24-hour-a-day custodial services for people unable to care for themselves. The completeness of Medicaid's nursing home coverage, in contrast to the limited nature of Medicaid-financed home health care, forces many low-income disabled people like Willie Robinson to go into nursing homes unless they have families capable of providing 24-hour-a-day custodial care. In order to qualify for Medicaid nursing home coverage, families may be forced to spend their savings down to low levels, although in some states, Medicaid allows spouses of nursing home residents to keep some of their assets.\n\nMedicaid's coverage of home health services has increased as a result of home- and community-based care 1915(c) waivers, initially authorized in 1981 (Ng et al, 2010). This program, which attempts to prevent nursing home admissions, allows Medicaid recipients to receive more home care services than previously. Whereas Oregon allocated 71% of its long-term care Medicaid dollars to this program in 2005, nationally Medicaid spent 35% of long-term care dollars for home and community-based care (Kaiser Family Foundation, 2006a).\n\n#### **Private Long-Term Care Insurance**\n\n_Sue and Lew MacPherson, both age 72, were worried about their future. They remembered their cousin, who was turned down for private long-term care insurance because of his high blood pressure and later spent his entire savings on nursing home bills. Hoping to protect their $32,000 in savings, they decided to apply for long-term care insurance before an illness would make them uninsurable. Their insurance agent calculated the cost of two policies at $6000 per year, or 30% of their $20,000 per year income. At that price, Sue and Lew would spend most of their savings on insurance premiums within a few years. They declined the insurance._\n\nPrivate insurance plays a minor role in long-term care financing, with only 8% of long-term care costs covered by private policies (Table 12\u20132). Experience rating (see Chapter 2) has had a profound effect on the dynamics of private long-term care insurance. The largest market for this type of insurance is the elderly population. Under experience-rated insurance, the elderly are charged high premiums because they are at considerable risk of requiring long-term care services. The 2009 median income of people over 65 is $31,000 (US Census Bureau, 2010). Only 17% of households with the head of the household aged 70 to 74 years could afford the average long-term care insurance policy (Kaiser Family Foundation, 2006b). The major attractive market for long-term care insurers is the younger employed population, but only a tiny fraction of this group is interested in long-term care insurance because the prospects of needing such care are so remote.\n\nPeople purchasing long-term care insurance may find it to be a poor investment. Some private policies specify that a policyholder must be dependent in three or more ADLs before receiving benefits for home health services. Yet many people with fewer than three ADL impairments need long-term care services; for these people, their insurance may pay nothing.\n\nLong-term care policies usually have a large deductible (measured in nursing home days) for nursing home care, and most policies pay a fixed daily fee rather than reimbursing actual charges. A typical policy might provide $150 per day after a 90-day deductible. The 2006 average daily nursing home charge was $220, meaning that $70 would be the patient's responsibility. Thus a year's stay would require out-of-pocket expenditures totaling   over and above payment of the insurance premium. Most policies limit their coverage to a few years, which places a cap on how much the insurance will pay.\n\n### **WHO PROVIDES LONG-TERM CARE?**\n\n#### **Informal Caregivers**\n\n_Since her husband died, Mrs. Dora Whitney has lived alone. At age 71, she became forgetful and one day left the gas stove on, causing a fire in the kitchen. Two months later, she was unable to find her way home after going to the store and was found by the police wandering in the streets. Her daughter, Kimberly, brought her to the university hospital, where she was diagnosed with Alzheimer's dementia. After a team conference with her mother's physicians, nurses, occupational therapist, and social worker, Kimberly admitted that her only option was to abandon her career as a teacher to care for her mother. Kimberly refused to place her mother in a nursing home, and funds were not available to hire the needed 24-hour-a-day help._\n\nMost people needing long-term care services receive them from their family and friends. In 2007, about 52 million people served as unpaid family caregivers, of whom the majority were women. For men, their wives often provide long-term care, and for women, their daughters are frequently caregivers. A growing number of the elderly do not have family living near enough to them to provide informal care; the absence of an informal caregiver is a common reason for nursing home placement. On average, informal caregivers provide 20 hours per week of care, and the estimated economic value of their unpaid contributions was approximately $375 billion in 2007. Thirty-seven percent of informal caregivers to persons age 50 and older reported quitting their job or reducing their work hours in order to assist their family members. Elderly people with care-givers have shorter hospital stays, fewer readmissions, and lower inpatient expenses, demonstrating that unpaid caregivers create a great deal of value for the health care system (Levine, 1999; AARP, 2008).\n\n#### **Community-Based and Home Health Services**\n\n_Ana Dominguez insisted that her daughter Juana accept the Yale scholarship. Though at age 49 Ms. Dominguez was bed- and wheelchair-bound with multiple sclerosis, she would feel too guilty if Juana remained in San Antonio, TX, just to care for her. Before Juana left, she arranged with the home care agency to have her mother transported to an adult day health center 3 days a week; for nursing, physical, and occupational therapy 3 times a week; and for meals-on-wheels. Medicare paid for these services. But Ms. Dominguez needed someone at home 24 hours a day, a service not covered by Medicare. For $15 a day, Juana was able to hire Vilma, an undocumented teenager from El Salvador, to live at home. Adding Vilma's pay and the cost of her food, Juana figured they would spend $35,000 of their $42,000 in savings by the time she graduated from Yale._\n\nCommunity-based long-term care is delivered through a variety of programs, such as home care, adult day care, assisted living settings, home-delivered meals, board and care homes, hospice care for the terminally ill, mental health programs, and others. During the 1970s, the independent living movement among disabled people created a strong push away from institutional (hospital and nursing home) care toward community-based and home care that fostered the greatest possible independence. During the 1980s, AIDS activists furthered the development of hospice programs that provide intensive home care services for people with terminal cancer and AIDS. The home is usually a more therapeutic, comforting environment than the hospital or nursing home.\n\nAs a product of the intersection of the popular movement toward home care and the DRG-created incentive to reduce Medicare hospital stays, home health services expanded rapidly from 1980 to 1997. This, in turn, prompted changes in Medicare payment policies to rein in home care expenditures. After concerns were voiced about excessive cuts in Medicare home care payments, in 2000 Medicare instituted a prospective payment system for home care based on the episode-of-illness model (see Chapter 4). Home care agencies are paid a lump sum (which, like DRG hospital payments varies with the severity of the illness) for 60 days of care.\n\nMany categories of health caregivers function in teams to perform home care, including nurses, physical, occupational, speech, and respiratory therapists, social workers, home health aides, case managers, and drivers delivering meals-on-wheels. Yet home care, designed to help fill the once low-tech niche in the health care system that assists the disabled with ADLs and IADLs, has become increasingly specialized. Home care agencies now offer intravenous antibiotic infusions, morphine pumps, indwelling central venous lines, and home renal dialysis, administered by highly skilled intravenous and wound care nurses, respiratory therapists, and other health care professionals. These developments are a major advance in shifting medical care from hospital to home, but they have not been matched by growth in the paid personal custodial care needed to allow disabled people to remain safely in their homes. Similarly, hospice care, while providing excellent nursing services for patients with terminal illnesses, is limited in the ADL support it provides. Hospice programs may not accept terminal patients without an informal caregiver at home; thus, the people who may need home hospice services the most cannot receive them.\n\nAssisted living, which provides housing with a graded intensity of services depending on the functional capabilities of its residents, has been growing rapidly. However, the average annual cost in 2009 was $34,000, most of which comes from out-of-pocket payments, thereby pricing assisting living out of the reach of low- and moderate-income families (Stevenson and Grabowski, 2010).\n\n#### **Nursing Homes**\n\n_Each morning, more than one and a quarter million Americans awaken in nursing homes. Most of them are very old and very feeble. Most will stay in the nursing home for a long time. For most, it will be the last place they ever live.... [Nursing home] residents live out the last of their days in an enclosedsociety without privacy, dignity, or pleasure, subsisting on minimally palatable diets, multiple sedatives, and large doses of television\u2014eventually dying, one suspects at least partially of boredom. (Vladeck, 1980)_\n\nOften, informal help and formal home health services are unable to provide the care required for severely disabled people. Such people may be placed in nursing homes with 24-hour-a-day care provided by health aides and orderlies under the supervision of nurses. In 2007, 1.8 million people resided in US nursing homes. Sixty-seven percent of nursing home residents are women, who more often outlive their spouses (Kaye et al, 2010). Frequently, after caring for a sick husband at home, women will themselves fall ill and be placed in a nursing home because no one is left to care for them at home. People who reach the age of 65 have a 40% chance of entering a nursing home at some time in their life (www.medicare.gov\/longtermcare\/static\/home.asp).\n\nSeventy-six percent of nursing home residents have cognitive impairment and 93% have restricted mobility (Kaye et al, 2010). There are two main differences between the chronically ill inside and outside nursing homes: Nursing home residents have no family able to care for them, and a far larger proportion of nursing home patients suffer from dementia, a condition whose care is extremely difficult to provide at home by family members.\n\nNursing homes vary widely in quality. The Omnibus Budget Reconciliation Act of 1987 set standards for nursing home quality and mandated surveys to enforce these standards. Serious quality problems persist; the average number of deficiencies per facility increased from 5.7 in 1999 to 7.1 in 2005. Only 9% of nursing homes had no deficiencies in 2005. The most frequently cited deficiencies in 2005 were inadequate food sanitation, quality of care, professional standards, accident prevention, housekeeping, comprehensive care plans, infection control, pressure sores, and dignity (Harrington et al, 2006; Werner and Konetzka, 2010). Compared with non-Hispanic whites, Hispanics requiring nursing home are more likely to be placed in low-quality facilities (Fennell et al, 2010).\n\nLower-income people are housed in close quarters with several other patients and become totally dependent on an underpaid, inadequately trained staff. Hour after hour may be spent lying in bed or sitting in a chair in front of a TV. While quality of life varies between one nursing home and another, placement in a nursing home almost always thwarts the human yearning for some degree of independence of action and for companionship. A sense of futility overwhelms many nursing home residents, and the desire to live often wanes (Vladeck, 1980).\n\nTo keep down costs, most care in nursing homes is provided by nurse's aides, who are paid very little, receive minimal training, are inadequately supervised, and are required to care for more residents than they can properly serve. The job of the nursing home aide is very difficult, involving bathing, feeding, walking residents, cleaning them when they are incontinent, lifting them, and hearing their complaints. In 2005, 66% of all nursing homes were under for-profit ownership, many operated by large corporate chains (Harrington et al, 2006). For-profit ownership has been associated with lower staffing levels and poorer quality of care compared with nonprofit ownership (Comondore, 2009).\n\nOffering a humane existence to severely disabled people housed together in close quarters is a nearly impossible task. One view of nursing home reform holds that only the abolition of most nursing homes and the development of adequately financed home and community-based care can solve the nursing home problem.\n\n### **IMPROVING LONG-TERM CARE**\n\n#### **Financing Long-Term Care**\n\n_Boomer was mad. As a self-employed person, his family's health insurance coverage was costing $600 each month, in addition to his out-of-pocket dental bills. To make matters worse, a big chunk of his social security payments went to Medicare each year, not to mention federal and state income taxes and sales taxes going to finance Medicare and Medicaid, so that other people could get health care. While spending all this money, Boomer was healthy and had not seen a physician for 6 years._\n\n_One day Boomer's father, Abraham, suffered a devastating stroke. After weeks in the hospital, largely paid for by Medicare, Abraham was transferred to a nursing home. Because Medicare does not cover most long-term care, Boomer's mother paid the bills out of her savings until most of the money ran out. Abraham then became eligible for Medicaid,which took care of the nursing home bills. After Abraham's illness, Boomer stopped complaining about his social security and tax payments going to medical care. Even though Boomer was paying more than he was receiving, Abraham was receiving far more than he was paying. Boomer was grateful for the care his father received and figured that he might be in Abraham's shoes some day._\n\nIn the early 1960s, it was recognized that private insurance was unable to solve the problem of health care financing for people older than 65. The costs of health care for the elderly were too great, making experience-rated health insurance premiums unaffordable for most elderly people. Accordingly, Medicare, a social insurance program, was passed (see Chapter 2). An identical problem confronts long-term care financing: As shown earlier in this chapter, most people who might wish to purchase long-term care insurance are unable to afford an adequate policy. Table 12\u20133 lists some proposals for improving long-term care.\n\n**Table 12\u20133.** Proposals for improving long-term care\n\nThe Pepper Commission (1990) recommended that the nation institute a social insurance program to finance long-term care. This program, like Medicare Part A, could be financed by an increase in the rate of social security contributions by employers and employees. It would pay for caregivers to provide those services not currently covered by Medicare, especially in-home help in feeding, dressing, bathing, toileting, housework, grocery shopping, transportation, and other assistance with ADLs and IADLs. A similar proposal was offered by Physicians for a National Health Program (Harrington et al, 1991).\n\n#### **Providing Long-Term Care**\n\n_Mei Soon Wang was desperate to go home. Since a brain tumor had paralyzed her left side and left her incontinent, she had been confined to a nursing home because she had no family in San Francisco to care for her. Her daughter, visiting from Portland, heard of On Lok Senior Health Services, which cared for the frail elderly in their homes. On Lok accepted Ms. Wang, placed her in adult day care, arranged for meals to be delivered to her home, and paid for part-time help on evenings and weekends._\n\nBecause a reasonable quality of life and personal independence, within the confines of a patient's illness, are so difficult to achieve in the nursing home environment, long-term care reformers often advocate that most long-term care be provided at home. The first step toward deinstitutionalizing long-term care is a financing mechanism that pays for more comprehensive community-based and home long-term care services.\n\nThe ideal long-term caregivers are the patient's family and friends; thus, it can be argued that long-term care reform should support, assist, and pay informal caregivers, not replace them. Teams of nurses, physical and occupational therapists, physicians (who often know the least about long-term care), social workers, and attendants can train and work with informal caregivers, and personnel can be available to provide respite care so informal caregivers can have some relief from the 24-hours-a-day, 7-days-a-week burden. If informal caregivers are not available, all possible efforts can still be made to deliver long-term care in people's homes rather than in nursing homes (Harrington et al, 1991).\n\nAn innovative long-term care program that has achieved great success is the On Lok program in San Francisco. Translated from Chinese, On Lok means peaceful, happy abode. Begun in 1971 in San Francis-co's Chinatown, On Lok merges adult day services, in-home care, home-delivered meals, housing assistance, comprehensive medical care, respite care for caregivers, hospital care, and skilled nursing care into one program. Persons eligible for On Lok have chronic illness sufficiently severe to qualify them for nursing home placement, but only 15% ever spend time in a nursing home. Services for each participant are organized by a multidisciplinary team, including physicians, nurses, social workers, rehabilitation and recreation therapists, and nutritionists.\n\nIn 1983, On Lok became the first organization in the United States to assume full financial risk for the care of a frail elderly population, receiving monthly capitation payments from Medicare and Medicaid to cover all services. Whereas 45% of US personal health care expenditures go to hospital and nursing home services, On Lok spent a mere 17% on these items, making 83% of the health care dollar available for ambulatory home- and community-based services. While its services are far more comprehensive, On Lok's costs are no higher than those for a similar frail elderly population under traditional Medicare and Medicaid (Eng et al, 1997; Bodenheimer, 1999). Seventy-five On Lok \"look alikes\" now exist in 29 states under the Program of All-Inclusive Care for the Elderly (PACE). However, PACE sites care for fewer than 25,000 of the 3 million frail elderly and disabled people in the United States.\n\nThe United States has not implemented a social insurance program for long-term care. However, other nations have been more proactive in addressing the needs of their aging populations. In 1995, Germany enacted a system of near-universal social insurance for long-term care\u2014a program that the public has accepted as both affordable and beneficial (Harrington et al, 2002). A major expansion of the PACE concept combined with comprehensive social insurance for long-term care could provide a badly needed solution to the problems of long-term care in the United States.\n\n### **REFERENCES**\n\nAARP. _Valuing the invaluable: the economic value of family caregiving, 2008 update_. AARP Public Policy Institute. November 2008. www.aarp.org\/ppi.\n\nAdministration on Aging. _A Profile of Older Americans, 2010_. US Department of Health and Human Services; 2010. www.aoa.gov\/aoaroot\/aging_statistics\/Profile\/2010\/docs\/2010profile.pdf. Accessed November 16, 2011.\n\nBodenheimer T. Long-term care for frail elderly people\u2014the On Lok model. _N Engl J Med_. 1999;341:1324.\n\nComondore VR. Quality of care in for-profit and notfor-profit nursing homes: Systematic review and meta-analysis. _BMJ._ 2009;339:b2732.\n\nEng C et al. Program of All-inclusive Care for the Elderly (PACE). _J Am Geriatr Soc_. 1997;45:223.\n\nFennell ML et al. Elderly Hispanics more likely to reside in poor quality nursing homes. _Health Aff (Millwood)._ 2010;29:65.\n\nHarrington C et al. A national long-term care program for the United States: A caring vision. _JAMA_. 1991;266:3023.\n\nHarrington C et al. Germany's long-term care insurance model: Lessons for the United States. _J Public Health Policy_. 2002;23:44.\n\nHarrington C et al. Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1999 through 2005. University of California at San Francisco, September 2006. www.nccnhr.org.\n\nKaiser Family Foundation. Medicaid and long-term care services. July 2006a. www.kff.org\/medicaid\/upload\/Medicaid-and-Long-Term-Care-Services-PDF.pdf. Accessed November 16, 2011.\n\nKaiser Family Foundation. Private long-term care insurance: A viable option for low and middle-income seniors? July 2006b. www.kff.org\/uninsured\/upload\/7459.pdf. Accessed November 16, 2011.\n\nKaiser Family Foundation. Revisiting \"skin in the game\" among Medicare beneficiaries. February 2009. www.kff.org\/medicare\/upload\/7860.pdf. Accessed November 16, 2011.\n\nKaye HS et al. Long-term care: who gets it, how provides it, who pays, and how much? _Health Aff (Millwood)._ 2010;29:11.\n\nLevine C. The loneliness of the long-term care giver. _N Engl J Med_. 1999;340:1587.\n\nMartin A et al. Recession contributes to slowest annual rate of increase in health spending in five decades. _Health Aff (Millwood)._ 2011;30:11.\n\nNg T et al. Medicare and Medicaid in long-term care. _Health Aff (Millwood)._ 2010;29:22.\n\nPepper Commission. _A Call for Action_. Washington, DC: US Government Printing Office; 1990.\n\nStevenson DG, Grabowski DC. Sizing up the market for assisted living. _Health Aff (Millwood)._ 2010;29:35.\n\nUS Census Bureau. _Income, Poverty, and Health Insurance Coverage in the United States, 2009_. P60\u2013238, September, 2010.\n\nVladeck BC. _Unloving Care: The Nursing Home Tragedy._ New York: Basic Books; 1980.\n\nWerner RM, Konetzka RT. Advancing nursing home quality through quality improvement itself. _Health Aff (Millwood)._ 2010;29:81.\n\n## **13 Medical Ethics and Rationing of Health Care**\n\nFor those who work in the healing professions, ethical values play a special role. The specific content of medical ethics was first formulated centuries ago, based on the sayings of Hippocrates and others. The refinement of medical ethics has continued up to the present by practicing health caregivers, health professional and religious organizations, and individual ethicists. As medical technology, health care financing, and the organization of health care transform themselves, so must the content of medical ethics change in order to acknowledge and guide new circumstances.\n\n### **FOUR PRINCIPLES OF MEDICAL ETHICS**\n\nOver the years, participants in and observers of medical care have distilled widely shared human beliefs about healing the sick into four major ethical principles: beneficence, nonmaleficence, autonomy, and justice (Beauchamp and Childress, 2008) (Table 13\u20131).\n\n**Table 13\u20131.** The four principles of medical ethics\n\n_Beneficence_ is the obligation of health care providers to help people in need.\n\n_Dr. Rolando Bueno is a hard-working family physician practicing in a low-income neighborhood of a large city. He shows concern for his patients, and his knowledge and judgment are respected by his medical and nursing colleagues. On one occasion, he was called before the hospital quality assurance committee when one of his patients unexpectedly died; he agreed that he had made mistakes in his care and incorporated the lessons of the case into his future practice._\n\nDr. Bueno tries to live up to the ideal of beneficence. He does not always succeed; like all physicians, he sometimes makes clinical errors. Overall, he treats his patients to the best of his ability. The principle of beneficence in the healing professions is the obligation to care for patients to the best of one's ability.\n\n_Nonmaleficence_ is the duty of health care providers to do no harm.\n\n_Mrs. Lucy Knight suffers from insomnia and Parkinson's disease. The insomnia does not bother her, because she likes to read at night, but it irritates her husband. Mr. Knight requests his wife's physician to order strong sleeping pills for her, but the physician declines, saying that the combination of sleeping pills and Parkinson's disease places Mrs. Knight at high risk for a serious fall._\n\nThe modern array of medical interventions has the capacity to do good or harm or both, thereby enmeshing the principle of nonmaleficence with the principle of beneficence. In the case of Mrs. Knight, the prescribing of sedatives has far more potential for harm than for good, particularly because Mrs. Knight does not see her insomnia as a problem.\n\n_Autonomy_ is the right of a person to choose and follow his or her own plan of life and action.\n\n_Mr. Winter is a frail 88-year-old found by Dr. James Washington, his family physician, to have colon cancer, which has spread to the liver. The cancer is causing no symptoms. An oncologist gives Mr. Winter the option of transfusions, parenteral nutrition, and surgery, followed by chemotherapy; or watchful waiting with palliative and hospicecare when symptoms appear. Mr. Winter is terrified of hospitals and prefers to remain at home. He feels that he might live a comfortable couple of years before the cancer claims his life. After talking it over with Dr. Washington, he chooses the second option._\n\nThe principle of autonomy adds another consideration to the interrelated principles of beneficence and nonmaleficence. Would Mr. Winter enjoy a longer life by submitting himself to aggressive cancer therapy that does harm in order to do good? Or, does he sense that the harm may exceed the good? The balance of risks and benefits confronts each physician on a daily basis (Eddy, 1990). But the decision cannot be made solely by a risk\u2013benefit analysis; the patient's preference is a critical addition to the equation.\n\nAutonomy is founded in the overall desire of most human beings to control their own destiny, to have choices in life, and to live in a society that places value on individual freedom. In medical ethics, autonomy refers to the right of competent adult patients to consent to or refuse treatment. While the physician has an obligation to respect the patient's wishes, he or she also has a duty to fully inform the patient of the probable consequences of those wishes. For children and for adults unable to make medical decisions, a parent, guardian, other family member, or surrogate decision maker named in a legal document becomes the autonomous agent on behalf of the patient.\n\n_Justice refers_ to the ethical concept of treating everyone in a fair manner.\n\n_Joe, a white businessman in the suburbs, suffers crushing chest pain and within 5 minutes is taken to a nearby private emergency department, where he receives immediate coronary angioplasty and state-of-the-art treatment for a heart attack. Five miles away, in a poor neighborhood, Josephine, an African American woman, experiences severe chest pain, calls 911, waits 25 minutes for help to arrive, and is brought to a public hospital whose emergency department staff is attending to five other acutely ill patients. Before receiving appropriate attention, she suffers an arrhythmia and dies._\n\nThe principle of justice as applied to medical ethics is newer, more controversial, and harder to define than the principles of beneficence, nonmaleficence, and autonomy. In a general sense, people are treated justly when they receive what they deserve. It is unjust not to grant a medical degree to someone who completes medical school and passes all the necessary examinations. It is unjust to punish a person who did not commit a crime. In another meaning, _justice_ refers to universal rights: to receive enough to eat, to be afforded shelter, to have access to basic medical care and education, and to be able to speak freely. If these rights are denied, justice has been violated. In yet another version, justice connotes equal opportunity: All people should have an equal chance to realize their human potential. Justice might be linked to the golden rule: Treat others as you would want others to treat you. While there is no clear agreement on the precise meaning of justice, most people would agree that the differential treatment of Joe and Josephine is unjust.\n\n#### **Distributive Justice**\n\nIn exploring the concept of justice, one area of concern is the allocation of benefits and burdens in society. This realm of ethical thinking is called _distributive justice_ , and it involves such questions as: Who receives what amount of wealth, of education, or of medical care? Who pays what amount of taxes?\n\nThe principle of justice is linked to the idea of fairness. In the arena of distributive justice, no agreement exists on what formula for allocating benefits and costs is fair. Should each person get an equal share? Should those who work harder receive more? Should the proper formula be \"to each according to ability to pay,\" as determined by a free market? Or \"to each according to need?\" In allocating costs, should each person pay an equal share or should those with greater wealth pay more? Most societies construct a mixture of these allocation formulas. Unemployment benefits consider effort (having had a job) and need (having lost the job). Welfare benefits are primarily based on need. Job promotions may be based on merit. Many goods are distributed according to ability to pay. Primary education in theory (but not always in practice) is founded on the belief that everyone should receive an equal share (Beauchamp and Childress, 2008; Jonsen et al, 2010).\n\nHow is the principle of distributive justice formulated for medical care? Throughout the history of the developed world, the concept that health care is a privilege that should be allocated according to ability to pay has competed with the idea that health care is a right and should be distributed according to need. In most developed nations, the allocation of health care according to need has become the dominant political belief, as demonstrated by the passage of universal or near-universal health insurance laws. In the United States, the failure of the 100-year battle to enact national health insurance, and the widely divergent opinions on the 2010 Affordable Care Act, attest to the ongoing debate between health care as a privilege and health care as a right (see Chapter 15).\n\nIf the overwhelming opinion in the developed world holds that health care should be allocated according to need, then all people should have equal access to a reasonable level of medical care without financial barriers (ie, people should have a right to health care). In this chapter, therefore, we consider that the principle of distributive justice requires all people to equally receive a reasonable level of medical services based on medical need without regard to ability to pay.\n\n### **ETHICAL DILEMMAS, OLD AND NEW**\n\nEthical dilemmas (Lo, 2009) are situations in which a provider of medical care is forced to make a decision that violates one of the four principles of medical ethics in order to adhere to another of the principles. Ethical dilemmas always involve disputes in which both sides have an ethical underpinning to their position. Financial conflicts of interest on the part of physicians (see Chapters 4 and ), in contrast, pit ethical behavior against individual gain and are not ethical dilemmas.\n\n_Anthony, a 22-year-old Jehovah's Witness, is admitted to the intensive care unit for gastrointestinal bleeding. His blood pressure is 80\/60 mm Hg, and in the past 4 hours, his hematocrit has fallen from 38% to 21%. The medical resident implores Anthony to accept life-saving transfusions, but he refuses, saying that his religion teaches him that death is preferable to receiving blood products. When the blood pressure reaches 60\/20 mm Hg, the desperate resident decides to give the blood while Anthony is unconscious. The attending physician vetoes the plan, saying that the patient has the right to refuse treatment, even if an avoidable death is the outcome._\n\nIn Anthony's case, the ethical dilemma is a conflict between beneficence and autonomy. Which principle has priority depends on the particular situation, and in this case, autonomy supersedes beneficence. If the patient were a child without sufficient knowledge or reasoning capability to make an informed choice, the physician would not be obligated to withhold transfusions, even if the family so demanded (Jonsen et al, 2010).\n\n_Pedro Navarro has lung cancer that has metastasized to his brain. No effective treatment is available, and Mr. Navarro is confused and unable to understand his medical condition. Mrs. Navarro demands that her husband undergo craniotomy to remove the tumor. The neurosurgeon refuses, arguing that the operation will do Mr. Navarro no good whatsoever and will cause him additional suffering._\n\nThe case of Mr. Navarro pits the principle of autonomy against the principle of nonmaleficence. Mr. Navarro's rightful surrogate decision maker, his wife, wants a particular course of treatment, but the neurosurgeon knows that this treatment will cause Mr. Navarro considerable harm and do him no good. In this case, nonmaleficence triumphs. Whereas patient autonomy allows the right to refuse treatment, it does not include the right to demand a harmful or ineffectual treatment.\n\nThe traditional dilemmas described in many articles and books on medical ethics feature beneficence or nonmaleficence in conflict with autonomy. In two famous ethical dilemmas, the families of Karen Ann Quinlan and Nancy Cruzan, young women with severe brain damage (persistent vegetative state) asked that physicians discontinue a respirator (in the Quinlan case) and a feeding tube (in the Cruzan case). Both cases were adjudicated in the courts. The Quinlan decision promoted the right of patients or their surrogate decision makers to withdraw treatment, even if the treatment is necessary to sustain life. The outcome of the Cruzan case placed limits on autonomy by requiring that life-supporting treatment can be withdrawn only when a patient has stated his or her wishes clearly in advance (Annas, 2005).\n\nIn 2005, the case of Terri Schiavo, for 15 years in a persistent vegetative state similar to the situations of Karen Ann Quinlan and Nancy Cruzan, made national headlines. In spite of multiple decisions of state and federal courts\u2014up to the Supreme Courts of Florida and the United States\u2014supporting the right of Terri Schiavo's husband to discontinue Ms. Schiavo's feeding tube, the US Congress, encouraged by President George Bush, passed legislation reopening the option of reinserting the feeding tube. Eventually, based on the precedents of the Quinlan and Cruzan cases, the courts prevailed and Ms. Schiavo died (Annas, 2005).\n\nOverall, medical ethics has moved in the direction of giving priority to the principle of autonomy over that of beneficence.\n\nIn the late twentieth century, a new generation of ethical dilemmas emerged, moving beyond the individual physician\u2013patient relationship to involve the broader society. These social\u2013ethical problems derive from the new reality that money may not be available to pay for a reasonable level of medical services for all people. When money and resources are bountiful, the issue of distributive justice refers to equality in medical care access and health outcomes (see Chapter 3). Is it fair that some people are unable to receive needed care because they lack money and insurance? When money and resources become scarce, the issue of justice takes on a new twist. Should limits be set on treatments given to people with high-cost medical needs, so that other people can receive basic services? If not, might health care consume so many resources that other social needs are sacrificed? If limits should be set, who decides these limits?\n\n_Angela and Amy Lakeberg [actual names] were Siamese twins sharing one heart. Without surgery, they would die shortly. With surgery, Amy would die and Angela's chance of survival would be less than 1%. On August 20, 1993, a team of 18 physicians and nurses at Children's Hospital of Philadelphia performed an all-day operation to separate the twins. Amy died. The cost of the treatment was_ $ _1 million. The Medicaid program covered_ $ _700 to_ $ _1000 per day, and the hospital underwrote the balance of the costs. On June 9, 1994, Angela died; she had spent her brief life on a respirator in the hospital._\n\nThe new fiscal reality has spawned two related dilemmas.\n\n1. The first involves a conflict between the duty of the physician to follow the principles of beneficence and nonmaleficence and the growing sentiment that physicians should pay attention to issues of distributive justice. In the case of the Lakeberg twins, the hospital and the surgeons adhered strictly to the principle of beneficence: Even a remote chance of aiding one twin was seen as worthwhile. The hospital could have balked, arguing that its funding of the surgery would be unfairly shifted to other payers. The surgeons could have declined to operate on the grounds that the money spent on the Lakebergs could have been better used by patients with a greater chance of survival. But, the surgeons could argue, who can guarantee that the money saved would have gone to better use?\n\n2. The second category of social\u2013ethical dilemma is the conflict between the individual patient's right to autonomy and society's claim to distributive justice. In the Lakeberg case, individual autonomy won out. The Lakeberg parents could have decided that spending $1 million of society's money on a less than 1% chance of saving one of two infants was excessive and could indirectly harm other patients. On the other hand, would not most parents have done what the Lakebergs did?\n\nPhysicians take up the practice of medicine with a recognition that they have a duty to help and not harm their patients. Individuals claim a right to health care and do not want others to restrict that care. Yet the principle of distributive justice (recognizing that resources for health care are limited and should be fairly allocated among the entire population) might lead to physicians denying legitimate services or patients setting aside rightful claims to treatment.\n\nThe basis for the principle of justice is the desire shared by many human beings to live in a civilized society. To live in a state of harmony, each person must balance the concerns of the individual with the needs of the larger community. There is no right or wrong answer to the question of whether the Lakeberg surgery should have been done, but the surgery must be seen as a choice. The $1 million spent on the twins might have been spent on immunizing 10,000 children, with greater overall benefit. When health resources are scarce, the principle of justice creates ethical dilemmas that touch many people beyond those involved in an individual physician\u2013patient relationship. The imperatives of cost control have thrust the principle of justice to the forefront of health policy in the debate over rationing.\n\n### **WHAT IS RATIONING?**\n\n_Dr. Everett Wall works in a health maintenance organization (HMO). Betty Ailes came to him with a headache and wanted a magnetic resonance imaging (MRI) scan. After a complete history and physical examination, Dr. Wall prescribed medication and denied the scan. Ms. Ailes wrote to the medical director, complaining that Dr. Wall was rationing services to her._\n\n_Perry Hiler arrives at Vacant Hospital with fever and severe cough. His chest x-ray shows an infiltrate near the hilum of the lung consistent with pneumonia or tumor. Since Mr. Hiler has no insurance, the emergency department physician sends him to the county hospital. At the time, Vacant Hospital has 35 empty beds and plenty of staff. When he recovers, Mr. Hiler calls the newspaper to complain. The next day, a headline appears: \"Vacant Hospital Rations Care.\"_\n\n_Jim Delacour is a 50-year-old man with terminal cardiomyopathy. His physician sends him to a transplant center, where an evaluation concludes that he is an ideal candidate for a heart transplant. Because the number of transplant candidates is larger than the supply of donor hearts available, Mr. Delacour is placed on the waiting list. After waiting 6 weeks, he dies._\n\n_When the emergency department called, Dr. Marco Intensivo's heart sank. The eight-bed intensive care unit is filled with extremely ill patients, all capable of full recovery if they survive their acute illnesses. He has worried all day about another patient needing intensive care: a 55-year-old with a heart attack complicated by unstable arrhythmias. Which one of the nine needy cases will not get intensive care? Dr. Intensivo needs to make a decision, and fast._\n\nThe general public and the media often view rationing as a limitation of medical care such that \"not all care expected to be beneficial is provided to all patients\" (Aaron and Schwartz, 1984). Such a view only partially explains the concept of rationing. More precisely, rationing means a conscious policy of equitably distributing needed resources that are in limited supply (Reagan, 1988) (Table 13\u20132). Under this definition, only the last two cases presented above can be considered rationing. In the first case, Dr. Wall did not feel that the MRI was a resource needed by Betty Ailes. In the second, Vacant Hospital's refusal to care for Perry Hiler was simply a decision on the part of a private institution to place its financial well-being above a patient's health; there was no scarcity of health care resources. In the heart transplant and intensive care unit cases, in contrast, donor hearts and intensive care unit beds were in fact scarce. For Mr. Delacour, the scarcity was nationwide and prolonged; for Dr. Intensivo, the scarcity was within a particular hospital at a particular time. In both cases, decisions had to be made regarding the allocation of those resources.\n\n**Table 13\u20132.** Two definitions of rationing\n\nDuring World War II, insufficient gasoline was available to both power the military machine and satisfy the demands of automobile owners in the United States. The government rationed gasoline, giving priority to the military, yet allowing each civilian to obtain a limited amount of fuel. In a rural area, there may be a shortage of health care providers; in an overcrowded urban public hospital, there may be an insufficient number of beds; in the transplant arena, donor organs are truly in short supply. These are cases of commodity scarcity, wherein specific items are in limited supply.\n\nThe United States is a nation with an adequate supply of hospital beds and physicians in most communities; commodity scarcity in health care is the exception (eg, scarcity of primary care resources is becoming a reality). But a different kind of health resource is becoming scarce, and that is money. Those who pay the bills are insistent that the flow of money into the health sector be restricted. Most discussions of health care rationing presume fiscal scarcity, not commodity scarcity.\n\nIn summary, rationing in medical care means the limitation of resources, including money, going to medical care such that not all care expected to be beneficial is provided to all patients, and the fair distribution of these limited resources.\n\n### **COMMODITY SCARCITY: THE CASE OF ORGAN TRANSPLANTS**\n\nWhile fiscal scarcity is the more common form of resource limitation, commodity scarcity provides an instructive example of the interaction of ethics and rationing.\n\n_Mr. George Olds is a 76-year-old nonsmoking retired business executive with end-stage heart failure. He has good pulmonary and renal function and is not diabetic; thus, he is medically a good candidate for a heart transplant. His life expectancy without a transplant is 1 month. He has a loving family, with the resources to pay the $300,000 cost of the procedure._\n\n_Mr. Matt Younger is a 46-year-old divorced man who is unemployed, having lost his job as an auto worker 3 years ago. He has a history of smoking and alcohol use. He suffers a heart attack, develops intractable heart failure, and will die within 1 month without a heart transplant. He has good pulmonary and renal function and is not diabetic, making him a good candidate for the procedure._\n\n_Mr. Olds and Mr. Younger are in the same hospital and cared for by the same cardiologist, who applied for donor hearts on behalf of both patients on the same day. The cardiologist receives a call that one donor heart\u2014histocompatible with both patients\u2014has become available. Who should receive it?_\n\nIn 1951, the first kidney transplant was performed in Massachusetts. But it was in 1967, when Dr. Christiaan Barnard sewed a living heart into the chest of a person suffering end-stage cardiac disease, that modern medicine fully entered the age of transplantation. Since that time, thousands of people have been kept alive for many years by transplantation of the kidneys, hearts, lungs, and livers of their fellow human beings. In 2010, 17,000 kidney, 2300 heart, 6300 liver, and 1800 lung transplants were performed in the United States. Transplants are truly life saving in most cases. Seventy to eighty percent of patients receiving heart, liver, or kidney transplants survive at least 5 years after transplantation (<http:\/\/optn.transplant.hrsa.gov>).\n\nTransplantation of organs is both a medical miracle and an ethical watershed. It has generated debate on such questions as these: When are people really dead (so that their organs can be harvested for use in transplantation)? What is the responsibility of the families of brain-dead people to allow their organs to be harvested? Who pays and who is paid for organ transplants? Who should receive organs that are in short supply? We will focus only on the last of these issues.\n\nThe number of persons on the national waiting list for organ transplants rose from 16,000 in 1988 to 111,000 in 2010, yet the pool of organ donors has been estimated at 14,500. Even if all potential donors became actual donors, the number of organs that could be harvested each year falls far short of the required number. Nineteen patients in the United States die each day awaiting organs (www.mayoclinic.org\/transplant\/organdonation.html).\n\nTransplantation presents a classic case of commodity scarcity: There is insufficient supply to meet demand. Explicit rationing, which is a system that determines who gets organs and who does not, is inevitable. For heart, lung, and liver transplants, rationing is all or nothing: Those who receive organs may live, while those who do not will die.\n\nGiven the supply and demand imbalance, which potential transplant patients actually receive new organs? In the early 1980s, the major heart transplant center at Stanford University excluded people with \"a history of alcoholism, job instability, antisocial behavior, or psychiatric illness,\" and required transplant recipients to enjoy \"a stable, rewarding family and\/or vocational environment.\" Stanford's recipients had a better than 50% chance of surviving 5 years, signifying that acceptance or rejection from the program was a matter of life and death. The US Department of Health and Human Services was concerned about Stanford's selection criteria, which favored those middle-class or wealthy people with satisfying jobs. Moreover, the $100,000 cost restricted heart transplants to those with insurance coverage or ability to pay out of pocket. Both the social and economic criteria for access to this life-saving surgery raised serious issues of distributive justice.\n\nFollowing the passage of the National Organ Transplantation Act of 1984, the federal government designated the United Network for Organ Sharing (UNOS) as a national system for matching donated organs and potential recipients (www.unos.org). According to the Task Force on Organ Transplantation (1986), organ allocation should be governed by medical criteria, with the major factors being urgency of need and probability of success. The Task Force recommended that if two or more patients are equally good candidates for an organ according to the medical criteria, length of time on the waiting list is the fairest way to make the final selection. In 2006, the US Department of Health and Human Services issued updated guidelines and in 2007 the Medicare program promulgated conditions that hospitals with transplant programs needed to follow.\n\nOverall, UNOS follows these recommendations, placing potential recipients of organ transplants on its computerized waiting list. Recipients are prioritized according to a point scale based on severity of illness, time on the waiting list, and probability of a successful outcome. A serious attempt has been made to allocate scarce organs on the basis of justice criteria. But haunting the ethics of the prioritization process is the issue of ability to pay. In 2008, the average kidney transplant cost $259,000 and liver transplant $534,400. Persons needing a transplant are often rejected if they lack health insurance coverage (Laurentine and Bramstedt, 2010).\n\n### **FISCAL SCARCITY AND RESOURCE ALLOCATION**\n\nDuring the 1980s, technologic advances in medicine combined with the rapid rise in health care costs led to the belief that medical care rationing was upon us. The ethical issues raised by organ transplantation have thereby become generalized to all medical care. However, great differences separate the case of organ transplants from that of medical care as a whole.\n\n1. Medical care in general is not a scarce resource; in many geographic areas, facilities and personnel are overabundant.\n\n2. Whereas a nationwide structure is in place to decide who will receive a transplant, no such structure exists for medical care as a whole.\n\n_Dr. Ernest, who works in a for-profit HMO, wants to do her part to keep medical costs down. She prescribes low-cost amoxicillin at 20 cents per capsule rather than ciprofloxacin, which is priced at_ $ _1.50 for each dose. She teaches back pain patients home exercises at no cost rather than sending them to physical therapy visits at_ $ _75 per session. At the end of each year, she enjoys calculating how many thousands of dollars she has saved compared with one of her colleagues, who ignores costs in making medical decisions. Because of her efforts and those of other cost-conscious physicians, the HMO's pharmacy bill goes down, and HMO management is able to lay off one physical therapist, thereby raising its profit margin._\n\nWhile Dr. Ernest can be praised for attempting to reduce costs without sacrificing quality, her cost savings had no impact on overall national health care expenditures. Nor were the savings used to provide more childhood immunizations or to hire a physician assistant for a nearby rural community without any health care provider. In the United States, there is no structure within which to effect a trade-off between savings in one area and benefits in another. According to analyst Joshua Wiener. (1992)\n\n_In countries that have a socially determined health budget, cuts in one area can be justified on the grounds that the money will be spent on other, higher-priority services. This closed system of funding provides a moral underpinning for resource allocation across a range of potentially unlimited demands. In the United States, it is difficult to refuse additional resources for patients, because there is no certainty that the funds will be put to better use elsewhere (Wiener, 1992)._\n\nIn the United States, persuading physicians to save money on one patient in order to improve services for someone else is as illogical as telling a child to eat all the food on the plate because children in Africa are starving (Cassel, 1985).\n\nIn order for health care providers like Dr. Ernest to make their cost savings socially useful, two things are needed: a closed system of health care funding, whether governmental through a global budget or private through a network of HMOs; and a decision-making structure controlling such funding that has the responsibility to allocate budgets to health care interventions in a fair manner.\n\nFor the purposes of the following discussion, let us assume that the United States is in a position of fiscal scarcity and that a mechanism exists to fairly allocate medical care resources from one individual or population group to another. Which ethical conflicts arise between beneficence, nonmaleficence, and autonomy on the one hand and justice (equitable distribution of resources) on the other?\n\n### **THE RELATIONSHIP OF RATIONING TO COST CONTROL**\n\n_Assume that Limittown, USA, has a fixed budget of_ $ _250 million for medical care in 2011. Limittown has three imaging centers, each with an MRI scanner that is used only 4 hours each weekday. None of the medical facilities perform bone marrow transplantation, a procedure that can markedly prolong the lives of some leukemia patients. In 2010, Limittown spent_ $ _5 million to pay for bone marrow transplants at a university hospital 50 miles away._\n\n_Limittown's health commissioner projects that 2011 medical care expenditures will be_ $ _5 million over budget; she must implement cost savings. She considers two choices: (1) Two of the three MRI scanners could be closed, allowing the remaining scanner's cost per procedure to be drastically reduced or (2) Limittown could stop paying for bone marrow transplantation for leukemia patients._\n\nIs rationing the same as cost containment? We have defined rationing in medical care as the limitation of resources, including money, going to medical care such that not all care expected to be beneficial is provided to all patients, and the fair distribution of these limited resources. While the limitation of money going to medical care is cost containment, not all cost containment reduces beneficial care to patients. In the case of Limittown, both options for saving $5 million can be considered cost containment, but only denial of coverage for bone marrow transplants requires rationing. Consolidating MRI scanning at a single facility would allow the same number of scans to be performed but at a substantially lower cost. Rationing is associated with painful cost control (reducing effective medical care), but cost containment (see Chapter 8) can be either painful or painless (not reducing effective medical care) (Table 13\u20133). The extent of unnecessary care and administrative waste has led many health experts over the past three decades to conclude that the United States may not need to ration effective medical services (Brook and Lohr, 1986; Relman, 1990). Other health policy experts feel that rationing is likely to take place, and the issue is whether rationing is rational, based on the most effective medical interventions, or irrational, based on income or health insurance (Dranove, 2003). Whether or not rationing is needed today, advances in medical technology guarantee that rationing of medically efficacious services will be necessary in the future. But to maximize beneficence and autonomy without violating distributive justice, no rationing of beneficial services should take place until all wasteful practices are curtailed; painless cost control should precede painful cost control.\n\n**Table 13\u20133.** Rationing and cost control\n\n#### **Care Provided to Profoundly Ill People**\n\n_Lula Rogers is an 84-year-old diabetic woman with amputations of both legs; multiple strokes have rendered her unable to move, swallow, understand, or speak. She has been in a nursing home for three years during which time her medical condition has slowly deteriorated. Ms. Rogers' son wishes to remove her feeding tube, but her physician and the nursing staff feel it is cruel to cause her death by malnutrition and dehydration. Ms. Rogers continues to live for 3 more years, costing_ $ _300,000._\n\nA hotly debated issue is the amount of health care that should be provided to the profoundly and incurably ill. Were Lula Rogers' caregivers right to prolong a life that had value to her? Or were they prolonging Ms. Rogers' suffering and denying her a peaceful death? Should cost be a factor in such decisions, or should such matters of life and death be governed by autonomy, beneficence, and nonmaleficence alone (Luce, 1990)?\n\nTwenty-seven percent of Medicare's budget is spent on people in their last year of life, with almost half of those funds ($68 billion in 2009) spent in the final 60 days (Lubitz and Riley, 1993; Hogan et al, 2001) (Figure 13\u20131). In 2000, an estimated 67% of people who died had their last place of care in the hospital or nursing home; 33% died at home, with half of patients dying at home cared for by hospice programs (Teno et al, 2004). Patients in hospice programs have lower end-of-life costs than those not in hospice programs (Emanuel et al, 2002), and family members of patients receiving hospice care at home are more satisfied with the care than families of patients dying in hospitals or nursing homes (Teno et al, 2004). Thus, a strong possibility exists that reduced expenditures can go hand in hand with better care. If these savings could be transferred to more efficacious therapies for other people, then improving the care of the incurably ill could promote all four of the ethical principles\u2014beneficence, nonmaleficence, autonomy, and distributive justice.\n\n**Figure 13\u20131.** Medicare funds spent at the end of life.\n\n### **RATIONING BY MEDICAL EFFECTIVENESS**\n\nWe have seen that cost containment does not necessarily equal rationing and that eliminating administrative waste, medical waste, and unwanted interventions for the profoundly and incurably ill before rationing needed services best realizes the principles of beneficence and justice. However, if rationing of truly beneficial services is needed, the issues become even more difficult. If a health care system or program must compromise beneficence because of true fiscal scarcity, how can this compromise be made in a manner that yields the least harm and allocates the harm in the fairest possible way? In 2009 and 2010, federal legislation created a new structure for performing research on the comparative effectiveness of medical interventions (Benner et al, 2010)\n\n_Joy Fortune develops Hodgkin's disease, or cancer of the lymphatic system; she receives radiation therapy and is cured. Jessica Turner is moribund from advanced metastatic cancer of the pancreas. She undergoes chemotherapy and dies within 3 days._\n\nIn the event of rationing, science is the best guide: The providing or withholding of care is ideally determined by the probability that the treatment will maximize benefits and minimize harm, that is by the criterion of medical effectiveness. Radiation therapy can often cure Hodgkin's disease, but chemotherapy is unlikely to provide much benefit to people with very advanced pancreatic cancer. If rationing is needed and only one of these therapies can be offered, a decision based on the criterion of medical effectiveness would allow for the treatment of Hodgkin's disease but not of terminal pancreatic cancer.\n\nIf intervention A increases person-years of reasonable-quality life more than intervention B, intervention A is more medically effective. The cost of the two interventions is not considered. Cost-effectiveness adds dollars to the equation: If intervention A increases person-years of reasonable-quality life per dollar spent more than intervention B, it is more cost-effective. Which is a better standard for rationing medical care: medical effectiveness or cost-effectiveness?\n\nIf money were not scarce, medical effectiveness (maximizing benefit and minimizing harm) would be the ideal standard upon which to ration care (ie, the less effective the therapy, the lower its priority on the list of treatments to be offered). But if money were not scarce, we would not need to ration. It is unrealistic to pretend that costs can be ignored (Garber and Sox, 2010). Suppose that bone marrow transplantation saves as many person-years of life by treating advanced cancers as does doxycycline by curing pneumonia. The former costs $150,000, while the latter can be obtained for $10. There is no reason to ration doxycycline, as its cost is negligible, whereas to make bone marrow transplantation similarly accessible is costly. Thus consideration of costs is essential as a means of deciding which services to ration.\n\n#### **Rationing for Society as a Whole**\n\n_Mrs. Smith's breast cancer has spread to her liver and bone. She has been told that her only slim hope lies in high-dose chemotherapy with autologous bone marrow transplantation (HDC-ABMT), costing $250,000. Even with the optimistic assumption that HDC-ABMT has a 5% cure rate, screening mammography is eight times as cost-effective as HDC-ABMT in person-years of life saved._\n\nIn 1991, Dr. David Eddy (1991a) published a compelling article entitled \"The individual vs society: Is there a conflict?\" Dr. Eddy poses the preceding case of Mrs. Smith. If medical care must be rationed, it seems logical to spend funds on mammography rather than HDC-ABMT because the former intervention is more cost-effective. Dr. Eddy does not confine his analysis to cost-effectiveness, however, but moves on to the ethical issues.\n\n_Each of us can be in two positions when we make judgments about the value of different health care activities. We are in one position when we are healthy, contemplating diseases we might get, and writing out checks for taxes and insurance premiums. Call this the \"first position.\" We are in a different position when we actually have a disease, are sitting in a physician's office, and have already paid our taxes and premiums (the \"second position\").... Imagine that you are a 50-year-old woman employed by Mrs. Smith's corporation.... [The company] is considering two options: (1) cover screening for breast cancer.... or (2) cover HDCABMT.... Now imagine you are in the firstposition.... as long as you do not yet have the disease (the first position), option 1 will always deliver greater benefit at lower cost than option 2.... Now, let us switch you to the second position. Imagine that you already have breast cancer and have just been told that it has metastasized and is terminal.... The value to you of the screening option has plummeted because you already have breast cancer and can no longer benefit from screening...._\n\n_Maximizing care for individual patients attempts to maximize care for individuals when they are in the second position. Maximizing care for society expands the scope of concern to include individuals when they are in the first position. As this example illustrates, the program that delivers the most benefit for the least cost for society (option 1) is not necessarily best for the individual patient (option 2), and vice versa. But as this example also illustrates, individual patients and society are not distinct entities. Rather, they represent the different positions that each of us will be in at various times in our lives. When we serve ourselves in the second position, we can harm ourselves in the first. (Eddy, 1991a)_\n\nPhysicians generally care for patients in Dr. Eddy's second position\u2014when they are sick. But if the cost of treating those in the second position reduces resources available to prevent illness for the far larger number of people in the first position (who may not be seeing physicians because they feel fine), the individual principles of beneficence and autonomy are superseding the societal principle of justice. One could even say that choosing for individuals in the second position violates beneficence for those in the first position. On the other hand, if all resources go to those in the first position (eg, to cost-effective screening rather than highly technical treatment for those with life-threatening disease), injustice is committed in the other direction by ignoring the costly needs of the very ill.\n\nClearly, no ideal method of rationing medical care exists. The use of cost-effectiveness as a measuring stick raises ethical problems, and because of the difficulty in determining the cost-effectiveness of different interventions, has scientific limitations. All efforts should be made to control costs painlessly before resorting to the painful limitation of effective medical care. But if rationing is inevitable, a balance must be struck among many legitimate needs: The concerns of healthy people for illness prevention, the imperative for acutely sick people to obtain diagnosis and treatment, and the obligation to provide care and comfort to those with untreatable chronic illness.\n\n#### **Rationing within One Health Program: The Oregon Health Plan**\n\nThe previous discussion of rationing medical care nationwide presumes a mechanism that redirects savings from interventions not performed toward more cost-effective services. In fact, such a mechanism does not exist nationwide. Only in specific medical care programs do we find a decision-making apparatus for allocating expenditures. One example is the Oregon Health Plan (Bodenheimer, 1997).\n\nIn 1994, Oregon added 100,000 poor uninsured Oregonians to its Medicaid program. To control costs, a prioritized list of services was developed, and the state legislature decided how many services would be covered. The prioritized list was based on how much improvement in quantity and quality of life the treatment was likely to produce. The final list contained 745 condition\u2013treatment pairs, and the State of Oregon paid for items above line 574 on the list; conditions below that line were not covered (Kilborn, 1999). What are some of the Oregon Health Plan's ethical implications?\n\n1. The plan was more than a rationing proposal; its chief feature was to extend health care coverage to 100,000 more people. That aspect of the Oregon plan promotes the principle of justice.\n\n2. Another positive feature of the plan was its attempt to prioritize medical care services on the basis of effectiveness, which, if rationing is needed, is a reasonable method for deciding which services to eliminate.\n\nOther features of the Oregon plan must be viewed as negatively impacting distributive justice, or equal access to care without regard for ability to pay.\n\n1. In 1996, 12% of beneficiaries reported being denied services because they were below the line on the priority list. Of those, 78% reported that the denial had worsened their health (Mitchell and Bentley, 2000). Medical services were rationed for Oregon's poor but not for anyone else.\n\n2. The plan targeted beneficial medical services in a state with considerable medical waste. In 1988, many areas of Oregon had average hospital occupancy rates below 50%. The closing of unneeded hospital beds could have saved $50 million per year, enough to pay for some of the treatments eliminated in the plan (Fisher et al, 1992). Oregon did not exhaust its options for painless cost control before proceeding to potentially painful rationing.\n\nBy 2004, the Oregon Health Plan had unraveled (Oberlander, 2006). The state entered a period of budgetary woes, new premiums and copays were instituted, and Oregon Health Plan enrollees responded by dropping out of the program. The rate of uninsurance climbed from 11% to 17%. But the bold experiment in rational rationing remains alive in the minds of health care policymakers.\n\n#### **Rationing within One Institution: Intensive Care**\n\n_Ms. Wilson is a 71-year-old woman with a recently diagnosed lung cancer. Obstructing a bronchus, the tumor causes pneumonia, and Ms. Wilson is admitted to the hospital in her rural town. She deteriorates and becomes comatose, requiring a respirator. By the eighth hospital day, she is no better. On that day, Louis Ford, a previously healthy 27-year-old, is brought to the hospital with a crushed chest and pneumothorax suffered in an automobile accident. Mr. Ford is in immediate need of a respirator. None of the six patients in the intensive care unit can be removed from respirators without dying; of the six, Ms. Wilson has the poorest prognosis. She has no family. No other respirators exist within a 50-mile radius (Jonsen et al, 2010). Should Ms. Wilson be removed from the respirator in favor of Mr. Ford?_\n\nResources may be scarce throughout an entire nation or within a small hospital. _Macroallocation_ refers to the amount and distribution of resources within a society, whereas _microallocation_ refers to resource constraints at the level of an individual physician or institution. Macroallocation decisions may be more significant, affecting thousands or millions of people. Microallocation choices can be more acute, bringing ethical dilemmas into stark, uncompromising focus and placing issues of resource allocation squarely in the lap of the practicing physician. The microallocation choice involving Ms. Wilson incorporates all four ethical principles, which must be weighed and acted on within minutes: (1) Beneficence: For whom? This ideal cannot be realized for both patients. (2) Nonmaleficence: If Ms. Wilson is removed from the respirator, harm is done to her, but the price of not harming her is great for Mr. Ford. (3) Autonomy: Withdrawal of therapy requires the consent of the patient or family, which is impossible in Ms. Wilson's case. (4) Justice: Should resources be distributed on a first-come first-served basis or according to need?\n\nThese are tragic decisions. Many physicians would remove Ms. Wilson from the respirator and make all efforts to save Mr. Ford. The main consideration would be medical effectiveness: Ms. Wilson's chance of living more than a few months is slim, while Mr. Ford could be cured and live for many decades.\n\nLess stark but similar decisions face physicians on a daily basis. On a busy day, which patients get more of the physician's time? In a public hospital with an MRI waiting list, when should a physician call the radiologist and argue for an urgent scan, thereby pushing other people down on the waiting list? Situations involving microallocation demonstrate why, in real life, health care professionals are forced to balance the interests of one patient against those of another and the interests of individuals against the imperatives of society.\n\n### **A BASIC LEVEL OF GUARANTEED MEDICAL BENEFITS**\n\n_Don Rich is a bank executive who receives his care through a New York City HMO. He develops angina pectoris, which remains stable for over a year. An exercise treadmill test suggests mild coronary artery disease. Although this evaluation indicates that Mr. Rich's condition can be safely managed with medications, he asks his cardiologist to arrange a coronary angiogram with an angioplasty or coronary bypass if indicated. He is told that the HMO has finite resources for such procedures and limits their use to patients with unstable angina or highly abnormal treadmill tests, for whom the procedures are more efficacious. Mr. Rich flies to Texas, consults with a private cardiac surgeon, and receives a coronary angiogram at his own expense._\n\nMost people in the United States believe that health care should be a right. But how much health care? If every person has a right to all beneficial health care, the nation may be unable to pay the bill or may be forced to limit other rights such as education or fire and police protection. One approach to this problem is to limit the health care right to a basic package of services. (In the case of Don Rich's HMO, angiography for stable angina pectoris is not within the basic package.) Any services beyond the basics can be purchased by individuals who choose to spend their own money. This solution creates an ethical problem. If a service that does produce medical benefit is not included in the basic package or is denied by an insurance company medical director, that service becomes available only to those who can afford it. Where should society draw the line between a basic level of care that should be equally available to all, and \"more than basic\" services that may be purchased according to individual ability and willingness to pay (Eddy, 1991b)? Unless the basic package covers all beneficial health services, the principle of distributive justice, that all people equally receive a reasonable level of medical services without regard to ability to pay, will be compromised.\n\n### **THE ETHICS OF HEALTH CARE FINANCING**\n\n_Yoshiko Takahashi's first heart attack came at age 59. It was minor, and she felt well the next day. Then came the real shock: because of her high blood pressure, her private insurance policy considers disease of the cardiovascular system a preexisting condition and will not cover costs for complications of hypertension. She demands to go home to limit her hospital bill. Twelve hours later comes the second heart attack, which is severe. She is readmitted to intensive care and remains in the hospital for 8 more days. Because of persistent pain, she is a candidate for coronary angiography, which she refuses on account of the cost. When she purchased the insurance, Ms. Takahashi had not understood its terms because her English skills were poor._\n\nDecisions by physicians encompass only one aspect of resource allocation; the payers of health care have great power in the distribution of medical care. The policies of the private insurance industry, which covers the largest number of people in the United States, raise important ethical issues. In the case of Yoshiko Takahashi, the insurance company, rather than her physicians, largely determined what kind of medical care she received.\n\nPrivate insurance may be experience rated (see Chapter 2), with premiums costing more for people or groups with a higher risk of illness. Under the practice of experience rating, people who need health care the most (because they have a chronic illness) are less likely to be able to purchase affordable health insurance. Many people feel that private insurers violate the justice principle because those most in need of services have the least chance of gaining coverage for those services.\n\nHealth insurance executives, however, have a different view, believing that private health insurance is fair. An advertisement sponsored by the insurance industry argued,\n\n_If insurance companies didn't put people into risk groups [experience rating], it would mean that low-risk people would be arbitrarily mixed in with high-risk people.... and [low-risk people] would have to pay higher rates. That would be unfair to everyone. (Light, 1992)_\n\nAccording to this notion, it is unfair to force one person or group to pay for the needs or burdens of another. An alternative view, citing the principle of distributive justice, holds that young and healthy people should pay more in health costs than they use in health services so that older and less healthy people can receive health services at a reasonable cost. Even from the perspective of one's own long-term self-interest, it makes sense to pay more for health care while young and healthy, and to pay less when advanced age creates a greater risk of becoming sick.\n\nA much-discussed issue involves individuals whose behavior, particularly smoking, eating unhealthy diets, and drinking alcohol in excess, is seen as contributing to their ill health.\n\n_Jim Butts, a heavy smoker, develops emphysema and has multiple hospitalizations for respiratory failure, including many days on the respirator. Randy Schipp, a former shipyard worker, develops work-related asbestosis and has multiple hospitalizations for respiratory failure, including many days on the respirator. Should Jim pay more for health insurance than Randy?_\n\n_Gene eats a low-fat diet, exercises regularly, but has a strong family history of heart disease; he suffers a heart attack at age 44. Mac eats fast food, does not exercise, and has a heart attack at age 44. Should Mac pay more for health care coverage than Gene?_\n\nOne view holds that individuals who fall sick as a result of high-risk behavior such as smoking, substance abuse including use of alcohol, and consumption of high-fat foods are entirely responsible for their behavior and should pay higher health insurance premiums. Opponents of this idea see it as \"blaming the victim\" and argue that high-risk behaviors have a complex causation that may involve genetic and environmental factors including uncontrollable addiction. They cite a number of facts to support their position. The food industry spends billions of dollars each year on television advertising; the average child sees thousands of food commercials each year, most of them for products with poor nutritional value. The tobacco industry heavily advertises to teenagers. Illegal drug use is associated with poverty, hopelessness, and easy availability of drugs. Some evidence finds a genetic predisposition to alcoholism. To the extent that individuals are not entirely at fault for their high-risk behavior, it would be unfair to charge them more for health insurance. On the other hand, it seems sensible that users of tobacco and alcohol pay through taxes on those products.\n\n### **WHO ALLOCATES HEALTH CARE RESOURCES?**\n\nThe predicament of limited resources has been likened to a herd of cattle grazing on a common pasture. The total grazing area may be regarded as the entirety of economic resources in the United States. A smaller pasture, the _medical commons_ , comprises that portion of the grazing area dedicated to health care. The herd represents the nation's physicians, using the resources of the commons in the process of providing care to patients. Physicians, guided by medicine's moral imperative to \"do everything possible for the patient,\" continually attempt to extend the borders of the medical commons. But communities outside the medical commons have legitimate claims to societal resources and view the herd as encroaching on resources needed for other pursuits (Grumbach and Bodenheimer, 1990).\n\nWho decides the magnitude of the medical commons, that is, the resources devoted to health care? Physicians and other health care providers, whose interventions on behalf of their patients add up to the totality of medical resources used? The sum of individual consumer choices operating through a free market? Health insurance plans, watching over their particular piece of the commons? Or government, using the political process to set budgetary limits on the entire health care system?\n\nTraditionally, physicians and patients have had a great deal to say about the size of the medical commons. In the United States, the medical commons traditionally has been an open range. The quantity and price of medical visits, hospital days, surgeries, diagnostic studies, pharmaceuticals, and other such interventions determine the total costs of medical care. This is not the case in other nations, where government health care budgets constitute a \"fence\" around the medical commons, setting a clear limit on the quantity of resources available. Some advocates of fence-building in the United States have considered parceling the medical commons into numerous sub-pastures, each representing an HMO or Accountable Care Organization (see Chapter 6) working within the constraints of fixed, prepaid budgets. Not all pastures would be equal in size, and the fences would have holes that allow patients to purchase additional services outside of the organized systems of care.\n\nEthical considerations play a role in both open and closed medical care systems. In the US open range, the principles of beneficence and autonomy have the upper hand, tending toward an expanding, though not equitable, system. Fenced-in systems, in contrast, balance the more expansive principles of beneficence and autonomy with the demands of distributive justice in order to allocate resources within the medical commons.\n\nIf the United States moves toward a more fenced-in medical commons, decisions will be needed about who gets what. Do all 90-year-old people with multiple organ failure receive kidney dialysis that may extend their lives only a few months? Are very low-birth-weight infants afforded neonatal intensive care even with a small chance of leading a normal life? Do individual physicians, interacting with their patients, have the final say in making these decisions? Should societal bodies such as government, commissions of interested parties, or professional associations set the rules?\n\nMicroallocation issues come down to daily clinical decisions about which individual patients will receive what types of care (Lo, 2009). Physicians and other caregivers may well recoil from the prospect of \"bedside rationing,\" believing that allocative decision making unduly compromises their commitment to the principles of beneficence and autonomy. Levinsky (1984) has argued that physicians must maintain their single-mindedness in maximizing care for each patient:\n\n_There is increasing pressure on doctors to serve two masters. Physicians in practice are being enjoined to consider society's needs as well as each patient's needs in deciding what type and amount of medical care to deliver.... When practicing medicine, doctors cannot serve two masters. It is to the advantage both of our society and of the individuals it comprises that physicians retain their historic single-mindedness. The doctor's master must be the patient. (Levinsky, 1984)_\n\nYet if physicians abstain from the arena of macroal-location decision making, who is to decide? Currently, these decisions are often made by medical directors of private insurance companies and the leaders of the Medicare and Medicaid programs. Studies have documented that such decisions vary from plan to plan, and even within a single insurance plan, a medical director may make different decisions on different days for similar patients (Light, 1994). If physicians refuse to accept two masters, then medicine will be granting allocation decisions to insurance company and governmental officials. The physician of the twenty-first century will continue to face individual patient responsibilities but will find it difficult to escape the obligation to balance the wishes of individual patients against the larger needs of society (Cassel, 1985; Morreim, 1989).\n\nIf physicians are to serve two masters (ie, to maintain their dedication to individual patients while at the same time responsibly managing resources), they need rules to assist them. These rules should operate at both a population and an individual level. At the population level, society should ideally decide which general treatments are to be collectively paid for through the process of universal health insurance. At the individual level, rules are needed to guide decisions about the prioritization of resources for specific patients. The workings of organ transplantation provide a model of how physicians can serve two masters: They do everything possible to procure organs for their transplant patients, but also accept the rules of the system that attempt to allocate organs in a fair manner (Benjamin et al, 1994). The modern health care professional is caught in a global ethical dilemma. On the one hand, patients and their families expect the best that modern technology can offer, paid for through private or public insurance. The imperatives of beneficence, nonmaleficence, and autonomy rule the bedside. On the other hand, grave injustices take place on a daily basis: An uninsured young person with a curable illness is unable to pay for care, while an insured, bedridden individual who had a stroke incurs vast medical bills during the last weeks of her ebbing life. Should not the physician at the stroke patient's bedside be concerned about both patients? However this dilemma is resolved, the principle of justice will relentlessly peek at the physician from under the bed.\n\n### **REFERENCES**\n\nAaron HJ, Schwartz WB. _The Painful Prescription_. Washington, DC: The Brookings Institution; 1984.\n\nAnnas GJ. \"Culture of life\" politics at the bedside\u2014the case of Terri Schiavo. _N Engl J Med_. 2005;352:1710.\n\nBeauchamp TL, Childress JF. _Principles of Biomedical Ethics_. 6th ed. New York: Oxford University Press; 2008.\n\nBenjamin M et al. What transplantation can teach us about health care reform. _N Engl J Med_. 1994;330:858.\n\nBenner JS et al. An evaluation of recent federal spending on comparative effectiveness research. _Health Affairs._ 2010;29:1768.\n\nBodenheimer T. The Oregon Health Plan: Lessons for the nation. _N Engl J Med_. 1997;337:651, 720.\n\nBrook RH, Lohr KN. Will we need to ration effective health care? _Issues Sci Technol_. 1986;3:68.\n\nCassel CK. Doctors and allocation decisions: A new role in the new Medicare. _J Health Polit Policy Law_. 1985;10:549.\n\nDranove D. _What's Your Life Worth? Health Care Rationing... Who Lives? Who Dies? And Who Decides?_ Upper Saddle River, NJ: Prentice Hall; 2003.\n\nEddy DM. Comparing benefits and harms: The balance sheet. _JAMA_. 1990;263:2493.\n\nEddy DM. The individual vs society: Is there a conflict? _JAMA_. 1991a;265:1446.\n\nEddy DM. What care is \"essential?\" What services are \"basic?\" _JAMA_. 1991b;265:782.\n\nEmanuel EJ et al. Managed care, hospice use, site of death, and medical expenditures in the last year of life. _Arch Intern Med_. 2002;162:1722.\n\nFisher ES, Welch HG, Wennberg JE. Prioritizing Oregon's hospital resources. _JAMA_. 1992;267:1925.\n\nGarber AM, Sox HC. The role of costs in comparative effectiveness research. _Health Aff_. 2010;29:1805.\n\nGrumbach K, Bodenheimer T. Reins or fences: A physician's view of cost containment. _Health Aff_. 1990;9:120.\n\nHogan C et al. Medicare beneficiaries' costs of care in the last year of life. _Health Aff_. 2001;20:188.\n\nJonsen AR et al. _Clinical Ethics: A Practical Guide to Ethical Decisions in Clinical Medicine_. 7th ed. New York, NY: McGraw-Hill; 2010.\n\nKilborn PT. Oregon falters on a new path to health care. _New York Times_. January 3, 1999.\n\nLaurentine KA, Bramstedt KA. Too poor for transplant: Finance and insurance issues in transplant ethics. _Prog Transplant_. 2010;20:178.\n\nLevinsky NG. The doctor's master. _N Engl J Med_. 1984;311:1573.\n\nLight DW. The practice and ethics of risk-rated health insurance. _JAMA_. 1992;267:2503.\n\nLight DW. Life, death, and the insurance companies. _N Engl J Med_. 1994;330:498.\n\nLo B. _Resolving Ethical Dilemmas. A Guide for Clinicians_. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2009.\n\nLubitz JD, Riley GF. Trends in Medicare payments in the last year of life. _N Engl J Med_. 1993;328:1092.\n\nLuce JM. Ethical principles in critical care. _JAMA_. 1990;263:696.\n\nMitchell JB, Bentley F. Impact of Oregon's priority list on Medicaid beneficiaries. _Med Care Res Rev_. 2000;57:216.\n\nMorreim EH. Fiscal scarcity and the inevitability of bedside budget balancing. _Arch Intern Med_. 1989;149:1012.\n\nOberlander J. Health reform interrupted: The unraveling of the Oregon Health Plan. _Health Affairs._ 2006:w96\u2013w105.\n\nReagan MD. Health care rationing: What does it mean? _N Engl J Med_. 1988;319:1149.\n\nRelman AS. Is rationing inevitable? _N Engl J Med_. 1990;322:1809.\n\nTask Force on Organ Transplantation. _Issues and Recommendations_. Washington, DC: US Department of Health and Human Services; 1986.\n\nTeno JM et al. Family perspectives on end-of-life care at the last place of care. _JAMA_. 2004;291:88.\n\nWiener JM. Rationing in America: overt and covert. In: Strosberg MA et al, eds. _Rationing America's Medical Care: The Oregon Plan and Beyond_. Washington, DC: The Brookings Institution; 1992.\n\n## **14 Health Care in Four Nations**\n\nThe financing and organization of medical care throughout the developed world spans a broad spectrum. In most countries, the preponderance of medical care is financed or delivered (or both) in the public sector; in others, like the United States, most people both pay for and receive their care through private institutions.\n\nIn this chapter, we describe the health care systems of four nations: Germany, Canada, the United Kingdom, and Japan. Each of these nations resides at a different point on the international health care continuum. Examining their diverse systems may aid us in our search for a suitable health care system for the United States.\n\nRecall from Chapter 2 the four varieties of health care financing: out-of-pocket payments, individual private insurance, employment-based private insurance, and government financing. Germany, Canada, the United Kingdom, and Japan emphasize the last two modes of payment. Germany finances medical care through government-mandated, employment-based private insurance, though German private insurance is a world apart from that found in the United States. Canada and the United Kingdom feature government-financed systems. Japan's financing falls between the German method of financing and the government model of Canada and the United Kingdom. Regarding the delivery of medical care, the German, Japanese, and Canadian systems are predominantly private, while the United Kingdom's is largely public.\n\nAlthough these four nations demonstrate great differences in their manner of financing and organizing medical care, in one respect they are identical: They all provide universal health care coverage, thereby guaranteeing to their populations financial access to medical services.\n\n### **GERMANY**\n\n#### **Health Insurance**\n\n_Hans Deutsch is a bank teller living in Germany. He and his family receive health insurance through a sickness fund that insures other employees and their families at his bank and at other workplaces in his city. When Hans went to work at the bank, he was required by law to join the sickness fund selected by his employer. The bank contributes 7.3% of Hans's salary to the sickness fund, and 8.2% is withheld from Hans's paycheck and sent to the fund. Hans's sickness fund collects the same 15.5% employer-employee contribution for all its members._\n\nGermany was the first nation to enact compulsory health insurance legislation. Its pioneering law of 1883 required certain employers and employees to make payments to existing voluntary sickness funds, which would pay for the covered employees' medical care. Initially, only industrial wage earners with incomes less than $500 per year were included; the eligible population was extended in later years.\n\nAlmost 90% of Germans now receive their health insurance through the mandatory sickness funds, with 10% covered by voluntary insurance plans (Figure 14\u20131). Several categories of sickness funds exist. Thirty-seven percent of people (mostly blue-collar workers and their families) belong to funds organized by geographic area; 33% (for the most part the families of white-collar workers) are in nationally based \"substitute\" funds; 21% are employees or dependents of employees who work in 700 companies that have their own sickness funds; and 6% are in funds covering all workers in a particular craft (Busse and Riesberg, 2004; Busse, 2008).\n\n**Figure 14\u20131.** The German national health insurance system.\n\nIn 2010, the proportion of earnings going to a sickness fund was set at 15.5%, with employers paying 47% and employees 53% of that amount. These contributions formerly went directly to the sickness funds, which are nonprofit, closely regulated entities that lie somewhere between the private and public sectors. Since 2009, employee and employer contributions are collected by a government-run health fund, which then distributes the money to health funds based on a risk-adjusted (more for older and sicker people) amount per insured person (Ornyanova and Busse, 2009). The number of sickness funds is shrinking, down from 1000 to less than 200 in 2011. The funds are not allowed to exclude people because of illness, or to raise contribution rates according to age or medical condition; that is, they may not use experience rating. The funds are required to cover a broad range of benefits, including hospital and physician services, prescription drugs, and dental, preventive, and maternity care. Because wages supporting health care financing are declining relative to health care costs, employers are proposing that their contribution be capped at 7% of earnings so that further increases are borne by employees (Zander et al, 2009).\n\n_Hans's father, Peter Deutsch, is retired from his job as a machinist in a steel plant. When he worked, his family received health insurance through a sickness fund set up for employees of the steel company. The fund was run by a board, half of whose members represented employees and the other half the employer. On retirement, Peter's family continuedits coverage through the same sickness fund with no change in benefits. The sickness fund continues to pay approximately 60% of his family's health care costs (subsidized by the contributions of active workers and the employer), with 40% paid from Peter's retirement pension fund._\n\n_Hans has a cousin, Georg, who formerly worked for a gas station in Hans's city, but is now unemployed. Georg remained in his sickness fund after losing his job. His contribution to the fund is paid by the government. Hans's best friend at the bank was diagnosed with lymphoma and became permanently disabled and unable to work. He remained in the sickness fund, with his contribution paid by the government._\n\nUpon retiring from or losing a job, people and their families retain membership in their sickness funds. Health insurance in Germany, as in the United States, is employment based, but German health insurance, unlike in the United States, must continue to cover its members whether or not they change jobs or stop working for any reason.\n\n_Hans's Uncle Karl is an assistant vice-president at the bank. Because he earns more than 49,500 Euros per year, he is not required to join a sickness fund, but can opt to purchase private health insurance. Many higher-paid employees choose a sickness fund; they are not required to join the fund selected by the employer for lower-paid workers but can join one of 15 national \"substitute\" funds._\n\nTen percent of Germans, with incomes more than 49,500 Euros per year (2011), choose voluntary private insurance. Private insurers pay higher fees to physicians than do sickness funds, often allowing their policyholders to receive preferential treatment. In summary, in Germany 88% of the populace belong to the mandatory sickness fund system, 10% opt for private insurance, 2% receive medical services as members of the armed forces or police, and less than 0.2% (all of whom are wealthy) have no coverage.\n\nGermany finances health care through a merged social insurance and public assistance structure (see Chapters 2, , and  for discussion of these concepts), such that no distinctions are made between employed people who contribute to their health insurance, and unemployed people, whose contribution is made by the government.\n\n#### **Medical Care**\n\n_Hans Deutsch develops chest pain while walking, and it worries him. He does not have a physician, and a friend recommends a general practitioner (GP), Dr. Helmut Arzt. Because Hans is free to see any ambulatory care physician he chooses, he indeed visits Dr. Arzt, who diagnoses angina pectoris\u2014coronary artery disease. Dr. Arzt prescribes some medications and a low-fat diet, but the pain persists. One morning, Hans awakens with severe, suffocating chest pain. He calls Dr. Arzt, who orders an ambulance to take Hans to a nearby hospital. Hans is admitted for a heart attack and is cared for by Dr. Edgar Hertz, a cardiologist. Dr. Arzt does not visit Hans in the hospital. Upon discharge, Dr. Hertz sends a report to Dr. Arzt, who then resumes Hans's medical care. Hans never receives a bill._\n\nGerman medicine maintains a strict separation of ambulatory care physicians and hospital-based physicians. Most ambulatory care physicians are prohibited from treating patients in hospitals, and most hospital-based physicians do not have private offices for treating outpatients. People often have their own primary care physician (PCP) but are allowed to make appointments to see ambulatory care specialists without referral from the primary care physician. Fifty-one percent of Germany's physicians are generalists, compared with only 35% in the United States. The German system tends to use a dispersed model of medical care organization (see Chapter 5), with little coordination between ambulatory care physicians and hospitals (Busse and Riesberg, 2004).\n\n#### **Paying Physicians and Hospitals**\n\n_Dr. Arzt was used to billing his regional association of physicians and receiving a fee for each patient visit and for each procedure done during the visit. In 1986, he was shocked to find that spending caps had been placed on the total ambulatory physician budget. If in the first quarter of the year, the physicians in his regional association billed for more patient services than expected, each fee would be proportionately reduced during the next quarter. If the volume of services continued to increase, fees would drop again in the third and fourth quarters of the year. Dr. Arzt discussed the situationwith his friend Dr. Hertz, but Dr. Hertz, as a hospital physician, received a salary and was not affected by the spending cap._\n\nAmbulatory care physicians are required to join their regional physicians' association. Rather than paying physicians directly, sickness funds pay a global sum each year to the physicians' association in their region, which in turn pays physicians on the basis of a detailed fee schedule. These sums have been based on the number of patients cared for by the physicians in each regional association, but in 2007, a risk-adjustment factor is being introduced that increases payments for populations with greater health problems. Since 1986, physicians' associations, in an attempt to stay within their global budgets, have reduced fees on a quarterly basis if the volume of services delivered by their physicians was too high. Sickness funds pay hospitals on a basis similar to the diagnosis-related groups used in the US Medicare program. Included within this payment is the salary of hospital-based physicians (Busse and Riesberg, 2004).\n\n#### **Cost Control**\n\nThe 1977 German Cost Containment Act created a body called Concerted Action, made up of representatives of the nation's health providers, sickness funds, employers, unions, and different levels of government. Concerted Action is convened twice each year, and every spring, it sets guidelines for physician fees, hospital rates, and the prices of pharmaceuticals and other supplies. Based on these guidelines, negotiations are conducted at state, regional, and local levels between the sickness funds in a region, the regional physicians' association, and the hospitals to set physician fees and hospital rates that reflect Concerted Action guidelines. Since 1986, not only have physician fees been controlled, but as described in the above vignette about Dr. Arzt, the total amount of money flowing to physicians has been capped. As a result of these efforts, Germany's health expenditures as a percentage of the gross domestic product actually fell between 1985 and 1991 from 8.7% to 8.5%.\n\nIn 1991, however, German health care costs resumed an upward surge, paving the way for a 1993 cost control law restricting the growth of sickness fund budgets. In 2004, Germany raised copayments, ceased coverage of over-the-counter drugs, and enacted new controls on pharmaceutical prices (Stock et al, 2006). While Germany's 2008 health care expenditures as a percent of GDP was the fifth highest among developed nations, this figure has remained stable since 2000, indicating that cost control measures limiting the size of sickness fund budgets are having success.\n\n### **CANADA**\n\n#### **Health Insurance**\n\n_The Maple family owns a small grocery store in Outer Snowshoe, a tiny Canadian town. Grandfather Maple has a heart condition for which he sees Dr. Rebecca North, his family physician, regularly. The rest of the family is healthy and goes to Dr. North for minor problems and preventive care, including children's immunizations. Neither as employers nor as health consumers do the Maples worry about health insurance. They receive a plastic card from their provincial government and show the card when they visit Dr. North._\n\n_The Maples do worry about taxes. The federal personal income tax, the goods and services tax, and the various provincial taxes take almost 40% of the family's income. But the Maples would never let anyone take away their health insurance system._\n\nIn 1947, the province of Saskatchewan initiated the first publicly financed universal hospital insurance program in North America. Other provinces followed suit, and in 1957, the Canadian government passed the Hospital Insurance Act, which was fully implemented by 1961. Hospital, but not physician, services were covered. In 1963, Saskatchewan again took the lead and enacted a medical insurance plan for physician services. The Canadian federal government passed universal medical insurance in 1966; the program was fully operational by 1971 (Taylor, 1990).\n\nCanada has a tax-financed, public, single-payer health care system. In each Canadian province, the single payer is the provincial government (Figure 14\u20132). During the 1970s, federal taxes financed 50% of health services, but the federal share declined to 22% by 1996, generating acrimony between the federal and provincial governments. In response to this political debate, the federal contributions began to increase in 2001. Currently, the federal government funds approximately one-third of provincial health expenditures (Canadian Institute for Health Information, 2010). Provincial taxes vary in type from province to province and include income taxes, payroll taxes, and sales taxes. Some provinces, for example British Columbia and Alberta, charge a compulsory health care premium\u2014essentially an earmarked tax\u2014to finance a portion of their health budgets.\n\n**Figure 14\u20132.** The Canadian national health insurance system.\n\nUnlike Germany, Canada has severed the link between employment and health insurance. Wealthy or poor, employed or jobless, retired or younger than 18, every Canadian receives the same health insurance, financed in the same way. No Canadian would even imagine that leaving, changing, retiring from, or losing a job has anything to do with health insurance. In Canada, no distinction is made between the two public financing mechanisms of social insurance (in which only those who contribute receive benefits) and public assistance (in which people receive benefits based on need rather than on having contributed). Everyone contributes through the tax structure and everyone receives benefits.\n\nThe benefits provided by Canadian provinces are broad, including hospital, physician, and ancillary services. Provincial plans also pay for outpatient drugs, although the scope of drug coverage\u2014and also long-term care benefits\u2014varies across provinces.\n\nThe Canadian health care system is unique in its prohibition of private health insurance for coverage of services included in the provincial health plans. Hospitals and physicians that receive payments from the provincial health plans are not allowed to bill private insurers for such services, thereby avoiding the preferential treatment of privately insured patients that occurs in many health care systems. Canadians can purchase private health insurance policies for gaps in provincial health plan coverage or for such amenities as private hospital rooms.\n\n#### **Medical Care**\n\n_Grandfather Maple has had intermittent sensations of palpitations in his chest for a few weeks. He calls Dr. North, who tells him to come right over. An electrocardiogram reveals rapid atrial fibrillation, an abnormal heart rhythm. Because Mr. Maple is tolerating the rapid rhythm, Dr. North starts treatment with metoprolol in the office to gradually slow his heart rate, tells him to return the next day, and writes out a referral slip to see Dr. Jonathan Hartwell, a cardiologist in a nearby small city._\n\n_Dr. Hartwell arranges a stress echocardiogram at the local hospital to evaluate Mr. Maple's arrhythmia, finds severe coronary ischemia, and explains to Mr. Maple that his coronary arteries are narrowed. He recommends a coronary angiogram and possible coronary artery bypass surgery. Because Mr. Maple's condition is not urgent, Dr. Hartwell arranges for his patient to be placed on the waiting list at the University Hospital in the provincial capital 50 miles away. One month later, Mr. Maple awakens at 2 AM in a cold sweat, gasping for breath. His daughter calls Dr. North, who urgently sends for an ambulance to transport Mr. Maple to the University Hospital. There Mr. Maple is admitted to the coronary care unit, his condition is stabilized, and he undergoes emergency coronary artery bypass surgery the next day. Ten days later, Mr. Maple returns home, complaining of pain in his incision but otherwise feeling well._\n\nApproximately half of Canadian physicians are family physicians (contrasted with the United States, where only 35% of physicians are generalists). Canadians have free choice of physician. As a rule, Canadians see their family physician for routine medical problems and visit specialists only through referral by the family physician. Specialists are allowed to see patients without referrals, but only receive the higher specialist fee if they specify the referring primary care physician in their billing; for that reason, most specialists will not see patients without a referral. Unlike the European model of separation between ambulatory and hospital physicians, Canadian family physicians are allowed to care for their patients in hospitals. Because of the close scientific interchange between Canada and the United States, the practice of Canadian medicine is similar to that in the United States; the differences lie in the financing system and the far greater use of primary care physicians. The treatment of Mr. Maple's heart condition is not significantly different from what would occur in the United States, with the exception that high-tech procedures such as cardiac surgery and magnetic resonance imaging (MRI) scans are regionalized in a limited number of facilities and performed far less frequently than in the United States. In 2007, Canada had 6.7 MRI scanners per million inhabitants compared with 25.9 in the United States (OECD, 2010).\n\nCanadians on average wait longer for elective operations than do insured people in the United States and also have slightly more difficulty accessing primary care physicians (Schoen et al, 2010). Over the past ten years the federal and provincial governments have implemented successful policies to reduce elective surgery delays (Ross and Detsky, 2009). The median 2005 wait time for nonemergency surgery in Canada was 4 weeks (Willcox et al, 2007). Despite queues for elective procedures, only a tiny number of Canadians cross the border to seek care in the United States (Katz et al, 2002).\n\nCanada's universal insurance program has created a fairer system for distributing health services. Canadians are much less likely than their counterparts in the United States to report experiencing financial barriers to medical care (Schoen et al, 2010). Low-income Canadians receive almost the same amount of medical services as Canadians from higher-income groups, whereas in the United States higher-income groups receive more health services than lower-income groups (Sanmartin et al, 2006). Nonetheless, inequities in care according to socioeconomic status remain in Canada despite universal insurance coverage (Guilfoyle, 2008).\n\n#### **Paying Physicians and Hospitals**\n\n_For Dr. Rebecca North, collecting fees is a simple matter. Each week she electronically bills the provincial government, listing the patients she saw and the services she provided. Within a month, she is paid in full according to a fee schedule. Dr. North wishes the fees were higher, but loves the simplicity of the billing process. Her staff spends 2 hours per week on billing, compared with the 30 hours of staff time her friend Dr. South in Michigan needs for billing purposes._\n\n_Dr. North is less happy about the global budget approach used to pay hospitals. She often begs the hospital administrator to hire more physical therapists, to speed up the reporting of laboratory results, and to institute a program of diabetic teaching. The administrator responds that he receives a fixed payment from the provincial government each year, and there is no extra money._\n\nMost physicians in Canada\u2014primary care physicians and specialists\u2014are paid on a fee-for-service basis, with fee levels negotiated between provincial governments and provincial medical associations (Figure 14\u20132). Physicians participating in the provincial programs must accept the government rate as payment in full and cannot bill patients directly for additional payment. Because fee-for-service payment emphasizes volume over quality of care and makes cost control difficult (see Chapter 9), Canadian provinces are experimenting with alternative forms of payment such as salary or capitation for physicians in group practice and clinic settings. By 2009, many primary care physicians in the province of Ontario were being paid capitation with bonuses for high quality (Collier, 2009).\n\nCanadian hospitals, most of which are private nonprofit institutions, negotiate a global budget with the provincial government each year. Hospitals have no need to prepare the itemized patient bills that are so administratively costly in the United States. Hospitals must receive approval from their provincial health plan for new capital projects such as the purchase of expensive new technology or the construction of new facilities. Canada also regulates pharmaceutical prices and provincial plans maintain formularies of drugs approved for coverage.\n\n#### **Cost Control**\n\nThe Canadian system has attracted the interest of many people in the United States because in contrast to the United States, the Canadians have found a way to deliver comprehensive care to their entire population at far less cost. In 1970, the year before Canada's single-payer system was fully in place, Canada and the United States spent approximately the same proportion of their gross domestic products on health care\u20147.2% and 7.4%, respectively. By 1990, Canada's health expenditures had risen to 9% of the gross domestic product, compared with 12% for the United States. In 2008, Canada dedicated 10.4% of its gross domestic product to health care while the United States reached 16% (OECD, 2010). The differences in cost between the United States and Canada are primarily accounted for by four items: (1) administrative costs, which are more than 300% greater per capita in the United States; (2) more widespread use of expensive high-tech services in the United States; (3) cost per patient day in hospitals, which reflects a greater intensity of service in the United States; and (4) physician fees and pharmaceutical prices, which are much higher in the United States (Anderson et al, 2003; Woolhandler et al, 2003; Reinhardt, 2008).\n\nWhile 2008 Canadian per capita health care costs ($4079) were far lower than those in the United States ($7538), Canada was the fifth highest on that measure among developed nations (OECD, 2010). Canadian concern with cost increases began in the 1990s, when Canadian provinces put into effect caps on physician payments similar to those used in Germany (Barer et al, 1996).\n\nHowever, the Canadian federal government's fiscal austerity policies of the 1990s appear to have shaken the public's traditionally high level of confidence in the Canadian health care system. In 2010, about one-quarter of Canadians were not confident that they would receive the care they needed (Schoen et al, 2010). This unrest in public opinion has prompted vigorous debate in Canada about whether to allow greater private financing of health care, raise taxes to increase public financing, or restructure services to improve efficiency (Steinbrook, 2006). By 2010, Canada had opted for the latter two options: a commitment of substantial increases in federal funds for provincial health plans coupled with reform of the organization of primary care and other services (Hutchison et al, 2011).\n\n### **THE UNITED KINGDOM**\n\n#### **Health Insurance**\n\n_Roderick Pound owns a small bicycle repair shop in the north of England; he lives with his wife and two children. His sister Jennifer is a lawyer in Scotland. Roderick's younger brother is a student at Oxford, and their widowed mother, a retired sales-woman, lives in London. Their cousin Anne is totally and permanently disabled from a tragic automobile accident. A distant relative, who became a US citizen 15 years before, recently arrived to help care for Anne._\n\n_Simply by virtue of existing on the soil of the United Kingdom\u2014whether employed, retired, disabled, or a foreign visitor\u2014each of the Pound family members is entitled to receive tax-supported medical care through the National Health Service (NHS)._\n\nIn 1911, Great Britain established a system of health insurance similar to that of Germany. Approximately half the population was covered, and the insurance arrangements were highly complex, with contributions flowing to \"friendly societies,\" trade union and employer funds, commercial insurers, and county insurance committees. In 1942, the world's most renowned treatise on social insurance was published by Sir William Beveridge. The Beveridge Report proposed that Britain's diverse and complex social insurance and public assistance programs, including retirement, disability and unemployment benefits, welfare payments, and medical care, be financed and administered in a simple and uniform system. One part of Beveridge's vision was the creation of a national health service for the entire population. In 1948, the NHS began.\n\nThe great majority of NHS funding comes from taxes. As in Canada, the United Kingdom completely separates health insurance from employment, and no distinction exists between social insurance and public assistance financing. Unlike Canada, the United Kingdom allows private insurance companies to sell health insurance for services also covered by the NHS. A number of affluent people\u201412.5% of the population in 2007\u2014purchase private insurance in order to receive preferential treatment, \"hopping over\" the queues for services present in parts of the NHS. Some employers offer such supplemental insurance as a perk. People with private insurance are also paying taxes to support the NHS (Figure 14\u20133).\n\n**Figure 14\u20133.** The British National Health Service: traditional model.\n\n#### **Medical Care**\n\n_Dr. Timothy Broadman is an English GP, whose list of patients numbers 1750. Included on his list is Roderick Pound and his family. One day, Roderick's son broke his leg playing soccer. He was brought to the NHS district hospital by ambulance and treated by Dr. Pettibone, the hospital orthopedist, without ever seeing Dr. Broadman._\n\n_Roderick's mother has severe degenerative arthritis of the hip, which Dr. Broadman cares for. A year ago, Dr. Broadman sent her to Dr. Pettibone to be evaluated for a hip replacement. Because this was not an emergency, Mrs. Pound required a referral from Dr. Broadman to see Dr. Pettibone. The orthopedist examined and x-rayed her hip and agreed that she needed a hip replacement, but not on an urgent basis. Mrs. Pound has been on thewaiting list for her surgery for more than 6 months. Mrs. Pound has a wealthy friend with private health insurance who got her hip replacement within three weeks from Dr. Pettibone, who has a private practice in addition to his employment with the NHS._\n\nPrior to the NHS, most primary medical care was delivered through GPs. The NHS maintained this tradition and formalized a gatekeeper system by which specialty and hospital services (except in emergencies) are available only by referral from a GP. Every person in the United Kingdom who wants to use the NHS must be enrolled on the list of a GP. There is free choice of GP (unless the GP's list of patients is full), and people can switch from one GP's list to another.\n\nWhereas the creation of the NHS in 1948 left primary care essentially unchanged, it revolutionized Britain's hospital sector. As in the United States, hospitals had mainly been private nonprofit institutions or were run by local government; most of these hospitals were nationalized and arranged into administrative regions. Because the NHS unified the United Kingdom's hospitals under the national government, it was possible to institute a true regionalized plan (see Chapter 5).\n\nPatient flow in a regionalized system tends to go from GP (primary care for common illnesses) to local hospital (secondary care for more serious illnesses) to regional or national teaching hospital (tertiary care for complex illnesses). Traditionally, most specialists have had their offices in hospitals. As in Germany, GPs do not provide care in hospitals. GPs have a tradition of working closely with social service agencies in the community, and home care is highly developed in the United Kingdom.\n\n#### **Paying Physicians and Hospitals**\n\n_Dr. Timothy Broadman does not think much about money when he goes to his surgery (office) each morning. He receives a payment from the NHS to cover part of the cost of running his office, and every month he receives a capitation payment for each of the 1750 patients on his list. Ten percent of his income has been coming from extra fees he receives when he gives vaccinations to the kids; does Pap smears, family planning, and other preventive care; and makes home visits after hours. Recently, he also received a substantial bonus from the new pay-for-performance system._\n\nSince early in the twentieth century, the major method of payment for British GPs has been capitation (see Chapter 4). This mode of payment did not change when the NHS took over in 1948. The NHS did add some fee-for-service payments as an encouragement to provide certain preventive services and home visits during nights and weekends. Consultants (specialists) are salaried employees of the NHS, although some consultants are allowed to see privately insured patients on the side, whom they bill fee-for-service.\n\nIn 2004, a major new payment mode began for GPs: pay for performance (P4P) (see Chapter 10), known in the United Kingdom as the Quality and Outcomes Framework. NHS management negotiated the program with the British Medical Association (BMA), and the success of the negotiations was in large part because of the government's policy of increasing payment to GP, whose average income rose by 60% from 2002 to 2007, with GP incomes approaching those of hospital specialists (Doran and Roland, 2010). The NHS and BMA agreed on dozens of clinical indicators measuring quality for preventive services and common chronic illnesses such as coronary heart disease, hypertension, diabetes, and asthma. In addition, physician practices are measured on practice organization\u2014involving such measures as documentation in medical records, ability of patients to access the practice by phone, computerization, and safe management of medications\u2014and on the patient experience as measured by patient surveys. Physician practices were awarded a maximum of 1050 points for GPs who performed well on all these measures. In 2005, each point was worth approximately \u00a3120 annually (more than $200). GP practices achieving maximum quality could potentially increase earnings by approximately $77,000 per physician (Roland, 2004).\n\nIn preparation for P4P, UK GP practices employed more nurses, established chronic disease clinics, and increased use of electronic medical records. In the first year of the program, practices in England scored a median of 1003 points, suggesting that a high level of quality was achieved. Moreover, performance improved faster among lower-quality practices, which narrowed inequalities in care. As a result, GP income increased markedly and the cost to the NHS was far greater than expected.\n\nThe extent to which actual quality was improved is unclear; successes may have been related in part to improved documentation rather than improved quality. Practices were allowed to exclude certain patients in the performance calculations on the basis of repeated no-shows, serious comorbidities, and other factors, introducing the possibility of \"gaming\" the system. An analysis of performance improvement prior to and following the introduction of P4P suggests that performance had been increasing before P4P, but that quality increased slightly faster after P4P for some chronic conditions. Nurses in GP practices were responsible for much of the quality improvement, as GPs delegated many preventive and chronic care tasks to them.\n\nBy 2009, an evaluation of the Quality and Outcomes Framework revealed that the rate of improvement in the quality of care increased for asthma and diabetes from 2003 to 2005, but not for heart disease. By 2007 the rate of improvement had slowed for all three conditions. Many practices had reached the quality benchmarks, which meant that the financial incentive to continue improving was blunted. Moreover, performance for quality measures removed from the Framework fell in some cases, suggesting that practices might neglect quality of care unassociated with financial rewards. No significant changes were found in patient reports of access to care and interpersonal aspect of care, but continuity of care decreased after the introduction of the Framework (Campbell et al, 2009; Doran and Roland, 2010).\n\n#### **Cost Control**\n\nHealth expenditures in the United Kingdom accounted for 7.0% of the gross domestic product (GDP) in 2000, far below the US figure of 13.4%. Believing that the NHS needed more resources, the government of Prime Minister Tony Blair infused the NHS with a major increase in funds. Between 1999 and 2004, the number of NHS physicians increased by 25%. In addition, the pay-for-performance system channeled the equivalent of several billion new dollars into physician practices (Roland, 2004; Klein, 2006). By 2008, health expenditures as a proportion of the GDP had risen to 8.7% and per capita spending had increased from $1837 (2000) to $3129 (2008), a 37% increase (OECD, 2010). In 2005, as a result of this large growth in health expenditures, the NHS found itself in a serious deficit and scaled back some of the increase in NHS staffing (Klein, 2006).\n\nIn spite of these developments, the United Kingdom continues to have a relatively low level of per capita health expenditures. Two major factors allow the United Kingdom to keep its health care costs low: the power of the governmental single payer to limit budgets and the mode of reimbursement of physicians. While Canada also has a single payer of health services, it pays most physicians fee-for-service and had to create physician expenditure caps (like Germany) in an attempt to control the inflationary tendencies of fee-for-service reimbursement. In contrast, the United Kingdom relies chiefly on capitation and salary to pay physicians; payment can more easily be controlled by limiting increases in capitation payments and salaries. Moreover, because consultants (specialists) in the United Kingdom are NHS employees, the NHS can and does tightly restrict the number of consultant slots, including those for surgeons. As a result, queues have developed for nonemergency consultant visits and elective surgeries (Hurst and Siciliani, 2003). From 2005 to 2007, 30% of patients with cerebrovascular events and an indication for carotid artery surgery experienced a delay of over 12 weeks in spite of national guidelines recommending surgery within 2 weeks of the onset of symptoms (Halliday et al, 2009). In 2006, the United Kingdom had 5.6 MRI scanners per million population compared with the US rate of 25.9 (OECD, 2010). Overall, the United Kingdom controls costs by controlling the supply of personnel and facilities and the budget for medical resources, and by investing heavily in a primary care system that has achieved some of the best quality measures in the developed world (Doran and Roland, 2010).\n\nThe United Kingdom is often viewed as a nation that rations certain kinds of health care. In fact, primary and preventive care are not rationed, and average waiting times to see a GP in the United Kingdom are significantly shorter than those for people in the US seeking medical appointments (Schoen et al, 2010). Overall, a striking characteristic of British medicine is its economy. British physicians simply do less of nearly everything\u2014perform fewer surgeries, prescribe fewer medications, order fewer x-rays, and are more skeptical of new technologies than US physicians (Payer, 1988).\n\n#### **Reforms of the National Health Service**\n\nA series of dramatic structural changes have been introduced into the NHS over the past 2 decades. In 1991, the Conservative government of Margaret Thatcher implemented market-style reforms requiring hospitals to compete for business by reducing delays for specialty and surgical care, and introducing general practitioner fundholding, by which GP practices could choose to receive a global budget to purchase all care for their panel of patients. In 1997, Tony Blair's Labor government abolished GP fundholding and replaced it with primary care trusts\u2014a network of GPs working in the same district. All GP practices were required to join a primary care trust, which was given the responsibility for planning primary care and community health services in its area, contracting with hospitals and hospital consultants for specialty care, scrutinizing GP practice patterns, and implementing quality improvement activities. The average primary care trust had approximately 50 GP members, as well as additional primary care representatives from other professions, and covered a population of approximately 100,000 enrolled patients (Figure 14\u20134). Eighty-five percent of NHS funding flowed through the trusts, which were responsible for contracting for specialty and hospital services (Klein, 2004). As a result of the package of reforms (primary care trusts, the Quality and Outcomes Framework, and increased NHS funding), waiting times dropped, primary care access increased, chronic disease outcomes improved, and patient satisfaction grew.\n\n**Figure 14\u20134.** The British National Health Service: Recent reforms.\n\nIn 2010, the new coalition government proposed yet another major structural reform, abolishing the primary care trusts but strengthening the policy of giving groups of GPs large budgets from which they will fund primary care and buy specialty care for their patients. These GP commissioning groups will receive up to 70% of the NHS budget. GPs will either organize consortia to receive their budgets or be assigned to a consortium. This reform is touted as a shift in control from managers to physicians even though it is not clear that GPs want to manage budgets. As of early 2011, 170 consortia have been formed and 100 more are emerging. As the third major upheaval in 20 years, with each turnaround requiring several years to implement, it is unclear how health care providers and patients will fare in this constantly changing environment (Roland and Rosen, 2011), with critics complaining about a pattern of repeated \"redisorganization\" of the NHS from one governing party to the next.\n\n### **JAPAN**\n\n#### **Health Insurance**\n\n_Akiko Tanino works in the accounting department of the Mazda car company in Tokyo. Like all Mazda employees, she is enrolled in the health insurance plan directly operated by Mazda. Each month, 4% of Akiko's salary is deducted from her paycheck and paid to the Mazda health plan. Mazda makes an additional payment to its health plan equivalent to 4% of Akiko's salary._\n\n_Akiko's father Takeshi recently retired after working for many years as an engineer at Mazda. When he retired, his health insurance changed from the Mazda company plan to the community-based health insurance plan administered by the municipal government where he lives. Mazda makes payments to this health insurance plan to help pay for the health care costs of the company's retirees. In addition, the health insurance plan requires that Takeshi pay the plan a premium indexed to his income._\n\n_Akiko's brother Kazuo is a mechanic at a small auto repair shop in Tokyo. He is automatically enrolled in the government-managed health insurance plan operated by the Japanese national government. Kazuo and his employer each contribute payments equal to 4.1% of Kazuo's salary to the government plan._\n\nAlthough Japanese society has a cultural history distinct from the other nations discussed in this chapter, its health care system draws heavily from European and North American traditions. Similar to Germany, Japan's modern health insurance system is rooted in an employment-linked social insurance program. Japan first legislated mandatory employment-based social insurance for many workers in 1922, building on preexisting voluntary mutual aid societies. The system was gradually expanded until universal coverage was achieved in 1961 with passage of the National Health Insurance Act. The Japanese insurance system differs from the German model by having different categories of health plans with even more numerous individual plans and less flexibility in choice of plan (Figure 14\u20135).\n\n**Figure 14\u20135.** The Japanese health system.\n\nEmployers with 700 or more employees are required to operate self-insured plans for their employees and dependents, known as \"society-managed insurance\" plans. Although these plans resemble the German industry-specific sickness funds, each company must operate its own individual health plan. Approximately 1800 different employer-based plans exist. Eighty-five percent of these society plans are operated by individual companies, with the balance operated as joint plans between two or more employers, although none involve as many companies as the typical German sickness fund. The boards of directors of society plans comprise 50% employee and 50% employer representatives. Employees and their dependents are required to enroll in their company's society plan, and the employee and the employer must contribute a premium to fund the society. Because each plan is self-insured, the premium rate varies (from 3% to 9.5% in 2006) depending on the average income and health risk of the company's employees, creating considerable inequities (Imai, 2002; Kemporen, 2007). Society-managed insurance plans cover 24% of the Japanese population.\n\nEmployees and dependents in companies with fewer than 700 employees are compulsorily enrolled in a single national health insurance plan for small businesses that is operated by the national government. This government-managed insurance plan, primarily financed by a premium (8.2% in 2006) on employers and employees, covers 28% of the population. The federal government also uses general tax revenues to subsidize the government-managed insurance plan.\n\nYet a third type of health insurance, community-based health insurance (also called citizens' health insurance), covers self-employed workers and retirees (41% of the population). Each municipal government in Japan administers a local citizen's insurance plan and levies a compulsory premium on the self-employed workers and retirees in its jurisdiction. In addition, each employer-operated society-managed insurance plan and the single government-managed insurance plan must contribute payments to subsidize the costs for retirees. Approximately 40% of the financing for the citizens health insurance program comes from contributions from the society-managed and government-managed insurance plans, making employers liable for a large portion of the costs of their retirees' health care. Additional funds for the community-based health insurance plan come from general tax revenues.\n\nA smattering of smaller insurance programs exist for government employees and other special categories of workers, and resemble the society-managed insurance plans. Persons who become unemployed remain enrolled in their health plan with the payroll tax waived. All plans are required to provide standard comprehensive benefits, including payment for hospital and physician services, prescription drugs, maternity care, and dental care. In addition, in 2000 Japan implemented a new long-term insurance plan, financed by general tax revenues and a new earmarked income tax, which provides comprehensive benefits to disabled adults, including payment for home care, case management, and institutional services.\n\nBecause Japan's society is aging more rapidly than any other developed nation, inequities and imbalances have developed in the financing of care for the most expensive patients\u2014those at the highest age levels. In 2006, a new law was passed creating a more rational financing plan for retirees older than 75 (Kemporen, 2007).\n\nIn summary, Japan\u2014like Germany\u2014builds on an employment-based social insurance model, using additional general tax subsidies to create a universal insurance program. Compared with Germany, the national and local governments in Japan are more involved in directly administering health plans and a majority of Japanese are covered by government-run or government-managed plans rather than by employer-managed private plans (Kemporen, 2007).\n\n#### **Medical Care**\n\n_Takeshi Tanino's knee has been aching for several weeks. He makes an appointment at a clinic operated by an orthopedic surgeon. At the clinic Takeshi has a medical examination, an x-ray of the knee, and is scheduled for regular physical therapy. During the examination the orthopedist notes that Takeshi's blood pressure is high and recommends that Takeshi see an internist at a different clinic about this problem._\n\n_Six months later, Takeshi develops a cough and fever. He makes an appointment at the medical clinic of a nearby hospital run by Dr. Suzuki, is diagnosed with pneumonia, and is admitted to the medical ward. He is treated with intravenous antibiotics for 2 weeks and remains in the hospital for an additional 2 weeks after completing antibiotics for further intravenous hydration and nursing care._\n\nHealth plans place no restrictions on choice of hospital and physician and do not require preauthorization before using medical services. Most medical care is based on three types of settings: (1) independent clinics, each owned by a physician and staffed by the physician and other employees, with many clinics also having small inpatient wards; (2) small hospitals with inpatient and outpatient departments, owned by a physician with employed physician staff; and (3) larger public and private hospitals with outpatient and inpatient departments and salaried physician staff. Facilities are organized by specialty, with larger hospitals having a wide range of specialties and smaller hospitals and clinics offering a more limited selection of specialty departments. Care is delivered in a specialty-specific manner, with a few organizations using a primary care-oriented gatekeeper model (Reid, 2009).\n\nPhysician entrepreneurship is a strong element in the organization of health care in Japan. Most clinics and small hospitals are family-owned businesses founded and operated by independent physicians. Unlike clinics in the United States such as the Mayo Clinic and Palo Alto Medical Foundation that began as family-owned institutions but evolved into nonprofit organizations with ownership shared among a larger group of physician partners, most clinics in Japan have remained under the ownership of a single physician, often passed down within a family from one generation to another. Many physicians expanded their clinics to become small hospitals, but the government builds and operates the larger medical centers. The distinction between clinics and hospitals in Japan is not as great as in most nations. Clinics are permitted to operate inpatient beds and only become classified as hospitals when they have more than 20 beds. Approximately 30% of clinics in Japan have inpatient beds. Virtually all physicians either own clinics and hospitals or work as employees of a clinic or hospital, and practice only within their single institution. Although many physician-owned clinics and hospitals are modest facilities, others are larger institutions offering a wide array of outpatient and inpatient services featuring the latest biomedical technology, electronic medical records, and automated dispensing of medications.\n\nRates of hospital admission are relatively low in Japan and rates of surgery are approximately one-third the rate in the United States. A cultural norm that makes patients reluctant to undergo invasive procedures in part explains the low surgical rate in Japan. When hospitalized, patients remain unusually long compared with most developed nations; average lengths of stay vary by hospital from 16 to 29 days. Patients are allowed long periods to convalesce while still in the hospital (Ikegami and Campbell, 2004).\n\n#### **Paying Physicians and Hospitals**\n\n_One month after returning home from the hospital, Takeshi Tanino develops stomach pain that awakens him several nights. He makes an appointment at a general medical clinic run by Dr. Sansei. Dr. Sansei performs an endoscopy, which reveals gastritis. Dr. Sansei prescribes an H 2 blocker and arranges for Takeshi to return to the clinic every 4 weeks for the next 6 months. Takeshi's stomach ache improves after a few days of using the medication. At each follow-up visit, Dr. Sansei questions Takeshi about his symptoms and dispenses a new 4-week supply of medications._\n\nUntil recently, insurance plans paid both physicians and hospitals on a fee-for-service basis. In 2003, a per diem hospital payment based on diagnosis was introduced (Nawata et al, 2009) while physicians continue to be paid fee-for-service. The government strictly regulates physician fees, hospital payments, and medication prices, which are very low by US standards. The fee schedule is in many ways the opposite of US fees: In Japan, primary care services tend to command higher fees than do more specialized services such as surgical procedures and imaging studies. Services such as MRI scans that have shown large increases in volumes have had substantial cuts in fees (Ikegami and Campbell, 2004). Based on fee schedules in place in 2007, a family physician office visit might be reimbursed $5 or $10, one night's stay in a hospital $11, and a brain MRI $105 (Reid, 2009). Physicians make up for low fees with high volume, at times seeing 60 patients per day. In 2007 the number of physician visits per capita was 13.4, compared with 4.0 for the United States (OECD, 2010). Physicians are permitted to directly dispense medications, not just to prescribe them, and make a profit from the sale of pharmaceuticals. The government recently restricted how much physicians could charge patients for medications (Kemporen, 2007), but many physician visits are solely for the purpose of refilling medications. Quality of care in Japan is not systematically measured and is believed to vary greatly among physicians and hospitals (Henke et al, 2009).\n\n#### **Cost Control**\n\nHealth care costs in Japan were only 8.1% of GDP in 2007. However this is a considerable rise from 1990's 6.0%, and concerns are mounting due to Japan's demographics. The health care system relies heavily on payroll taxes and thus requires a large employed population. But with, a plummeting birth rate and the longest life expectancy in the world, Japan's population is aging faster than that of other developed nations. The proportion of Japanese older than 65 years is projected to increase from 12% in 1990 to 40% in 2050 (Kemporen, 2007). In comparison, the proportion of the US population older than 65 years will increase much more modestly, from 12% to 21%, during this same period.\n\nThrough its fee schedule, the government has kept medical prices low, which is the main cost containment strategy. But physicians are unhappy and see too many patients for short visits, while many hospitals are old and underfunded. The stresses resulting from Japan's demographic reality and its overstretched health care providers make for an uncertain future (Reid, 2009).\n\n### **CONCLUSION**\n\nKey issues in evaluating and comparing health care systems are access to care, level of health expenditures, public satisfaction with health care, and the overall quality of care as expressed by the health of the population. Germany, Canada, the United Kingdom, and Japan provide universal financial access to health care through government-run or government-mandated programs. These four nations have controlled health care costs more successfully than has the United States (Tables 14\u20131 and 14\u20132), though all four face challenges in containing their spending.\n\n**Table 14\u20131.** Total health expenditures as a percentage of gross domestic product (GDP), 1970\u20132008\n\n**Table 14\u20132.** Per capita health spending in US dollars, 2008\n\nSixteen percent of US adults surveyed in 2007 felt that the health system works well with only minor changes needed; 48% felt that fundamental change is needed, and 34% wanted the system rebuilt completely. Adults in Germany, Canada, and the United Kingdom had somewhat more favorable views of their health systems, though the majority in those countries also felt that major changes were needed (Schoen et al, 2007). Adults in the United States were much more likely than adults in Germany, the United Kingdom, and Canada to report problems with access to medical services due to costs (Figure 14\u20136).\n\n**Figure 14\u20136.** Problems accessing medical services due to costs.\n\nCrossnational comparisons of health care quality are treacherous since it is difficult to disentangle the impacts of socioeconomic factors and medical care on the health status of the population. But such comparisons can convey rough impressions of whether a health care system is functioning at a reasonable level of quality. From Table 14\u20133, it is clear that the United States has an infant mortality rate higher than Germany, Canada, the United Kingdom, and Japan, with the Japanese rate being the lowest. Japan also has the highest male and female life expectancy rates at birth. The life expectancy rate at age 65 is believed by some observers to measure the impact of medical care, especially its more high-tech component, more than it measures underlying socioeconomic influences. Even by this standard, the United States ranks below the other four nations (OECD, 2010). Researchers have developed another metric intended to assess the functioning of national health care systems, known as \"mortality amenable to health care\" (Nolte and McKee, 2008); the United States performs poorly on this metric as well relative to other nations (Table 14\u20133).\n\n**Table 14\u20133.** Health outcome measures\n\nJust as epidemiologic studies often derive their most profound insights from comparisons of different populations (see Chapter 11), research into health services can glean insights from the experience of other nations. As the United States confronts the challenge of achieving universal access to high-quality health care at an affordable cost, lessons may be learned from examining how other nations have addressed this challenge.\n\n### **REFERENCES**\n\nAnderson GF et al. It's the prices, stupid: Why the United States is so different from other countries. _Health Aff._ 2003;22(3):89.\n\nBarer ML, Lomas J, Sanmartin C. Re-minding our Ps and Qs: Medical cost controls in Canada. _Health Aff._ 1996;15(2):216.\n\nBusse R. The health system in Germany. _Eurohealth_. 2008;14(1):5.\n\nBusse R, Riesberg A. _Health Care Systems in Transition: Germany_. Copenhagen: WHO Regional Office for Europe; 2004.\n\nCampbell SM et al. Effects of pay for performance on the quality of primary care in England. _N Engl J Med_. 2009;261:368.\n\nCanadian Institute for Health Information. Health Care in Canada, 2010, December 2010. www.cihi.ca.\n\nCollier R. Shift toward capitation in Ontario. _Canadian Med Assoc J_. 2009;181:668.\n\nDoran T, Roland M. Lessons from major initiatives to improve primary care in the United Kingdom. _Health Aff._ 2010;29:1023. <https:\/\/www.mckinseyquarterly.com\/Improving_Japans_health_care_system_2311>. Accessed November 17, 2011.\n\nGuilfoyle J. Prejudice in medicine. Our role in creating health care disparities. _Can Fam Physician._ 2008;54:1511.\n\nHalliday AW et al. Waiting times for carotid endarterectomy in UK. _BMJ._ 2009;338:b1847.\n\nHenke N et al. Improving Japan's health care system. _McKinsey Q._ 2009.\n\nHurst J, Siciliani L. _Tackling Excessive Waiting Times for Elective Surgery_ : _A Comparison of Policies in Twelve OECD Countries_. Paris: Organisation for Economic Co-operation and Development; 2003.\n\nHutchison B et al. Primary health care in Canada: Systems in motion. _Milbank_ Q. 2011:89(2):256.\n\nIkegami N, Campbell JC. Japan's health care system: Containing costs and attempting reform. _Health Aff._ 2004;23(3):26.\n\nImai Y. Health Care Reform in Japan. Organisation for Economic Co-operation and Development, February 2002. www.oecd.org.\n\nKatz SJ et al. Phantoms in the snow: Canadians' use of health care services in the United States. _Health Aff._ 2002;21(3):19.\n\nKemporen (National Federation of Health Insurance Societies). Health Insurance, Long-Term Care Insurance and Health Insurance Societies in Japan, 2007. Kemporen, 2007.\n\nKlein R. Britain's National Health Service revisited. _N Engl J Med._ 2004;350:937.\n\nKlein R. The troubled transformation of Britain's National Health Service. _N Engl J Med._ 2006;355:409.\n\nNawata K, et al. Analysis of the new medical payment system in Japan, July 2009. www.mssanz.org.au\/modsim09\/A2\/nawata.pdf.\n\nNolte E, McKee CM. Measuring the health of nations: Updating an earlier analysis. _Health Aff_. 2008;27:58. Erratum in: _Health Aff_. 2008;27:593.\n\nOrnyanova D, Busse R. Health Fund now operational Health Policy Monitor, May 2009. www.hpm.org.\n\nOrganisation for Economic Co-operation and Development. OECD Health Data, 2010. www.oecd.org.\n\nPayer L. _Medicine and Culture._ New York: Henry Holt; 1988. Reid TR. _The Healing of America_. New York: The Penguin Press; 2009.\n\nReinhardt U. Why does US health care cost so much? _Economix_. November 14, 2008. <http:\/\/economix.blogs.nytimes.com>.\n\nRoland M. Linking physicians' pay to the quality of care\u2014a major experiment in the United Kingdom. _N Engl J Med._ 2004;351:1448.\n\nRoland M, Rosen R. British NHS embarks on controversial and risky market-style reforms in health care. _N Engl J Med_. 2011;364:1360.\n\nRoss JS, Detsky AS. Choice? Making health care decisions in the United States and Canada. _JAMA_. 2009;302:1803.\n\nSanmartin C et al. Comparing health and health care use in Canada and the United States. _Health Aff._ 2006;25:1133.\n\nSchoen C et al. Toward higher-performance health systems: Adults' health care experiences in seven countries, 2007. _Health Aff._ 2007;26:w717.\n\nSchoen C et al. How health insurance design affects access to care and costs: by income, in eleven countries. _Health Aff_. 2010;29:2323.\n\nSteinbrook R. Private health care in Canada. _N Engl J Med._ 2006;354:1661.\n\nStock S et al. The influence of the labor market on German health care reforms. _Health Aff._ 2006;25:1143.\n\nTaylor MG. _Insuring National Health Care. The Canadian Experience._ Chapel Hill, NC: University of North Carolina Press; 1990.\n\nWillcox S et al. Measuring and reducing waiting times: A cross-national comparison of strategies. _Health Aff._ 2007;26:1078.\n\nWoolhandler S et al. Costs of health care administration in the United States and Canada. _N Engl J Med._ 2003;349:768.\n\nZander B et al. Health policy in Germany after the election. _Health Policy Monitor_. November 2009. www.hpm.org.\n\n## **15 Health Care Reform and National Health Insurance**\n\nFor 100 years, reformers in the United States have argued for the passage of a national health insurance program, a government guarantee that every person is insured for basic health care. Finally in 2010, the United States took a major step forward toward universal health insurance.\n\nThe subject of national health insurance has seen six periods of intense legislative activity, alternating with times of political inattention. From 1912 to 1916, 1946 to 1949, 1963 to 1965, 1970 to 1974, 1991 to 1994, and 2009 to 2010, it was the topic of major national debate. In 1916, 1949, 1974, and 1994, national health insurance was defeated and temporarily consigned to the nation's back burner. Guaranteed health coverage for two groups\u2014the elderly and some of the poor\u2014was enacted in 1965 through Medicare and Medicaid. Expansion of coverage to over 30 million uninsured people was legislated with the Patient Protection and Affordable Care Act of 2010. National health insurance means the guarantee of health insurance for all the nation's residents\u2014what is commonly referred to as \"universal coverage.\" Most of the focus, as well as the political contentiousness, of national health insurance proposals tends to concern how to finance universal coverage. Because health care financing is so interwoven with provider reimbursement and cost containment, national health insurance proposals usually also address those topics.\n\nThe controversies that erupt over universal health care coverage become simpler to understand if one returns to the four basic modes of health care financing outlined in Chapter 2: out-of-pocket payment, individual private insurance, employment-based private insurance, and government financing. There is general agreement that out-of-pocket payment does not work as a sole financing method for costly contemporary health care. National health insurance involves the replacement of out-of-pocket payments by one, or a mixture, of the other three financing modes.\n\nUnder government-financed national health insurance plans, funds are collected by a government or quasigovernmental fund, which in turn pays hospitals, physicians, health maintenance organizations (HMOs), and other health care providers. Under private individual or employment-based national health insurance, funds are collected by private insurance companies, which then pay providers of care.\n\nHistorically, health care financing in the United States began with out-of-pocket payment and progressed through individual private insurance, then employment-based insurance, and finally government financing for Medicare and Medicaid (see Chapter 2). In the history of US national health insurance, the chronologic sequence is reversed. Early attempts at national health insurance legislation proposed government programs; private employment-based national health insurance was not seriously entertained until 1971, and individually purchased universal coverage was not suggested until the 1980s (Table 15\u20131). Following this historical progression, we shall first discuss government-financed national health insurance, followed by private employment-based and then individually purchased universal coverage. The most recent chapter of this history is the enactment under the administration of President Obama of the Patient Protection and Affordable Care Act of 2010, a pluralistic approach to national health insurance that draws on all three of these financing models: government financing, employment-based private insurance, and individually purchased private insurance.\n\n**Table 15\u20131.** Attempts to legislate national health insurance\n\n### **GOVERNMENT-FINANCED NATIONAL HEALTH INSURANCE**\n\n#### **The American Association for Labor Legislation Plan**\n\nIn the early 1900s, 25% to 40% of people who became sick did not receive any medical care. In 1915, the American Association for Labor Legislation (AALL) published a national health insurance proposal to provide medical care, sick pay, and funeral expenses to lower-paid workers\u2014those earning less than $1200 a year\u2014and to their dependents. The program would be run by states rather than the federal government and would be financed by a payroll tax\u2013like contribution from employers and employees, perhaps with an additional contribution from state governments. Payments would go to regional funds (not private insurance companies) under extensive government control. The funds would pay physicians and hospitals. Thus, the first national health insurance proposal in the United States\u2014because the money was collected by quasi-public funds through a mandatory tax\u2014can be considered a government-financed program (Starr, 1982).\n\n_In 1910, Edgar Peoples worked as a clerk for Standard Oil, earning $800 a year. He lived with his wife and three sons. Under the AALL proposal, Standard Oil and Mr. Peoples would each pay $13 per year into the regional health insurance fund, with the state government contributing $6. The total of $32 (4% of wages) would cover the Peoples family._\n\nThe AALL's road to national health insurance followed the example of European nations, which often began their programs with lower-paid workers and gradually extended coverage to other groups in the population. Key to the financing of national health insurance was its compulsory nature; mandatory payments were to be made on behalf of every eligible person, ensuring sufficient funds to pay for people who fell sick.\n\nThe AALL proposal initially had the support of the American Medical Association (AMA) leadership. However, the AMA reversed its position and the conservative branch of labor, the American Federation of Labor, along with business interests, opposed the plan (Starr, 1982). The first attempt at national health insurance failed.\n\n#### **The Wagner\u2013Murray\u2013Dingell Bill**\n\nIn 1943, Democratic Senators Robert Wagner of New York and James Murray of Montana, and Representative John Dingell of Michigan introduced a health insurance plan based on the social security system enacted in 1935. Employer and employee contributions to cover physician and hospital care would be paid to the federal social insurance trust fund, which would in turn pay health providers. The Wagner\u2013Murray\u2013Dingell bill had its lineage in the New Deal reforms enacted during the administration of President Franklin Delano Roosevelt. President Roosevelt had initially considered including a national health plan as part of the Social Security Act, but facing resistance from the AMA decided to omit health reform from the New Deal legislative package.\n\n_In the 1940s, Edgar Peoples' daughter Elena worked in a General Motors plant manufacturing trucks to be used in World War II. Elena earned $3500 per year. Under the 1943 Wagner\u2013Murray\u2013Dingell bill, General Motors would pay 6% of her wages up to $3000 into the social insurance trust fund for retirement, disability, unemployment, and health insurance. An identical 6% would be taken out of Elena's check for the same purpose. One-fourth of this total amount ($90) would be dedicated to the healthinsurance portion of social security. If Elena or her children became sick, the social insurance trust fund would reimburse their physician and hospital._\n\n_Edgar Peoples, in his seventies, would also receive health insurance under the Wagner\u2013Murray\u2013Dingell bill, because he was a social security beneficiary._\n\n_Elena's younger brother Marvin was permanently disabled and unable to work. Under the Wagner\u2013Murray\u2013Dingell bill he would not have received government health insurance unless his state added unemployed people to the program._\n\nAs discussed in Chapter 2, government-financed health insurance can be divided into two categories. Under the social insurance model, only those who pay into the program, usually through social security contributions, are eligible for the program's benefits. Under the public assistance (welfare) model, eligibility is based on a means test; those below a certain income may receive assistance. In the welfare model, those who benefit may not necessarily contribute, and those who contribute (usually through taxes) may not benefit (Bodenheimer and Grumbach, 1992). The Wagner\u2013Murray\u2013Dingell bill, like the AALL proposal, was a social insurance proposal. Working people and their dependents were eligible because they made social security contributions, and retired people receiving social security benefits were eligible because they paid into social security prior to their retirement. The permanently unemployed were not eligible.\n\nIn 1945, President Truman, embracing the general principles of the Wagner\u2013Murray\u2013Dingell legislation, became the first US president to strongly champion national health insurance. After Truman's surprise election in 1948, the AMA succeeded in a massive campaign to defeat the Wagner\u2013Murray\u2013Dingell bill. In 1950, national health insurance returned to obscurity (Starr, 1982).\n\n#### **Medicare and Medicaid**\n\nIn the late 1950s, less than 15% of the elderly had health insurance (see Chapter 2) and a strong social movement clamored for the federal government to come up with a solution. The Medicare law of 1965 took the Wagner\u2013Murray\u2013Dingell approach to national health insurance, narrowing it to people 65 years and older. Medicare was financed through social security contributions, federal income taxes, and individual premiums. Congress also enacted the Medicaid program in 1965, a public assistance or \"welfare\" model of government insurance that covered a portion of the low-income population. Medicaid was paid for by federal and state taxes.\n\n_In 1966, at age 66, Elena Peoples was automatically enrolled in the federal government's Medicare Part A hospital insurance plan, and she chose to sign up for the Medicare Part B physician insurance plan by paying a $3 monthly premium to the Social Security Administration. Elena's son, Tom, and Tom's employer helped to finance Medicare Part A; each paid 0.5% of wages (up to a wage level of $6600 per year) into a Medicare trust fund within the social security system. Elena's Part B coverage was financed in part by federal income taxes and in part by Elena's monthly premiums. In case of illness, Medicare would pay for most of Elena's hospital and physician bills._\n\n_Elena's disabled younger brother, Marvin, age 60, was too young to qualify for Medicare in 1966. Marvin instead became a recipient of Medicaid, the federal\u2013state program for certain groups of low-income people. When Marvin required medical care, the state Medicaid program paid the hospital, physician, and pharmacy, and a substantial portion of the state's costs were picked up by the federal government._\n\nMedicare is a social insurance program, requiring individuals or families to have made social security contributions to gain eligibility to the plan. Medicaid, in contrast, is a public assistance program that does not require recipients to make contributions but instead is financed from general tax revenues. Because of the rapid increase in Medicare costs, the social security contribution has risen substantially. In 1966, Medicare took 1% of wages, up to a $6600 wage level (0.5% each from employer and employee); in 2004, the payments had risen to 2.9% of all wages. The Part B premium has jumped from $3 per month in 1966 to $115.40 per month in 2011.\n\n#### **The 1970 Kennedy Bill and the Single-Payer Plan of the 1990s**\n\nMany people believed that Medicare and Medicaid were a first step toward universal health insurance. European nations started their national health insurance programs by covering a portion of the population and later extending coverage to more people. Medicare and Medicaid seemed to fit that tradition. Shortly after Medicare and Medicaid became law, the labor movement, Senator Edward Kennedy of Massachusetts, and Representative Martha Griffiths of Michigan drafted legislation to cover the entire population through a national health insurance program. The 1970 Kennedy\u2013Griffiths Health Security Act followed in the footsteps of the Wagner\u2013Murray\u2013Dingell bill, calling for a single federally operated health insurance system that would replace all public and private health insurance plans.\n\n_Under the Kennedy\u2013Griffiths 1970 Health Security Program, Tom Peoples, who worked for Great Books, a small book publisher, would continue to see his family physician as before. Rather than receiving payment from Tom's private insurance company, his physician would be paid by the federal government, perhaps through a regional intermediary. Tom's employer would no longer make a social security contribution to Medicare (which would be folded into the Health Security Program) and would instead make a larger contribution of 3% of wages up to a wage level of $15,000 for each employee. Tom's employee contribution was set at 1% up to a wage level of $15,000. These social insurance contributions would pay for approximately 60% of the program; federal income taxes would pay for the other 40%._\n\n_Tom's Uncle Marvin, on Medicaid since 1966, would be included in the Health Security Program, as would all residents of the United States. Medicaid would be phased out as a separate public assistance program._\n\nThe Health Security Act went one step further than the AALL and Wagner\u2013Murray\u2013Dingell proposals: It combined the social insurance and public assistance approaches into one unified program. In part because of the staunch opposition of the AMA and the private insurance industry, the legislation went the way of its predecessors: political defeat.\n\nIn 1989, Physicians for a National Health Program offered a new government-financed national health insurance proposal. The plan came to be known as the \"single-payer\" program, because it would establish a single government fund within each state to pay hospitals, physicians, and other health care providers, replacing the multipayer system of private insurance companies (Himmelstein and Woolhandler, 1989). Several versions of the single-payer plan were introduced into Congress in the 1990s, each bringing the entire population together into one health care financing system, merging the social insurance and public assistance approaches (Table 15\u20132). The California Legislature, with the backing of the California Nurses Association, passed a single-payer plan in 2006 and 2008, but the proposals were vetoed by the Governor.\n\n**Table 15\u20132.** Categories of national health insurance plans\n\n### **THE EMPLOYER-MANDATE MODEL OF NATIONAL HEALTH INSURANCE**\n\nIn response to Democratic Senator Kennedy's introduction of the 1970 Health Security Act, President Nixon, a Republican, countered with a plan of his own, the nation's first employment-based, privately administered national health insurance proposal. For 3 years, the Nixon and Kennedy approaches competed in the congressional battleground; however, because most of the population was covered under private insurance, Medicare, or Medicaid, there was relatively little public pressure on Congress. In 1974, the momentum for national health insurance collapsed, not to be seriously revived until the 1990s. The essence of the Nixon proposal was the employer mandate, under which the federal government requires (or mandates) employers to purchase private health insurance for their employees.\n\n_Tom Peoples' cousin Blanche was a receptionist in a physician's office in 1971. The physician did not provide health insurance to his employees. Under Nixon's 1971 plan, Blanche's employer would be required to pay 75% of the private health insurance premium for his employees; the employees would pay the other 25%._\n\n_Blanche's boyfriend, Al, had been laid off from his job in 1970 and was receiving unemployment benefits. He had no health insurance. Under Nixon's proposal, the federal government would pay a portion of Al's health insurance premium._\n\nNo longer was national health insurance equated with government financing. Employer mandate plans preserve and enlarge the role of the private health insurance industry rather than replacing it with tax-financed government-administered plans. While the Nixon plan preserved existing government programs such as Medicare and Medicaid, it proposed to expand coverage for the uninsured through a widening role for private, employment-based insurance. Government's new role under the Nixon plan would be to enforce private health insurance as a required benefit for employed people. The Nixon proposal changed the entire political landscape of national health insurance, moving it toward the private sector. In later years, Senator Kennedy embraced the employer mandate approach himself, fearing that the opposition of the insurance industry and organized medicine would kill any attempt to legislate government-financed national health insurance.\n\nDuring the 1980s and 1990s, the number of people in the United States without any health insurance rose from 25 million to more than 40 million (see Chapter 3). Approximately three-quarters of the uninsured were employed or were dependents of employed persons. The rapidly rising cost of health insurance premiums made insurance unaffordable for many businesses. In response to this crisis in health care access, President Clinton submitted legislation to Congress in 1993 calling for universal health insurance through an employer mandate, as well as broadened eligibility for Medicaid. Like the Nixon proposal, the essence of the Clinton plan was the requirement that employers pay for most of their employees' private insurance premiums.\n\nA variation on the employer mandate type of national health insurance is the voluntary approach. Rather than requiring employers to purchase health insurance for employees, employers are given incentives such as tax credits to cover employees voluntarily. The attempt of some states to implement this type of voluntary approach has failed to significantly reduce the numbers of uninsured workers.\n\n### **THE INDIVIDUAL-MANDATE MODEL OF NATIONAL HEALTH INSURANCE**\n\nIn 1989, a new species of national health insurance appeared, sponsored by the conservative Heritage Foundation: the individual mandate. Just as many states require motor vehicle drivers to purchase automobile insurance, the Heritage plan called for the federal government to require all US residents to purchase individual health insurance policies. Tax credits would be made available on a sliding scale to individuals and families too poor to afford health insurance premiums (Butler, 1991). Under the most ambitious versions of universal individual insurance proposals, neither employer-sponsored group insurance nor government-administered insurance would continue to play a role in financing health care. These existing financing models would be dismantled and replaced by a universal, individual mandate program. Ironically, the individual insurance mandate shares at least one feature with the single-payer, government-financed approach to universal coverage: Both would severe the connection between employment and health insurance, allowing portability and continuity of coverage as workers moved from one employer to another or became self-employed.\n\n_Tom Peoples received health insurance through his employer, Great Books. Under an individual mandate plan, Tom would be legally required to purchase health insurance for his family. Great Bookscould offer a health plan to Tom and his coworkers but would not be required to contribute anything to the premium. If Tom purchased private health insurance for his family at a cost of $8000 per year, he would receive a tax credit of $4000 (ie, he would pay $4000 less in income taxes). Tom's Uncle Marvin, formerly on Medicaid, would be given a voucher to purchase a private health insurance policy._\n\nWith individual mandate health insurance, the tax credits may vary widely in their amount depending on characteristics such as household income and how much of a subsidy the architects of individual mandate proposals build into the plan. In a generous case, a family might receive a $10,000 tax credit, subsidizing much of its health insurance premium. If the family's tax liability is less than the value of the tax credit, the government would pay the family the difference between the family's tax liability and $10,000.\n\nA related version of the individual mandate is a voucher system. Instead of issuing tax credits, the federal government would issue a voucher for a fixed dollar amount that could be used toward the purchase of health insurance, just as some local government jurisdictions issue vouchers that may be used to enroll children in private schools. In the most sweeping proposals, a tax-financed voucher system would completely replace existing insurance programs directly administered by government as well as employer-sponsorship of private insurance (Emanuel and Fuchs, 2005). Another version of individual health insurance expansion is the voluntary concept, which was proposed by President George W. Bush. Uninsured individuals would not be required to purchase individual insurance but would receive a tax credit if they chose to purchase insurance. The level of the tax credits in the Bush plan and similar proposals have been small compared to the cost of most health insurance policies, with the result that these voluntary approaches if enacted would have induced very few uninsured people to purchase coverage.\n\n#### **The Massachusetts Individual Mandate Plan of 2006**\n\nNearly 20 years after the Heritage Foundation drafted a proposal for a national individual mandate, Massachusetts enacted a state-level universal health coverage bill implementing the nation's first legislated individual mandate. The Massachusetts plan, enacted under the leadership of Republican Governor Mitt Romney, mandates that every state resident must have health insurance coverage meeting a minimum standard set by the state. Individuals are required to provide proof of coverage at the time of filing their annual tax return, and face a financial penalty for failing to provide evidence of coverage. The state provides subsidies for purchase of private health insurance coverage to individuals with incomes below 300% of the federal poverty level if they are not covered by the state's Medicaid program or through employment-based insurance.\n\n_Brian Mayflower earns $16,000 a year as a waiter to support himself as an aspiring actor in Boston. He has chronic asthma, with his inhaler medications alone costing more than $1,000 annually. He is not eligible for Medicaid and is required under the Massachusetts Plan to purchase a private health plan. As a low-income person, Brian receives a state subsidy for most of the premium cost of the plan. The plan has a $500 per year deductible but pays for most of Brian's medications once he meets the annual deductible._\n\n_Brian's sister Dorothy Mayflower is a self-employed accountant living in Springfield and earning $58,000 a year. At her income level, the Massachusetts state subsidy for insurance coverage would leave her having to pay $3000 per year toward the premium for a plan that has a $2000 per year deductible. Dorothy is in good health and is having trouble paying the mortgage on her house, which recently ballooned. She decides she will not enroll in a health insurance plan and instead pays the $900 fine to the state for not complying with the individual mandate._\n\nLike the Nixon employer mandate proposal, the Massachusetts individual mandate does not eliminate existing government insurance programs; it extends the reach of private insurance through a government mandate, in this case for individually purchased private insurance. State government provides an income-adjusted subsidy for individual coverage for people not eligible for employer-sponsored insurance and limits the degree to which private plans can experience-rate their premiums. The Massachusetts plan allows insurers to offer policies with large amounts of cost-sharing in the form of high deductibles and coinsurance. The plan also includes a weak employer mandate, requiring employers with more than 10 employees to either contribute toward insurance coverage for their employees or pay into the state fund that underwrites public subsidies for the individual mandate and related programs.\n\nThe Massachusetts Health Plan of 2006 is credited with reducing the uninsurance rate among nonelderly adults in Massachusetts from 13% in 2006 to 5% in 2009 (Long and Stockley, 2010). Some residents of the state, such as Dorothy Mayflower, continue to have trouble affording private insurance even with some degree of state subsidy, and the high levels of cost-sharing allowed under the minimum benefit standards leave many insured individuals with substantial out-of-pocket payments. In 2008, 18% of low-income people in Massachusetts reported unmet health care needs due to costs (copayments, deductibles, uncovered services) and about 20% of the entire population experienced difficulty accessing primary care due to the primary care shortage (Clark et al, 2011).\n\n### **THE PLURALISTIC REFORM MODEL: THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010**\n\nFollowing a year-long bitter debate, the Democrat-controlled House of Representatives and Senate passed the Affordable Care Act (ACA) without a single Republican vote. President Obama, on March 23, 2010, signed the most significant health legislation since Medicare and Medicaid in 1965 (Morone, 2010). Although the ACA was attacked as \"socialized medicine\" and a \"government takeover of health care,\" its policy pedigree derives much more from the proposals of a Republican President (Nixon) and Republican Governor (Romney) than from the single-payer national health insurance tradition of Democratic Presidents Roosevelt and Truman. The pluralistic financing model of the ACA includes individual and employer mandates for private insurance and an expansion of the publicly financed Medicaid program. Ironically, despite the ACA's close resemblance to the Massachusetts Health Plan of 2006, Mitt Romney, the former Governor of Massachusetts who supported and signed that state's reform bill, upon turning his sights to his candidacy for the Republican nomination for the 2012 presidential election, called for repeal of the ACA.\n\n_In 2013, Mandy Must is uninsured and works for a small shipping company in Texas that does not offer health insurance benefits. In 2014, if the ACA survives legal and political challenges, she would be required to obtain private insurance coverage. Mandy earns about $35,000 per year, and in 2014 would receive a federal subsidy of about $2000 toward her purchase of an individual insurance policy with a premium cost of $5000._\n\n_In 2013, Walter Groop works full-time as a salesperson for a large department store in Miami which does not offer health insurance benefits to its workers. In 2014, he begins to apply for an individual policy to meet the requirements of the ACA, but his employer informs him that the department store would start contributing toward group health insurance coverage for its employees to avoid paying penalties under the ACA._\n\n_In 2013, Job Knaught has been an unemployed construction worker in St. Louis for over 18 months and, aside from an occasional odd job, has no regular source of income. Because he is not disabled, he does not qualify for Medicaid despite being poor. In 2014, Job becomes eligible for Missouri's Medicaid program._\n\nThe ACA has four main components to its reform of health care financing:\n\n1. _Individual mandate_ : Beginning in 2014, the ACA requires virtually all US citizens and legal residents to have insurance coverage meeting a federally determined \"essential benefits\" standard. This standard would allow high-deductible plans to qualify, with out-of-pocket cost-sharing capped at $5950 per individual and $11,900 per family, in 2010 dollars. Those who fail to purchase insurance and do not qualify for public programs such as Medicaid, Medicare, or veteran's health care benefits must pay a tax penalty which would be gradually phased in by 2016, when it would equal the greater of $695 per year for an individual (up to $2085 for a family) or 2.5% of household income. Individuals and families below 400% of the Federal Policy Level are eligible for income-based sliding-scale federal subsidies to help them purchase the required health insurance.\n\n2. _Employer mandate_ : Also beginning in 2014, employers with 50 or more full-time employees face a financial penalty if their employees are not enrolled in an employer-sponsored health plan meeting the essential benefit standard and any of their employees apply for federal subsidies for individually purchased insurance. While this measure does not technically mandate large employers to provide health benefits to their full-time workers, it functionally has this effect by penalizing employers who do not provide insurance benefits and leave their employees to fend for themselves to comply with the individual mandate.\n\n3. _Medicaid eligibility expansion_ : As discussed in Chapter 2, Medicaid eligibility has traditionally required both a low income and a \"categorical\" eligibility requirement, such as being a child or an adult with a permanent disability. Effective in 2014, the ACA eliminates the categorical eligibility requirement and requires that states make all US citizens and legal residents below 133% of the Federal Poverty Level eligible for their Medicaid programs. In 2011, 133% of the Federal Poverty Level was $14,484 for a single person and $29,726 for a family of 4. The federal government pays states 100% of the Medicaid costs for beneficiaries qualifying under the expanded eligibility criteria for 2014 through 2016, with states contributing 10% after 2016. The benefit package is similar to current Medicaid benefits.\n\n4. _Insurance market regulation_ : The ACA also imposes some new rules on private insurance. One of the first measures of the ACA to be implemented in 2010 was a requirement that private health plans allow young adults up to age 26 to remain covered as dependents under their parents' health insurance policies. The ACA also eliminates caps on total insurance benefits payouts, prohibits denial of coverage based on preexisting conditions, and limits the extent of experience rating to a maximum ratio of 3-to-1 between a plan's highest and lowest premium charge for the same benefit package. The ACA also establishes state-based insurance exchanges to function as a clearing house to assist people seeking coverage under the individual mandate to shop for insurance plans meeting the federal standards (Kingsdale and Bertko, 2010). The benefit packages offered by plans in the exchanges would vary depending on whether individuals purchase a low-premium bronze plan with high out-of-pocket costs, a high-premium platinum plan with low out-of-pocket costs, or the intermediate silver or gold plans. These regulatory measures were deemed by many to be essential to the feasibility and fairness of an individual mandate. For example, mandates cannot work if insurers may deny coverage to individuals with preexisting conditions or steeply experience rate premiums. The insurance industry, for its part, balks at these types of market reforms in the absence of a mandate, fearing adverse disproportionate enrollment of high-risk individuals when coverage is voluntary.\n\nThe major coverage provisions of the ACA and their timeline for implementation are summarized in Table 15\u20133.\n\n**Table 15\u20133.** Key coverage measures and implementation timeline for the Affordable Care Act of 2010\n\nIf the ACA is implemented in its entirety, 32 million of the 51 million uninsured Americans are expected to receive insurance coverage, an estimated 16 million through Medicaid expansion and 16 million through the individual mandate (Kaiser Family Foundation, 2010). None of the coverage expansion measures would benefit undocumented immigrants; they would not be eligible for federal premium subsidies under the individual mandate nor for Medicaid except for emergency care.\n\nThe ACA is expected to cost $938 billion over 10 years, with most of the costs associated with Medicaid expansion and individual mandate subsidies. The law is financed by a combination of new taxes and fees and by cost savings in the Medicare and Medicaid programs. Individuals with earnings over $200,000 and married couples with earnings over $250,000 would pay more for Medicare Part A. Health insurance companies, pharmaceutical firms, and medical device manufacturers would pay yearly fees. Medicare Advantage insurance plans and hospitals would receive less payment from the Medicare program. The Congressional Budget Office estimated that the new law would reduce the federal deficit by $124 billion over 10 years, though the CBO projection is not universally accepted.\n\nIn developing a proposal to expand coverage by building on the existing pluralistic funding model rather than turning to a single-payer model, President Obama and his congressional allies successfully calculated that they would be able to garner the political support of some powerful interest groups, such as the American Medical Association and pharmaceutical industry, that had been stalwart opponents of health reform proposals in prior eras (Morone, 2010). However, some conservative groups that opposed the ACA did not relent after the Act's passage, and the ACA has come under political and judicial threats since its enactment. One of the first acts passed by the House of Representatives in its 2011 session after Republicans regained a majority of seats in the House was repeal of the ACA. The ACA remained law because the Senate, with a Democratic majority, did not vote to repeal. Republican Governors and Attorney Generals in many states filed suits against the ACA, challenging the constitutionality of the federal government's mandating of individuals to purchase a private product. Federal judges in district courts have issued different rulings on the constitutionality of the ACA, and the case will ultimately be heard by the US Supreme Court.\n\n### **SECONDARY FEATURES OF NATIONAL HEALTH INSURANCE PLANS**\n\nThe primary distinction among national health insurance approaches is the mode of financing: government versus employment-based versus individual-based health insurance, or a mixture of all three. But while the overall financing approach may be considered the headline news of reform proposals, some of the details in the fine print are extremely important in determining whether a universal coverage plan will be able to deliver true health security to the public (Table 15\u20134). What are some of these secondary features?\n\n**Table 15\u20134.** Features of national health insurance plans\n\n#### **Benefit Package**\n\nAn important feature of any health plan is its benefit package. Most national health insurance proposals cover hospital care, physician visits, laboratory, x-rays, physical and occupational therapy, inpatient pharmacy, and other services usually emphasizing acute care. One important benefit not included in the original Medicare program was coverage of outpatient medications. This coverage was later added in 2003 under Medicare Part D. Mental health services have often not been fully integrated into the benefit package of universal coverage proposals, a situation that has in part been addressed by the Mental Health Parity Act of 1996 and Mental Health Parity and Addiction Equity Act of 2008 which apply to group private health insurance plans. Neither the ACA nor most of its reform proposal precursors have included comprehensive benefits for dental care, long-term care, or complementary medicine services such as acupuncture.\n\n#### **Patient Cost Sharing**\n\nPatient cost sharing involves payments made by patients at the time of receiving medical care services. It is sometimes broadened to include the amount of health insurance premium paid directly by an individual. Naturally, the breadth of the benefit package influences the amount of patient cost sharing: The more the services are not covered, the more the patients must pay out of pocket. Many plans impose patient cost sharing requirements on covered services, usually in the form of deductibles (a lump sum each year), coin-surance payments (a percentage of the cost of the service), or copayments (a fixed fee, eg, $10 per visit or per prescription). In general, single payer proposals restrict cost sharing to minimal levels, financing most benefits from taxes. In comparison, the individual mandate provisions of the Massachusetts Health Act and the ACA include considerable amounts of cost sharing. The ACA, for example, would require an individual such as Mandy Must with an income between 300% and 400% of the federal poverty level to pay up to 9.5% of her income toward a health insurance premium, in addition to having to potentially pay thousands of dollars per year in deductibles and copayments at the time of service. Critics have argued that this degree of out-of-pocket payment raises questions about whether the Affordable Care Act is a bit of a misnomer and that people of modest incomes will continue to be underinsured and subject to large amounts of out-of-pocket expenses. The arguments for and against cost sharing as a cost containment tool are discussed in Chapter 9.\n\n#### **Effects on Medicare, Medicaid, and Private Insurance**\n\nAny national health insurance program must interact with existing health care programs, whether Medicare, Medicaid, or private insurance plans. Single-payer proposals make among the most far-reaching changes: Medicaid and private insurance are eliminated in their current form and are melded into a single insurance program that resembles a Medicare-type program for all Americans. The most sweeping versions of individual mandate plans, such as that proposed by the Heritage Foundation, would dismantle both employment-based private insurance and government-administered insurance programs. Employer mandates, which extend rather than supplant employment-based coverage, tend to have the least effect on existing dollar flow in the health care system, as do pluralistic models such as the ACA that preserve and extend existing financing models through mandates for private insurance and broadened eligibility for Medicaid.\n\n#### **Cost Containment**\n\nBy increasing people's access to medical care, national health insurance has the capacity to cause a rapid increase in national health expenditures, as did Medicare and Medicaid (see Chapter 2). By the 1990s, policymakers recognized that an increase in access must be balanced with measures to control costs.\n\nDifferent national health insurance proposals have vastly disparate methods of containing costs. As noted above, individual- and employment-based proposals tend to use patient cost sharing as their chief cost control mechanism. In contrast, government-financed plans look more to global budgeting and regulation of fees to keep expenditures down. Single-payer plans, which concentrate health care funds in a single public insurer, can more easily establish a global budgeting approach than can plans with multiple private insurers.\n\nProposals that build on the existing pluralistic financing model of US health care, such as the Clinton health plan and the ACA, face challenges in taming the unrelenting increases in national health care expenditures that seem to be endemic to a fragmented financing system. One of the items that contributed to the demise of President Clinton's health reform proposal before it could even be formally introduced as a bill in Congress was the inclusion of a measure to allow the federal government to cap the annual rates of increases in private health insurance premiums. President Obama eschewed such a regulatory approach in developing the ACA, and the ACA includes much weaker language about private insurance plans needing to \"justify\" premium increases to be able to continue to participate in state health insurance exchanges. In an effort to control costs, the ACA limits the percentage of health insurance premiums that can be retained by an insurance company in the form of overhead and profits (a concept known as the \"medical loss ratio,\" whereby a greater loss ratio means more premium dollars being \"lost\" by the company in the form of payments for actual health care services). The ACA also caps the amount that an employer can contribute toward a health insurance premium as a nontaxable benefit to the employee ($10,200 for an individual policy and $27,500 for a family policy), in an attempt to discourage enrollment in the most expensive plans. Many of the savings in the ACA are expected to come from slowing the rate of growth in expenditures for Medicare through measures such as reducing payments to Medicare Advantage HMO plans and appointing an Independent Payment Advisory Board to recommend methods to contain Medicare costs. Yet another strategy of the ACA for addressing costs is to redesign health care delivery to achieve better value, discussed next.\n\n#### **Reform of Health Care Delivery**\n\nThroughout the history of national health insurance proposals in the United States, reformers viewed their primary goal as modifying the methods of financing health care to achieve universal coverage. Addressing how providers were paid often emerged as a closely related consideration because of its importance for making universal coverage affordable. However, intervening in the way in which health care was organized and delivered was typically not something that featured prominently in reform proposals. Reformers tended to have their work cut out to overcome the strong opposition of the AMA and hospital associations to health insurance reform without further antagonizing those interests by challenging professional sovereignty over health care organization and delivery. Even many advocates of single payer reform in the United States looked to the lessons of the introduction of government insurance programs in the Canadian provinces, where until recently government took great pains to largely focus on insurance financing and payment rate regulation and not on reforming models for care delivery.\n\nThe ACA went considerably farther than most previous major reform proposals in the United States in including measures to shape health care delivery. The ACA created an Innovation Center in the Centers for Medicare and Medicaid Services to spearhead efforts to redesign care models in the United States. One of the charges to the Innovation Center is to promote Accountable Care Organizations. As discussed in Chapter 6, Accountable Care Organizations are intended to be provider-organized systems for delivering care that can emphasize more integrated and coordinated models of care for defined populations of patients, with financial incentives to reward higher value care. The Innovation Center also has responsibility for encouraging development of primary care Patient-Centered Medical Homes, also discussed in Chapter 5. Other measures in the ACA call for pilot programs to expand the roles of nurses, pharmacists, and other health care professionals in redesigned care models.\n\n### **WHICH FINANCING MODEL FOR NATIONAL HEALTH INSURANCE PLAN IS BEST?**\n\nHistorically, in the United States the government-financed single payer road to national health insurance is the oldest and most traveled of the three approaches. Advocates of government financing cite its universality: Everyone is insured in the same plan simply by virtue of being a US resident. Its simplicity creates a potential cost saving: The 25% of health expenditures spent on administration could be reduced, thus making available funds to extend health insurance to the uninsured. Employers would be relieved of the burden of providing health insurance to their employees. Employees would regain free choice of physician, choice that is being lost as employers are choosing which health plans (and therefore which physicians) are available to their workforce. Health insurance would be delinked from jobs, so that people changing jobs or losing a job would not be forced to change or lose their health coverage. Single-payer advocates, citing the experience of other nations, argue that cost control works only when all health care moneys are channeled through a single mechanism with the capacity to set budgets (Himmelstein and Woolhandler, 1989). While opponents accuse the government-financed approach as an invitation to bureaucracy, single-payer advocates point out that private insurers have average administrative costs of 14%, far higher than government programs such as Medicare with its 2% administrative overhead. A cost-control advantage intrinsic to tax-financed systems in which a public agency serves as the single payer for health care is the administrative efficiency of collecting and dispensing revenues under this arrangement.\n\nSingle-payer detractors charge that one single government payer would have too much power over people's health choices, dictating to physicians and patients which treatments they can receive and which they cannot, resulting in waiting lines and the rationing of care. Opponents also state that the shift in health care financing from private payments (out of pocket, individual insurance, and employment-based insurance) to taxes would be unacceptable in an antitax society. Moreover, the United States has a long history of politicians and government agencies being overly influenced by wealthy private interests, and this has contributed to making the public mistrustful of the government.\n\nThe employer mandate approach\u2014requiring all employers to pay for the health insurance of their employees\u2014is seen by its supporters as the most logical way to raise enough funds to insure the uninsured without massive tax increases (though employer mandates have been called hidden taxes). Because most people younger than 65 years now receive their health insurance through the workplace, it may be less disruptive to extend this process rather than change it.\n\nThe conservative advocates of individual-based insurance and the liberal supporters of single-payer plans both criticize employer mandate plans, saying that forcing small businesses\u2014many of whom do not insure their employees\u2014to shoulder the fiscal burden of insuring the uninsured is inequitable and economically disastrous; rather than purchasing health insurance for their employees, many small businesses may simply lay off workers, thereby pitting health insurance against jobs. Moreover, because millions of people change their jobs in a given year, job-linked health insurance is administratively cumbersome and insecure for employees, whose health security is tied to their job. Finally, critics point out that under the employer mandate approach, \"Your boss, not your family, chooses your physician\"; changes in the health plans offered by employers often force employees and their families to change physicians, who may not belong to the health plans being offered.\n\nAdvocates of the individual mandate assert that their approach, if adopted as the primary means of financing coverage, would free employers of the obligation to provide health insurance, and would grant individuals a stable source of health insurance whether they are employed, change jobs, or become disabled. There would be no need either to burden small businesses with new expenses and thereby disrupt job growth or to raise taxes substantially. While opponents argue that low-income families would be unable to afford the mandatory purchase of health insurance, supporters claim that income-related tax credits are a fair and effective method to assist such families (Butler, 1991).\n\nThe individual mandate approach is criticized as inefficient, with each family having to purchase its own health insurance. To enforce a requirement that every person buy coverage could be even more difficult for health insurance than for automobile insurance. Moreover, to reduce the price of their premiums, many families would purchase \"bare-bones insurance\" plans with low-cost, high-deductible coverage and a scanty benefit package, thereby leaving lower- and middle-income families with potentially unaffordable out-of-pocket costs.\n\n### **CONCLUSION**\n\nThe concept of national health insurance rests on the belief that everyone should contribute to finance health care and everyone should benefit. People who pay more than they benefit are likely to benefit more than they pay years down the road when they face an expensive health problem. In 2009, national health insurance took center stage in the United States with the fierce debate over health reform legislation that resulted in the ACA. This debate revealed a wide gulf between those who believe that all people should have financial access to health care and those who do not. The fate of the ACA will determine which of those two beliefs holds sway in the United States, until now the only developed nation that does not insure virtually all its citizens for health care.\n\n### **REFERENCES**\n\nBodenheimer T, Grumbach K. Financing universal health insurance: Taxes, premiums, and the lessons of social insurance. _J Health Polit Policy Law_. 1992;17:439.\n\nButler SM. A tax reform strategy to deal with the uninsured. _JAMA_. 1991;265:2541.\n\nClark CR et al. Lack of access due to costs remains a problem for some in Massachusetts despite the state's health reforms. _Health Aff._ 2011;30:247.\n\nEmanuel EJ, Fuchs VR. Health care vouchers\u2014a proposal for universal coverage. _N Engl J Med_. 2005;352:1255.\n\nHimmelstein DU, Woolhandler S. Writing Committee of Physicians for a National Health Program: A national health program for the United States: A physicians' proposal. _N Engl J Med_. 1989;320:102.\n\nKaiser Family Foundation. Summary of New Health Reform Law, 2010. <http:\/\/www.kff.org\/healthreform\/upload\/8061.pdf>. Accessed August 22, 2011.\n\nKingsdale J, Bertko J. Insurance exchanges under health reform: Six design issues for the states. _Health Aff._ 2010;29:1158.\n\nLong SK, Stockley K. Sustaining health reform in a recession: An update on Massachusetts as of Fall 2009. _Health Aff_. 2010;29:1234.\n\nMorone J. Presidents and health reform: From Franklin D. Roosevelt to Barack Obama. _Health Aff._ 2010;29:1096.\n\nStarr P. _The Social Transformation of American Medicine._ New York: Basic Books; 1982.\n\n## **16 Conflict and Change in America's Health Care System**\n\nAs this book enters its closing chapters, it is worth stepping back from the detailed workings of the US health care system to view the system as a larger whole. Who are the major actors? How have they interacted over the past few decades? What might the future bring?\n\n### **THE FOUR MAJOR ACTORS**\n\nThe health care sector of the nation's economy is a 2.5 trillion dollar-plus system that finances, organizes, and provides health care services for the people of the United States. Four major actors can be found on this stage (Table 16\u20131).\n\n**Table 16\u20131.** The four major actors\n\n1. The _purchasers_ supply the funds. These include individual health care consumers, businesses that pay for the health insurance of their employees, and the government, which pays for care through public programs such as Medicare and Medicaid. All purchasers of health care are ultimately individuals, because individuals finance businesses by purchasing their products and fund the government by paying taxes. Nonetheless, businesses and the government assume special importance as the nation's _organized_ purchasers of health care.\n\n2. The _insurers_ receive money from the purchasers and reimburse the providers. Traditional insurers take money from purchasers (individuals or businesses), assume risk, and pay providers when policyholders require medical care. Yet some insurers are the same as purchasers; the government can be viewed as an insurer or purchaser in the Medicare and Medicaid programs, and businesses that self-insure their employees can similarly occupy both roles. (In previous chapters, we have used the term \"payer\" to refer to both purchasers and insurers.)\n\n3. The _providers_ , including hospitals, physicians, nurses, nurse practitioners, physician assistants, pharmacists, social workers, nursing homes, home care agencies, and pharmacies, actually provide the care. While health maintenance organizations (HMOs) are generally insurers, some are also providers, owning hospitals and employing physicians.\n\n4. The _suppliers_ are the pharmaceutical, medical supply, and computer industries, which manufacture equipment, supplies, and medications used by providers to treat patients.\n\nInsurers, providers, and suppliers make up the health care industry. Each dollar spent on health care represents an expense to the purchasers and a gain to the health care industry. In the past, purchasers viewed this expense as an investment, money spent to improve the health of the population and thereby the economic and social vitality of the nation. But over the past 35 years, a fundamental conflict has intensified between the purchasers and the health care industry: The purchasers wish to reduce, and the health care industry to increase, the number of dollars spent on health care. We will now explore the changing relationships among purchasers, insurers, providers, and suppliers.\n\n### **THE YEARS 1945 TO 1970: THE PROVIDER\u2013INSURER PACT**\n\nDuring this period, independent hospitals and small private physician offices populated the US health delivery system (see Chapter 6). Some large institutions existed that combined hospital and physician care (eg, the Kaiser\u2013Permanente system, the Mayo Clinic, and urban medical school complexes), but these were the exception (Starr, 1982). Competition among health care providers was minimal because most geographic areas did not have an excess of facilities and personnel. The health care financing system included hundreds of private insurance companies, joined by the governmental Medicare and Medicaid programs enacted in 1965. The United States had a relatively dispersed health care industry.\n\n_Bert Neighbor was a 63-year-old man who developed abdominal pain in 1962. Because he was well insured under Blue Cross, his physician placed him in Metropolitan Hospital for diagnostic studies. On the sixth hospital day, a colon cancer was surgically removed. On the fifteenth day, Mr. Neighbor went home. The hospital sent its $1200 bill to Blue Cross, which paid the hospital for its total costs in caring for Mr. Neighbor. In calculating Mr. Neighbor's bill, Metropolitan Hospital included a small part of the cost of the 80-bed new building under construction._\n\n_At a subsequent meeting of the Blue Cross board of directors, the hospital administrator (also a Blue Cross director) was asked whether it was reasonable to include the cost of capital improvements when preparing a bill. Other Blue Cross directors, also hospital administrators with construction plans, argued that it was proper, and the matter was dropped. In the same meeting, the directors voted a 34% increase in Blue Cross premiums. Sixteen years later, a study revealed that the metropolitan area had 300 excess hospital beds, with hospital occupancy down from 82% to 60% over the past decade._\n\nA defining characteristic of the health care industry was an alliance of insurers and providers. This provider\u2013insurer pact was cemented with the creation of Blue Cross and Blue Shield, the nation's largest health insurance system for half a century (see Chapter 2). Blue Cross was formed by the American Hospital Association, and Blue Shield was run by state medical societies affiliated with the American Medical Association. In the case of the Blues, the provider\u2013insurer relationship was more than a political alliance; it involved legal control of insurers by providers. As in the example of Metropolitan Hospital, the providers set generous rules of reimbursement, and the Blues made the payments without asking too many questions (Law, 1974). Commercial insurers usually played by the reimbursement rules already formulated by the physicians, hospitals, and Blues, paying for medical services without asking providers to justify their prices or the reasons for the services.\n\nBy the 1960s, the power of the provider\u2013insurer pact was so great that the hospitals and Blue Cross virtually wrote the reimbursement provisions of Medicare and Medicaid, guaranteeing that physicians and hospitals would be paid with the same bountiful formulas used for private patients (Law, 1974). With open-ended reimbursement policies, the costs of health care inflated at a rapid pace.\n\nThe disinterest of the chief organized purchaser (business) stemmed from two sources: the healthy economy and the tax subsidy for health insurance. From 1945 through 1970, US business controlled domestic and foreign markets with little foreign competition. Labor unions in certain industries had gained generous wages and fringe benefits, and business could afford these costs because profits were high and world economic growth was robust (Kuttner, 1980; Kennedy, 1987). The cost of health insurance for employees was a tiny fraction of total business expenses. Moreover, payments by business for employee health insurance were considered a tax-deductible business expense, thereby cushioning any economic drain on business (Reinhardt, 1993). For these reasons, increasing costs generated by providers and reimbursed by insurers were passed on to business, which with few complaints paid higher and higher premiums for employees' health insurance, and thereby underwrote the expanding health care system. No countervailing forces \"put the brakes\" on the enthusiasm that united providers and the public in support of a medical industry that strived to translate the proliferation of biomedical breakthroughs into an improvement in people's lives.\n\n### **THE 1970S: TENSIONS DEVELOP**\n\n_Jerry Neighbor, Bert Neighbor's son, developed abdominal pain in 1978. Because Blue Cross no longer paid for in-hospital diagnostic testing, his physician ordered outpatient x-ray studies. When colon cancer was discovered, Jerry Neighbor was admitted to Metropolitan Hospital on the morning of his surgery. His total hospital stay was 9 days, 6 days shorter than his father's stay in 1962. Since 1962, medical care costs had risen by approximately 10% per year. Blue Cross paid Metropolitan Hospital $460 for each of the 9 days Jerry Neighbor spent in the hospital, for a total cost of $4140. The Blue Cross board of directors, which in 1977 included for the first time more business than hospital representatives, submitted a formal proposal to the regional health planning agency to reduce the number of hospital beds in the region, in order to keep hospital costs down. The planning agency board had a majority of hospital and physician representatives, and they voted the proposal down._\n\nIn the early 1970s, the United States fell from its postwar position of economic dominance, as Western Europe and Japan gobbled up markets (not only abroad but in the United States itself) formerly controlled by US companies. The United States' share of world industrial production was dropping, from 60% in 1950 to 30% in 1980. Except for a few years during the mid-1980s, inflation or unemployment plagued the United States from 1970 until the early 1990s.\n\nThe new economic reality was a critical motor of change in the health care system. With less money in their respective pockets, individual health care consumers, business, and government became concerned with the accelerating flow of dollars into health care. Prominent business-oriented journals published major critiques of the health care industry and its rising costs (Bergthold, 1990). A new concern for primary care, which seemed underemphasized in relation to specialty and hospital care, spread within the health professions. These developments produced tensions within the health industry itself.\n\nFaced with Blue Cross premium increases of 25% to 50% in a single year, angry Blue Cross subscribers protested at state hearings in eastern and midwestern states and challenged hospital control over Blue Cross boards (Law, 1974). Some state governments began to regulate hospital construction, and a few states initiated hospital rate regulation. The federal government established a network of health planning agencies, in an attempt to slow hospital growth. Peer review was established to monitor the appropriateness of physician services under Medicare. Thus, the purchasers took on an additional role as health care regulators. But the health care industry resisted these attempts by purchasers to control health care costs. Medical inflation continued at a rate far above that of inflation in the general economy (Starr, 1982).\n\nNonetheless, these early initiatives from the purchasers made an impact on the provider\u2013insurer pact. As pressure mounted on insurers not to increase premiums, insurers demanded that services be provided at lower cost. Blue Cross, widely criticized as playing the role of an intermediary that passed increased hospital costs on to a helpless public, legally separated from the American Hospital Association in 1972 (Law, 1974). State medical societies were forced to relinquish some of their control over Blue Shield plans. Conflicts erupted between providers and insurers as the latter imposed utilization review procedures to reduce the length of hospital stays. Hospitals, which had hitherto purchased the newest diagnostic and surgical technology desired by physicians or their medical staff, began to deny such requests because insurers would no longer guarantee their reimbursement. Moreover, the glut of hospital beds and specialty physicians, which had been produced by the attractive reimbursements of the 1960s and the influence of the biomedical model on medical education (see Chapter 5), turned on itself as half-empty hospitals and half-busy surgeons began to compete with one another for patients. Strains were showing within the provider\u2013insurer pact.\n\nBy the late 1970s, the deepening of the economic crisis created a nationwide tax revolt. As a result, governments attempted to reduce spending on such programs as health care (Kuttner, 1980). But major change was still awaiting the arrival of the other powerful purchaser: business.\n\n### **THE 1980S: THE REVOLT OF THE PURCHASERS**\n\n_In 1989, Ryan Neighbor, Jerry Neighbor's brother, became concerned when he noticed blood in his stools; he decided to see a physician. Six months earlier, his company had increased the annual health insurance deductible to $1000, which could be avoided by joining one of the HMOs offered by the company. Ryan Neighbor opted for the Blue Cross HMO, but his family physician was not involved in that HMO, and Mr. Neighbor had to pick another physician from the HMO's list. The physician diagnosed colon cancer; Ryan Neighbor was not allowed to see the surgeon who had operated on his brother but was sent to a Blue Cross HMO surgeon. While Mr. Neighbor respected Metropolitan Hospital, his surgery was scheduled at Crosstown Hospital; Blue Cross had refused to sign a contract with Metropolitan when the hospital failed to negotiate down from its $1800 per diem rate. Ryan Neighbor's entire Crosstown Hospital stay was 5 days, and the HMO paid the hospital $7500, based on its $1500 per diem contract._\n\nThe late 1980s produced a severe shock: The cost of employer-sponsored health plans jumped 18.6% in 1988 and 20.4% in 1989 (Cantor et al, 1991). Between 1976 and 1988, the percentage of total payroll spent on health benefits almost doubled from 5% to 9.7% (Bergthold, 1991). In another development, many large corporations began to self-insure. Rather than paying money to insurance companies to cover their employees, employers increasingly took on the health insurance function themselves and used insurance companies only for claims processing and related administrative tasks. In 1991, 40% of employees receiving employer-sponsored health benefits were in self-insured plans. Self-insurance placed employers at risk for health care expenditures and forced them to pay more attention to the health care issue. These three developments (ie, a troubled economy, rising health care costs, and self-insurance) catapulted big business into the center of the health policy debate, with cost control as its rallying cry. Business, the major private purchaser of health care, became the motor driving unprecedented change in the health care landscape (Bergthold, 1990). Business threw its clout behind managed care, particularly HMOs, as a cost-control device. By shifting from fee-for-service to capitated reimbursement, managed care could transfer a portion of the health expenditure risk from purchasers and insurers to providers (see Chapter 4).\n\nIndividual health care consumers, in their role as purchasers, also showed some clout during the late 1980s. Because employers were shifting health care payments to employees, labor unions began to complain bitterly about health care costs, and major strikes took place over the issue of health care benefits. More than 70% of people polled in a 1992 Louis Harris survey favored serious health care cost controls (Smith et al, 1992). The growing tendency of private health insurers to reduce their risks by dramatic premium increases and policy cancellations for policyholders with chronic illnesses created a series of horror stories in the media that turned health insurance companies into highly unpopular institutions.\n\nDuring the 1980s, the government was facing the tax revolt and budget deficits, and it took measures designed to slow the rising costs of Medicare and Medicaid, with limited success. The 1983 Medicare Prospective Payment System (diagnosis-related groups DRGs]) reduced the rate of increase of Medicare hospital costs, but outpatient Medicare costs and costs borne by private purchasers escalated in response. In 1989, Medicare physician payments were brought under tighter control, resulting in Medicare physician expenditures growing at only 5.3% per year from 1991 to 1993, compared with 11.3% per year from 1984 to 1991 (Davis and Burner, 1995). Numerous states scaled back their Medicaid programs, but because of the economic recession and the growing crisis of uninsurance (see [Chapter 3), the federal government was forced to expand Medicaid eligibility, and Medicaid costs rose faster than ever before. Governments began to experiment with managed care for Medicare and Medicaid as a cost-control device.\n\nThe most significant development of the 1980s was the growth of selective contracting. Purchasers and insurers had usually reimbursed any and all physicians and hospitals. Under selective contracting, purchasers and insurers choose which providers they will pay and which they will not (Bergthold, 1990). In 1982, for example, California passed a law bringing selective contracting to the state's Medicaid program and to private health insurance plans. The law was passed because large California corporations formed a political coalition to challenge physician and hospital interests, and because insurers deserted their former provider allies and joined the purchasers (Bergthold, 1990). The message of selective contracting was clear: Purchasers and insurers will do business only with providers who keep costs down. This development, especially when linked with capitation payments that placed providers at risk, changed the entire dynamic within the health care industry. For patients, it meant that like Ryan Neighbor, they had lost free choice of physician because employers could require employees to change health plans and therefore physicians. For the health care industry, selective contracting meant fierce competition for contracts and the crumbling of the provider\u2013insurer pact.\n\nAs a result of the purchasers' revolt, managed care became a burgeoning movement in US health care. By 1990, 95% of insured employees were enrolled in some form of managed care plan, including fee-for-service plans with utilization management, preferred provider organizations (PPOs), and HMOs. The growth of managed care plans, especially HMOs, competing against one another for contracts with business and the government, changed the entire political topography of US health care (Table 16\u20132).\n\n**Table 16\u20132.** Historical overview of US health care\n\n### **THE 1990S: THE BREAKUP OF THE PROVIDER\u2013INSURER PACT**\n\n_In 1994, Pamela Neighbor, Ryan's cousin, developed constipation. Earlier that year, her law firm had switched from Blue Cross HMO to Apple a Day HMO because the premiums were lower; all employees of the firm were forced to change their physicians. Apple a Day contracted only with Crosstown Hospital, whose rates were lower than those of Metropolitan, resulting in Metropolitan losing patients and closing its doors. Ms. Neighbor's new physician diagnosed colon cancer and arranged for her admission to Crosstown Hospital for surgery. The physician's office was across the street from the now-closed Metropolitan Hospital. Four days before the procedure, a newspaper headline proclaimed that Apple a Day and Crosstown had failed to agree on a contract. The colonoscopy was canceled. Pamela Neighbor waited to see what would happen next._\n\nDuring the 1990s, many metropolitan areas in the United States, and some smaller cities and towns, experienced upheavals of their medical care landscape. Independent hospitals began to merge into hospital systems. In the most mature managed care markets, three or four health care networks were competing for those patients with private insurance, Medicare, or Medicaid. Selective contracting allowed purchasers and insurers to set reimbursement rates to health care providers. HMOs that demanded higher premiums from employers did not get contracts and lost their enrollees. Providers who demanded higher payment from HMOs were cut out of HMO contracts and lost many of their patients.\n\nSelective contracting tended to disorganize rather than organize medical care patterns. Physicians were forced to admit patients from one HMO to one hospital and those from another HMO to a different hospital. Laboratory, x-ray, and specialist services close to a primary care physician's office were sometimes not covered under contracts with that physician's patients' HMO, forcing referrals to be made across town. In one highly publicized case with a tragic outcome, the parents of a 6-month-old infant with bacterial meningitis were told by their HMO to drive the child almost 40 miles to a hospital that had a contract with that HMO, passing several high-quality hospitals along the way (Anders, 1996).\n\nThe 1990s was a period of purchaser dominance over health care. The federal government stopped Medicare inflation in its tracks through the tough provisions of the Balanced Budget Act of 1997. The average annual growth in Medicare expenditures declined from 12% in the early 1990s to zero in 1999 and 2000. On the private side, employers bargained hard with HMOs, causing insurance premium annual growth to drop from 13% in 1990 to 3% in 1995 and 1996. In California, employer purchasers consolidated into coalitions to negotiate with HMOs. The Pacific Business Group on Health, negotiating on behalf of large companies for 400,000 employees, and California Public Employee Retirement System (CalPERS), representing a million public employees, forced HMO premiums to go down during the 1990s. Enrollment in HMOs grew rapidly in the 1990s, expanding from 40 million enrollees in 1990 to 80 million in 1999.\n\n### **THE NEW MILLENNIUM: PROVIDER POWER RE-EMERGES**\n\n_In 2005, Pamela Neighbor, who was feeling well, made an appointment for her yearly colon cancer follow-up. The IPA in which her physician practiced had recently gone bankrupt and closed its doors. Ms. Neighbor's employer had switched its employees from Apple a Day Insurance Company's HMO product to Apple a Day PPO, allowing patients to access most of the physicians and all the hospitals in town. Ms. Neighbor had a difficult time finding a new primary care physician, and when she found one, it took several weeks to get an appointment. Eventually, a colonoscopy was scheduled at a diagnostic center owned by a group ofgastroenterologists. She was diagnosed with a second colon cancer and her primary care physician arranged for her admission to Crosstown Hospital. Ms. Neighbor never saw her primary care physician in the hospital; a surgeon plus a salaried inpatient physician called a hospitalist cared for Ms. Neighbor during her 4-day hospital stay. Apple a Day paid Crosstown Hospital $7200, $1800 per diem._\n\nSeveral trends characterize the first decade of the twenty-first century: the counter-revolution by providers, consolidation in the health care market, growing power of specialists and specialty services, increasing physician\u2013hospital tensions, an emerging crisis in primary care, growing criticism of pharmaceutical companies, and a steady increase in the uninsured and underinsured population.\n\n#### **The Provider Counter-Revolution**\n\nIn the mid-1990s, most health care analysts were certain that tightly managed care\u2014with purchasers and insurers dominating health care providers\u2014had become the new paradigm for health care in the United States. By 2001, this certainty had evaporated (Robinson, 2001). From 2000 to 2010, HMO enrollment dropped from 32% to 19% of insured employees, with only 19% of HMOs affiliated with an integrated delivery system. During those years, preferred provider organization (PPO) enrollment grew from about 30% to 60% of insured employees (Claxton et al, 2010). Tightly managed care was faltering.\n\nThe first decade of the twenty-first century could be called the era of the provider counter-revolution. Hospitals consolidated into hospital systems and demanded large price increases from insurers. Physicians balked at tight managed care contracts. Negotiations between health care providers and insurers became increasingly hostile, with one side or the other often refusing to sign contracts. As hospitals and providers gained an upper hand in negotiations with health plans, HMOs in turn demanded more money from employers. Insurance premiums for family coverage went from an average of $6,000 per year in 2000 to almost $14,000 in 2010, with virtually no difference between HMO and PPO premiums (Claxton et al, 2010). Purchasers lost faith that HMOs could control costs.\n\nAt the same time, individuals have been stuck with a greater proportion of health care costs. Twenty percent of insured employees, up from 10% in 2006, have a deductible of $1000 or more for individual coverage. The percent of insured employees with high-deductible plans has risen from 5% in 2006 to 13% in 2010; in a typical high-deductible plan, employees pay over $3000 for their portion of the premium plus a deductible of $4000 (Claxton et al, 2010). Employees' out-of-pocket health care costs increased 34% from 2004 to 2007 (Gabel et al, 2009).\n\n#### **Consolidation in the Health Care Market**\n\nThe intense competition of the 1990s stimulated consolidation among insurers and providers, as each vied to improve its bargaining power. Large HMOs bought up smaller ones and merged with one another. In most states, three large insurance companies control more than 60% of the market (Robinson, 2004). These companies generally offer a variety of products including HMO, PPO, high deductible, and Medicare Advantage plans. Three huge insurers, all for-profit, are Wellpoint with 34 million enrollees in 2010, United Healthcare with 32 million, and Aetna with 18 million.\n\nProviders also consolidated. By 2001, 65% of hospitals were members of multihospital systems or networks (Bazzoli, 2004), and consolidation continued, though at a slower pace, through 2008. In many cities, two or three competing hospital systems encompass all hospitals. Hospital prices often rise rapidly after consolidation has taken place since payers are forced to contract with dominant hospital systems (Vogt, 2009). Specialists increasingly joined single-specialty groups, with the majority of cardiologists or orthopedists in some cities belonging to a dominant group (Liebhaber and Grossman, 2007). Private primary care and specialty practices are being acquired by hospital systems hoping to increase their market clout (Iglehart, 2011).\n\nConsolidation went hand in hand with organizations converting from nonprofit to investor-owned \"for-profit\" status as they sought to raise capital for buy-outs, market expansion, and organizational infrastructure. For decades, for-profit companies have played a prominent role in health care, with the rise in the 1970s of the \"medical\u2013industrial complex\" (Relman, 2007). For-profits, which owned 35% to 40% of health care services and facilities in 1990, expanded their reach during the 1990s. Nine of the largest 10 HMOs were for-profit by 1994. HMO stocks soared in the early 1990s and executives were rewarded with enormous compensation packages (Anders, 1996). Already in 1990, 77% of nursing homes and 50% of home health agencies were for-profit. Between 1993 and 1996, more than 100 nonprofit hospitals were taken over by forprofit hospital chains, though several financial scandals slowed down this trend. For-profit hospitals provide less charity care, treat fewer Medicaid patients, have higher administrative costs, and lower quality than nonprofit hospitals (Relman, 2007). By 2009, most specialty hospitals, imaging centers, ambulatory surgery centers were investor-owned (Relman, 2009).\n\n#### **The Quest for Profitability and the Growing Power of Specialists and Specialty Services**\n\nThat hospitals, physicians, and other providers respond to financial incentives is hardly a new phenomenon. As discussed in Chapter 5, more lucrative third-party payment for procedurally oriented specialty care has been one of the key factors shaping a physician workforce weighted toward nonprimary care fields and a hospital sector filled with tertiary care facilities. However, twenty-first-century health care in the United States is becoming characterized by a single-minded quest for profitability that is threatening traditional notions of professionalism and community service. Emblematic of this trend is the emergence of a new type of for-profit hospital, the specialty hospital fully or partially owned by groups of specialist physicians. As of 2010, 265 of these hospitals existed in the United States, typically limiting their services to cardiac and orthopedic procedures\u2014service lines that are well reimbursed (Perry, 2010). Physician owners of these hospitals doubly benefit financially, receiving income from both the payment for the services they directly provide and their share of hospital profits. Moreover, physician owners often channel well-insured patients from nonprofit general hospitals to their own for-profit specialty hospitals. In one example, 16 cardiac surgeons and cardiologists shifted their patients with heart disease from a university medical center to a new hospital only caring for patients with heart disease; the number of cardiac surgeries performed at the university medical center dropped from over 600 to below 200 between 2002 and 2004, resulting in the loss of $12 million in revenues. Uninsured patients continued to have cardiac procedures at the university hospital (Iglehart, 2005). For the community as a whole, the opening of a cardiac hospital is associated with increased rates of coronary revascularization (coronary artery bypass surgery and angioplasty), raising questions about whether all the additional procedures are medically appropriate (Nallamothu et al, 2007). Because of these problems with specialty hospitals, the Affordable Care Act of 2010 barred new specialty hospitals from receiving Medicare payments (Perry, 2010).\n\nSimilar financial incentives have attracted specialist physicians to set up many thousands of ambulatory surgery, diagnostic, and imaging centers that they own. A growing proportion of profitable services\u2014cataract surgery and orthopedic procedures, diagnostic studies such as colonoscopies, and CT or MRI studies\u2014have been shifted from hospital facilities to these physician-owned ambulatory centers. As with specialty hospitals, physicians earn income from both the services they directly provide and the facility's profits. Because general hospitals formerly earned considerable income from these procedures, this phenomenon has created major tensions between hospitals and specialists (Berenson et al, 2006b). The common practice of physicians referring patients for imaging tests at a facility owned by the same physician is associated with higher volumes of imaging services, increasing costs, and exposing patients to unnecessary radiation (Sunshine and Bhargavan, 2010).\n\nSingle-specialty groups have grown markedly since the late 1990s. Two major drivers of this growth are (1) the ability of organized specialists with market power in a local area to negotiate for high reimbursement rates from insurers and (2) the bringing together of capital to invest in specialist-owned surgery, diagnostic, and imaging centers. As a result of these trends, the income of specialists who offer procedural or imaging services has far outpaced the growth in earnings for primary care physicians (Bodenheimer et al, 2007). Multispecialty groups, which include primary care physicians and tend to have the best scores on quality report cards, are not growing in part because specialist physicians in multispecialty groups are expected to share their high revenues with lower-reimbursed primary care physicians (Casalino et al, 2004; Mehrotra et al, 2006).\n\nNonprofit community hospitals are responding to competition from specialist physicians by creating \"specialty service lines\" to attract specialist physicians and well-insured patients to their institutions. To create capacity for these profitable service lines, hospitals are de-emphasizing traditional medical-surgical wards. Whether the hospital is a nonprofit community hospital, a for-profit hospital, or a physician-owned specialty hospital, filling a hospital bed with a patient receiving an organ transplant or spine surgery is much more financially rewarding than filling the same bed with an elderly patient with pneumonia and heart failure, even if the latter patient has insurance. Strategic planning by hospitals increasingly focuses on how to maximize the most profitable service lines, rather than on how to provide the services most needed in the community (Berenson et al, 2006a).\n\nCompounding this situation is the weakening claim hospitals can make on physicians for community service. Surgeons, diagnostic cardiologists, gastroenterologists, ophthalmologists, and radiologists can successfully run a medical practice without ever setting foot in a hospital by focusing their work on ambulatory centers of which these physicians are owners. Because these specialists no longer need the hospital, they feel little obligation to be on call for hospital emergency departments or for patients in intensive care. Hospitals are forced to pay specialists large sums to provide nighttime emergency department backup or are employing specialists to perform the duties formerly done for free by specialists on the hospital medical staff. The divorce of physicians from the community hospital is not limited to specialists. As a result of the hospitalist movement, many primary care physicians are never seen in a hospital. Hospitalists are physicians who specialize in the care of hospitalized patients. Most are employees of a hospital or hospital system; others are members of single-specialty hospitalist groups, which contract with hospitals to supply hospitalist physicians. Hospitalists are the fastest growing specialty in the history of medicine in the United States; the 500 hospitalists existing in 1997 have multiplied into about 30,000 hospitalists in 2010.\n\nThe quest for profitability is further aggravating the primary care-specialist imbalance in the physician workforce in the United States. In 2007, only 7% of US medical school graduates planned careers in adult primary care, with an adult primary care physician shortage projected at about 40,000 by 2020. Nurse practitioners and physician assistants help mitigate this shortage but their numbers are not sufficient to solve the problem. As a result, patients are having increasing difficulty gaining timely access to primary care or finding a new primary care physician. Although the causes of the declining career interest in primary care are multifactorial, the gap between primary care and specialty incomes is one reasons why growing numbers of US medical students and residents\u2014many of whom have more than $150,000 in personal debts from medical school expenses\u2014have turned away from careers in primary care (Bodenheimer and Pham, 2010).\n\nThese trends pull health care in the United States farther away from a primary care-based, community-responsive model. Evidence suggests that this trend will fuel continued inflation in health care costs without yielding commensurate benefits for the health of the public. A major reform of payment policies in the United States, along with a rethinking of the role of investor-owned enterprises in health care, will be required in order to realign financial incentives with the values that make for a well-functioning system.\n\n#### **The Pharmaceutical Industry Comes Under Criticism**\n\nThe rising tensions among purchasers, insurers, and providers spilled over to engulf health care's major supplier: the pharmaceutical industry. In 1988, prescription drugs accounted for 5.5% of national health expenditures. With 71% of drug costs borne out of pocket by individuals and only 18% paid by private insurance plans, these costs had little impact on insurers. In contrast, by 2009, prescription drug costs had risen to 10.1% of total health expenditures, with only 21% paid out of pocket, the rest covered by employers, insurers, and governmental purchasers. The growing cost of pharmaceuticals for the elderly became a major national issue. Because of its unaffordable prices and high profits, the pharmaceutical industry was becoming public enemy number one (Spatz, 2010).\n\nFor years, drug companies have been the most profitable industry in the United States, earning net profits after taxes close to 20% of revenues (19.3% in 2008), compared with 5% for all Fortune 500 firms. The pharmaceutical industry argues that high drug prices are justified by its expenditures on research and development of new drugs, yet the National Science Foundation estimates that true R&D spending is half of what the pharmaceutical industry claims (Congressional Budget Office, 2006). R&D for the largest drug companies consumed 14% of revenues in 2002, while marketing and administration accounted for 33% and after-tax net profits 21% (Reinhardt, 2004). Unlike many nations, the US government does not impose regulated prices on drugs; as a result of drug industry lobbying, the Medicare prescription drug coverage law passed in 2003 forbid the government to regulate drug prices (see Chapter 2). From 2006 to 2008, the health industry spent more money on lobbying than any other sector of the economy, and the drug industry was the largest contributor within the health industry (Steinbrook, 2008).\n\nCompanies developing a new brand-name drug enjoy a patent for 20 years from the date the patent application is filed, during which time no other company can produce the same drug. Once the patent expires, generic drug manufacturers can compete by selling the same product at lower prices. Some drug companies have waged legal battles to delay patent expirations on their brand name products or have paid generic drug manufacturers not to market generic alternatives (Stolberg and Gerth, 2000; Hall, 2001). In addition, the industry attempts to persuade physicians and patients to use brand-name products, spending $7 billion in 2009 on sales representatives' visits to physicians, journal advertising, and sponsorship of professional meetings, plus $4 billion on direct-to-consumer television ads (Kaiser Family Foundation, 2010). The federal Food and Drug Administration (FDA) has sent hundreds of letters to drug manufacturers, citing advertising violations including minimizing side effects and exaggerating benefits (Donohue et al, 2007). Four out of five physicians have some type of financial relationship with the pharmaceutical industry, ranging from accepting gifts to serving as a paid lecturer on behalf of a company. These physician\u2013industry relationships influence physicians to prescribe new drugs that are the most expensive and whose safety has not been adequately evaluated (Campbell, 2007). Drug firms may pay medical school faculty physicians tens of thousands of dollars to participate on their corporate boards (Lo, 2010).\n\nMost trials to determine the efficacy of prescription drugs are funded by that drug's manufacturer, and trials funded by industry are more likely than those with nonindustry funding to report results favorable to the funding company (Bero, 2007). Yet physicians base treatment decisions on these trials, which inform clinical practice guidelines. Authors of clinical practice guidelines often have ties to the pharmaceutical industry (Abramson and Starfield, 2005). From 2006 to 2010, at least 18 relatively new drugs were removed from the market because of serious side effects; in some cases, the manufacturer knew of the problems but hid them from the FDA and the public; in other cases, the FDA ignored the evidence. Some members of FDA committees recommending approval of a drug have ties to that drug's manufacturer, and these members are often not recused from the process (Angell, 2004).\n\nThese revelations have tainted the image of the pharmaceutical industry in the eyes of the medical profession and the public. Private health insurance companies have mounted the most effective response to the drug industry by creating tiered formularies in which generic drugs have lower copayments than brand-name drugs. As a result, 75% of all prescriptions filled in the United States in 2009 were for generic products (Spatz, 2010). This development has slowed the rate of growth of pharmaceutical costs. However, some brand-name drug companies are starting to produce generics, and the generic industry is starting to consolidate into fewer and larger companies; these trends could mean that generic prices may rise to levels not far below brand name prices.\n\n### **THE CHALLENGE**\n\nThe health care system has been dominated by a series of unstable power relationships among purchasers, insurers, providers, and suppliers. One of these actors may take center stage for a time, only to be pushed into the corner by another actor. Which entity has the leverage to get its way varies from city to city, depending on who has consolidated into larger institutions. Larger institutions can (in the case of providers and suppliers) demand to receive more money, or (in the case of purchasers and insurers) succeed in paying out less money. Patients continue to be at the mercy of these powerful institutions, as health care costs rise and as individuals bear a greater share of those costs.\n\nInequities in insurance coverage and in access to care continue, and cost control remains elusive. Whether the Affordable Care Act of 2010 will succeed in improving access and containing costs remains to be seen. The drive to make money\u2014whether for specialist physicians, for-profit and nonprofit hospitals, insurers, or pharmaceutical companies\u2014increasingly determines what happens in health care. For physicians, this economic motivation may clash with the professional commitment to patient welfare. The commitment of all health care professionals to the ethical principles of beneficence, nonmaleficence, patient autonomy, and distributive justice is tested on a daily basis in the profit-oriented environment of twenty-first century health care in America.\n\nChapter 1 introduced the paradox of excess and deprivation: Some people get too little care while others receive too much, which is costly and may be harmful. The first decade of the twenty-first century saw a sharpening of this paradox, with the number of uninsured climbing from 40 million to 50 million at the same time as the increasing number of specialist physicians owning their facilities was associated with growing volumes of expensive procedures, many of questionable appropriateness (Brownlee, 2007; Welch et al, 2011). Overcoming this paradox remains the fundamental challenge facing the health care system of the United States.\n\n### **REFERENCES**\n\nAbramson J, Starfield B. The effect of conflict of interest on biomedical research and clinical practice guidelines. _J Am Board Fam Pract_. 2005;18:414.\n\nAnders G. _Health Against Wealth: HMOs and the Breakdown of Medical Trust._ Boston, MA: Houghton Mifflin Company; 1996.\n\nAngell M. _The Truth About the Drug Companies_. New York: Random House; 2004.\n\nBazzoli G. The corporatization of American hospitals. _J Health Polit Policy Law_. 2004;29:885.\n\nBerenson RA et al. Specialty service lines: Salvos in the new medical arms race. _Health Affairs Web Exclusive_. 2006a; 25(5):w337.\n\nBerenson RA et al. Hospital\u2013physician relations: Cooperation, competition, or separation? _Health Aff Web Exclusive_. 2006b;26(1):w31.\n\nBergthold L. _Purchasing Power in Health._ New Brunswick, NJ: Rutgers University Press; 1990.\n\nBergthold L. The fat kid on the seesaw: American business and health care cost containment, 1970\u20131990. _Annu Rev Public Health_. 1991;12:157.\n\nBero L et al. Factors associated with findings of published trials of drug\u2013drug comparisons. _PLoS Med_. 2007;4:e184.\n\nBodenheimer T et al. The primary care-specialty income gap: Why it matters. _Ann Intern Med_. 2007;146:301.\n\nBodenheimer T, Pham HH. Primary care: Current problems and proposed solutions. _Health Aff_. 2010;29:799.\n\nBrownlee S. _Overtreated. Why Too Much Medicine Is Making Us Sicker and Poorer_. New York, NY: Bloomsbury; 2007.\n\nCampbell EG. Doctors and drug companies\u2014scrutinizing influential relationships. _N Engl J Med_. 2007;357:1796.\n\nCantor JC et al. Business leaders' views on American health care. _Health Aff_. 1991;10(1):98.\n\nCasalino L et al. Growth of single-specialty medical groups. _Health Aff_. 2004;23(2):82.\n\nClaxton G et al. Health benefits in 2010: Premiums rise modestly, workers pay more toward coverage. _Health Aff_. 2010;29:1942.\n\nCongressional Budget Office. _Research and Development in the Pharmaceutical Industry_. 2006. www.cbo.gov\/ftpdocs\/76xx\/doc7615\/10-02-DrugR-D.pdf. Accessed November 26, 2011.\n\nDavis MH, Burner ST. Three decades of Medicare: What the numbers tell us. _Health Aff_. 1995;14(4):231.\n\nDonohue JM et al. A decade of direct-to-consumer advertising of prescription drugs. _N Engl J Med_. 2007;357:673.\n\nGabel JR et al. Trends in underinsurance and the afford-ability of employer coverage, 2004\u20132007. _Health Aff_. 2009;28:w595.\n\nHall SS. Prescription for profit. _New York Times Magazine._ March 11, 2001.\n\nIglehart JK. The emergence of physician-owned specialty hospitals. _N Engl J Med_. 2005;352:78.\n\nIglehart JK. Doctor-workers of the world, unite! _Health Aff_. 2011;30:556.\n\nKaiser Family Foundation. Prescription drug trends, 2010. www.kff.org.\n\nKennedy P. _The Rise and Fall of the Great Powers._ New York: Random House; 1987.\n\nKuttner R. _Revolt of the Haves._ New York, NY: Simon & Schuster; 1980.\n\nLaw SA. _Blue Cross: What Went Wrong?_ New Haven, CT: Yale University Press; 1974.\n\nLiebhaber A, Grossman JM. Physicians moving to mid-sized, single-specialty practices. Tracking Report No. 18. Washington, DC: Center for Studying Health System Change; August 2007.\n\nLight DW, Warburton R. Demythologizing the high costs of pharmaceutical research. _Biosocieties_. 2011;6:34.\n\nLo B. Serving two masters\u2014conflicts of interest in academic medicine. _N Engl J Med._ 2010;362:669.\n\nMehrotra A et al. Do integrated medical groups provide higher-quality medical care than individual practice associations? _Ann Intern Med_. 2006;145:826.\n\nNallamothu BK et al. Opening of specialty cardiac hospitals and use of coronary revascularization in Medicare beneficiaries. _JAMA_. 2007;297:962.\n\nPerry JE. A mortal wound for physician-owned specialty hospitals? 2010. www.academia.edu.\n\nReinhardt UE. Reorganizing the financial flows in US health care. _Health Aff_. 1993;12(suppl):172.\n\nReinhardt UE. An information infrastructure for the pharmaceutical market. _Health Aff_. 2004;23(1):107.\n\nRelman AS. _A Second Opinion. Rescuing America's Health Care._ New York, NY: Public Affairs; 2007.\n\nRelman AS. The health reform we need & are not getting. _New York Rev Books_. 2009;56(11):38.\n\nRobinson JC. The end of managed care. _JAMA_. 2001;285:2622.\n\nRobinson JC. Consolidation and the transformation of competition in health insurance. _Health Aff_. 2004;23(6):11.\n\nSmith MD et al. Taking the public's pulse on health system reform. _Health Aff_. 1992;11(2):125.\n\nSpatz ID. Health reform accelerates changes in the pharmaceutical industry. _Health Aff_. 2010;29:1331.\n\nStarr P. _The Social Transformation of American Medicine._ New York: Basic Books; 1982.\n\nSteinbrook R. Campaign contributions, lobbying, and the US health sector. _N Engl J Med_. 2008;359:1313.\n\nStolberg SG, Gerth J. How companies stall generics and keep themselves healthy. _NY Times._ 2000.\n\nSunshine J, Bhargavan M. The practice of imaging self-referral doesn't produce much one-stop service. _Health Aff_. 2010;29:2237.\n\nVogt WB. _Hospital Market Consolidation: Trends and Consequences_. National Institute for Health Care Management. November 2009. <http:\/\/nihcm.org\/pdf\/EV-Vogt_FINAL.pdf>. Accessed November 26, 2011.\n\nWelch HG et al. _Overdiagnosed. Making People Sick in the Pursuit of Health_. Boston, MA: Beacon Press; 2011.\n\n## **17 Conclusion: Tensions and Challenges**\n\nThe perfect health care system is like perfect health\u2014a noble aspiration but one that is impossible to attain. In the preceding chapters, we have discussed many fundamental issues and principles involved in formulating health care policy. A recurrent theme has been the notion that \"magic bullets\" are hard to come by. As stated in Chapter 2, policies tend to evolve in a cyclic process of finding solutions that create new problems that require new solutions. Policy changes may offer a degree of relief for a pressing problem, such as inadequate access to care, but frequently also give rise to various side effects, such as stimulating health care cost inflation.\n\nAll health care systems face the same challenges: improving health, controlling costs, prioritizing allocation of resources, enhancing the quality of care, and distributing services fairly. These challenges require the management of various tensions that pull at the health care system (O'Neil and Seifer, 1995). The goal of health policy is to find the points of equilibrium that produce the optimal system of health care (Table 17\u20131).\n\n**Table 17\u20131.** Major tensions in health care\n\n_Dr. Madeleine Longview is chief resident in critical care medicine and supervises the intensive care unit of a large municipal hospital. It's 5:30 AM, and the intensive care unit team has finally stabilized the condition of a 15-year-old admitted the previous evening with gunshot wounds to the abdomen and chest. Dr. Longview sits by the nursing desk and surveys the other patients in the unit: a 91-year-old woman admitted from a nursing home with sepsis from a urinary tract infection, a 50-year-old man with shock lung caused by drugs ingested in a suicide attempt, and a 32-year-old woman with lupus erythematosus who is rejecting her second kidney transplant. Dr. Longview feels personally responsible for the care of every one of these patients. She tells herself that she will do her best to help each of them survive._\n\n_As Dr. Longview gazes out of the windows of the intensive care unit, the apartment houses surrounding the hospital take shape in the breaking dawn. She wonders: Which block will be the scene of the next drive-by shooting or episode of spouse abuse? Which window shade hides a homebound elder lying on the floor dehydrated and unable to move, waiting for someone to find him and bring him to the emergency department? Which one of the unvaccinated kids in the neighborhood will one day be rushed into the unit limp with meningitis? In which room is someone lighting up the first cigarette of the day? Dr. Longview somehow feels responsible for all those patients-to-be, as well as for the patients lying in the hospital beds around her. After these sleepless nights on duty, the doubts about the value of all the work she does in the intensive care unit creep into her thoughts. She has visions of shutting down the unit and putting all the money to work hiring public health nurses in the community, or maybe just paying for a better grammar school in the neighborhood. But then what would happen to the patients needing her care right now?_\n\nOne of the most basic tensions affecting physicians and other caregivers is the tension between caring for the individual patient and caring for the larger community or population. Many of the most important decisions to be made in health policy\u2014decisions such as allocating health care resources, addressing the social context of health and illness, and augmenting activities in prevention and public health\u2014depend on broadening the practitioner's view to encompass the population health perspective. The challenge for physicians and other clinicians will be to make room for this broader perspective while preserving the ethical duty to care for the individual patients under their charge.\n\nLike Dr. Longview, the health care system as a whole will continue to struggle over finding the proper balance between the provision of acute care services and preventive and chronic care services, as well as striking the right balance between the levels of tertiary and primary care. Few observers would encourage Dr. Longview to succumb to her despair, close all the intensive care units, and expel all the critical care sub-specialists from the health care system. Yet most would agree that health care in the United States has drifted too far away from the primary care end of the tertiary care\u2013primary care axis.\n\n_Dr. Tom Ransom has performed what he believes to be a reasonably thorough workup for Zed's abdominal pain and decreased appetite, including a detailed history and physical examination, blood tests, and abdominal ultrasound\u2014all of which were normal. When Dr. Ransom tells Zed that they will have to work together to manage Zed's symptoms, Zed tells Dr. Ransom that he wants one more test, an abdominal CT scan. Zed says that he had a cousin with similar symptoms who was eventually diagnosed with advanced-stage lymphoma after complaining of pain for over a year._\n\n_Dr. Ransom is in a quandary. He believes it extremely unlikely that Zed has serious pathologic changes in his abdomen that will be detected on CT scan. He could order the scan, but then there's the issue of the cost. He can't recall whether Zed is covered by a fee-for-service plan or by one of the health maintenance organizations (HMOs) that pays on a capitated basis and puts Dr. Ransom at financial risk for all radiologic tests ordered. He starts to ask Zed about his coverage but feels a pang of guilt that he should allow these economic considerations to intrude into his clinical judgment._\n\nThe desire (and in many instances, expectation) of patients to receive all potentially beneficial care, and the unwillingness of these same individuals in their role as purchasers to spend unlimited amounts to finance health care, creates a strain for all caregivers and systems of care. Physicians increasingly are being called upon to incorporate considerations of costs when making clinical decisions. Debate will continue about the best ways to encourage physicians to be more accountable for the costs of care in a manner that is socially responsible and does not unduly intrude on the physician's ability to serve the individual patient. Is it necessary to use payment methods that place physicians at individual financial risk for their treatment decisions in order to control costs? Are more global methods available to induce physicians and other care-givers to practice in a more cost-conscious manner? If Zed does not get a CT scan, does that constitute painless or painful cost control?\n\n_On the eve of his retirement, Dr. Melvin Steadman reminisces with his son, Dr. Kevin Steadman. The elder Dr. Steadman has practiced as a solo pediatrician for more than 40 years in the same town. The only boss he has known in his professional life has been himself. He has served as president of the local medical society, helped spearhead efforts to build a special children's wing of the local hospital,and antagonized several of his colleagues when he pushed for a change in hospital policy that required physicians to attend extra continuing medical education courses in order to maintain their hospital privileges. Mel swore that he'd never retire; but he also swore that he'd never let the insurance companies \"tell me how to practice medicine.\" He has refused to sign any managed care contracts. Facing a dwindling supply of patients, Mel has decided to call it quits._\n\n_His son Kevin is also a pediatrician, working as a staff physician for a large for-profit multispecialty group that recently opened up an office in town. Kevin remembers the many nights when his father didn't get home from work until after he had gone to bed. Kevin's work hours are more regular at the group practice, and he is on call for only one weekend every 2 months. He considers his father's approach to medicine old-fashioned in many ways\u2014excessively paternalistic toward patients and irrationally scornful of the pediatric nurse practitioners who work with Kevin. He does, however, envy his father's professional independence. Just this week, the group practice notified Kevin that he would have to divide his time between his current office and a new site that would soon open in a suburban mall. His schedule will be limited to 10-minute drop-in appointments at the new site, rather than the style of practice that promotes a sense of continuity, one that allows him to get to know his patients over time._\n\nA system of health care formerly managed according to a professional model by independent practitioners is being pulled toward a corporate model of care featuring large organizations managed by administrators. As the role of corporate entities expands, traditional responsibilities toward patients and local communities are vying with new obligations to shareholders. Power relationships are changing, with insurance companies and organized purchasers challenging the dominance of the medical profession. A shift toward multidisciplinary group practice may provide more opportunity for health care professionals to work collegially and implement new approaches to quality improvement to elevate the competence of all health care providers. At the same time, a competitive, forprofit health care environment may induce physicians to compromise their humanity and turn toward the \"homo economicus\" model, basing clinical decisions in part on monetary considerations.\n\n_Aurora can't wait any longer in the crowded county hospital emergency department. She's already been there for 6 hours, and the physician hasn't seen her yet. Her lower abdomen still hurts, but she figures she'll just have to put up with it for a few more days. She really doesn't have much choice. Poor and uninsured, where else could she go? Aurora has two young children at home who need to be put to bed. In half an hour, their father has to get to his night job as a security officer. As she enters her apartment, she collapses, the pregnancy in her fallopian tube having ruptured, producing internal hemorrhage. Her husband frantically dials 911, praying that his wife won't die._\n\nPerhaps no tension within the US health care system is as far from reaching a point of satisfactory equilibrium as the achievement of a basic level of fairness in the distribution of health care services and the burden of paying for those services. Many more people in the country were uninsured in 2011 than in 1991. Because of persistent financial barriers, patients do not benefit from early detection of potentially curable cancers, patients with chronic diseases are hospitalized because of lack of timely primary care, hypertensive patients forego the medications that might avert the occurrence of strokes and kidney failure, and babies are born prematurely and spend their first weeks of life in a neonatal intensive care unit. The poor pay a greater proportion of their income for health care than do more affluent families. The Affordable Care Act of 2010 would greatly reduce the number of uninsured. However, implementation of the Act faces political, judicial, and financial challenges, and coverage would fall short of truly universal even if fully implemented.\n\nPeople providing and receiving care in the United States must work together to achieve a brighter future for the nation's health care system. Changing the future will require that people look beyond their immediate self-interest to view the common good of a health care system that is accessible, affordable, and of high quality for all. A heightened level of public discourse will be needed, with a populace that is better informed and more actively engaged in shaping the future of their health care system. Concepts in health policy based on established facts rather than ideologically driven myths will need to be discussed and debated in a manner that connects with the daily realities experienced by patients and caregivers. The attitudes and actions of physicians and other health care professionals will play a major role in determining the future of health care in the United States. With leadership and foresight among the community of health care professionals, our nation may yet achieve a system that allows the most honorable features of the healing professions to flourish.\n\n### **REFERENCE**\n\nO'Neil E, Seifer S. Health care reform and medical education: Forces towards generalism. _Acad Med_. 1995;70:S37.\n\n## **18 Questions and Discussion Topics**\n\n### **CHAPTER 2: PAYING FOR HEALTH CARE**\n\n1. What are the four modes of financing health care? Describe each.\n\n2. Describe regressive, proportional, and progressive financing. Explain how each of the following is regressive, proportional, or progressive: out-of-pocket payments, experience-rated individual private insurance, community-rated individual private insurance, health insurance purchased 100% by the employer (assuming that employees actually pay for health insurance as explained in the text), and the federal income tax.\n\n3. Harvey, who has worked all his life for General Electric, reaches 65 years of age. He does not retire. Is he eligible for Medicare Part A? Part B? Six months later, his wife, who has never worked, reaches 65 years of age. Is she eligible for Medicare Part A? Part B? How are Parts A and B paid for?\n\n4. Hubert has received social security disability for 24 months because he has AIDS. Is he eligible for Medicare?\n\n5. Rena developed chronic renal failure and started renal dialysis 2 weeks ago. She feels fine and is working. Is she eligible for Medicare?\n\n6. Heidi, aged 72 years, on Medicare Part A and B without Medicaid or a Medigap policy, is hospitalized for a stroke complicated by a deep vein thrombosis of the leg and a pulmonary embolus. She is in the acute hospital for 70 days and cared for by a family practitioner and a neurologist. She improves somewhat and is then transferred to the skilled nursing facility (SNF) for rehabilitation. She remains in the SNF for 30 days and is still severely disabled and unable to go home. She is sent to a nursing home for custodial care, where she stays for 3 months. Surprisingly, she improves and goes home, where she receives skilled physical therapy services from a home care agency and also has a homemaker come in for 4 hours a day to buy food, cook, and clean the house. She is on three prescription medications at home. What does Heidi pay and what does Medicare pay? Acute hospital? SNF? Nursing home? Home care? Physicians? Prescriptions while in hospital? Prescriptions while at home?\n\n#### **Discussion Topics**\n\n1. Discuss your experiences with health insurance that was provided through a job. How did you obtain the insurance? Did you pay part of the premium? Were there deductibles or copayments? How many choices of plans did you have? What happened if you left your job?\n\n2. Divide into two groups: one insurance company selling community-rated health insurance policies and the other selling experience-rated policies. Each side should try to convince the instructor to buy its policy, first with the instructor as a young, healthy person, and then with the instructor as an older person with diabetes. Which policy is the young person more likely to choose, and which the older person?\n\n### **CHAPTER 3: ACCESS TO HEALTH CARE**\n\n1. Describe the two main categories of people without health insurance.\n\n2. Why did uninsurance increase during the period 1980 to 2010?\n\n3. Compare access to health care for people with private insurance, for Medicaid recipients, and for people without insurance. Give examples.\n\n4. Compare health outcomes for people with private insurance, for Medicaid recipients, and for people without insurance. Give examples.\n\n#### **Discussion Topics**\n\n1. What are some explanations as to why Ace Banks was healthy at age 48 while Bill Downes died at that age?\n\n2. Women on average have more visits than men to physicians. Does that mean that women receive better health care than men?\n\n3. Discuss possible reasons why minority patients receive poorer quality of care than white patients for many diseases.\n\n4. What is the relationship between socioeconomic status (including factors such as income, education, and occupation) and health? Why does such a relationship exist?\n\n5. What would be the best strategies to improve the health status of African Americans in the United States?\n\n### **CHAPTER 4: REIMBURSING HEALTH CARE PROVIDERS**\n\n1. Explain each mode of physician reimbursement: fee-for-service, episode of illness, capitation, and salary. Explain each mode of hospital reimbursement: fee-for-service, per diem, episode of illness (diagnosis-related group [DRG]), and global budget.\n\n2. How does capitation payment free insurers of risk? How does capitation payment shift risk to providers of care?\n\n3. What are the arguments for risk-adjusting capitation payments?\n\n#### **Discussion Topics**\n\n1. You are a primary care physician (PCP) caring for a young woman with new onset of severe headaches and amenorrhea and a normal physical examination. What are the financial incentives and disincentives that would lead you to order or not to order a magnetic resonance imaging (MRI) scan in a case in which the need for the MRI was equivocal?\n\n(a) under traditional fee-for-service practice;\n\n(b) under fee-for-service practice with utilization review;\n\n(c) under an independent practice association (IPA)-model health maintenance organization (HMO) in which you receive a capitation payment that places you at risk for laboratory and x-ray studies and specialty referrals;\n\n(d) under a staff model HMO that has a two-month waiting list for elective MRI scans?\n\nIn the case of the staff model HMO, what would you do if you felt you needed to obtain the MRI within 48 hours?\n\n2. You are a hospital administrator and your hospital is in financial difficulty. You are about to address the medical staff, imploring them to help the hospital financially. In the old days, all you had to say was, in effect: \"Admit as many patients as possible and keep them in the hospital as long as you can,\" but times have changed. For some methods of reimbursement, you want physicians to admit more patients; for others, you don't. For some methods, you want patients to stay long, for others, you don't. What do you tell the medical staff regarding the following:\n\n(a) Medicare (DRG) patients\n\n(b) Medicaid (per diem) patients\n\n(c) HMO (per diem) patients\n\n(d) HMO (capitated) patients\n\nFor each of these categories of patients, does it help or hurt the hospital for physicians to\n\n(a) admit more patients;\n\n(b) keep them in the hospital more days;\n\n(c) order more diagnostic studies?\n\n### **CHAPTER 5: HOW HEALTH CARE IS ORGANIZED\u2014I: PRIMARY, SECONDARY, AND TERTIARY CARE**\n\n#### **Discussion Topics**\n\n1. You are 63 years old and you begin to experience chest pain when walking. You do not have a physician. A friend suggests that you need a coronary artery bypass and recommends a cardiac surgeon at the medical school. What do you do\n\n(a) under a dispersed model of health care delivery?\n\n(b) under a regionalized model?\n\n2. Give some examples of the statement, \"Common disorders commonly occur and rare ones rarely happen.\" What are the implications of this statement for the ratio of generalist to specialist physicians in the United States?\n\n3. In Great Britain, 65% of physicians are general practitioners. In Canada, 50% of physicians are generalists. In the United States, approximately one-third of physicians are generalists (general and family practitioners, general internists, and general pediatricians). Assume you are Chair of the Health Subcommittee of the US House of Representatives Ways and Means Committee. What legislation might you propose to increase the proportion of generalist physicians?\n\n4. Discuss the pros and cons of requiring everyone to enter the health care system through a \"gatekeeper\" health care provider (generalist physician, nurse practitioner, or physician assistant).\n\n5. What are some advantages of a primary-care-based health system?\n\n### **CHAPTER 6: HOW HEALTH CARE IS ORGANIZED\u2014II: HEALTH DELIVERY SYSTEMS**\n\n1. What are the two generations of HMOs? Give examples of each (if possible, in your community).\n\n2. What is vertical integration? What is virtual integration?\n\n3. What is an ACO? What is a medical home and a medical neighborhood? Is a medical neighborhood the same as an ACO?\n\n### **CHAPTER 7: THE HEALTH CARE WORKFORCE AND THE EDUCATION OF HEALTH PROFESSIONALS**\n\nDescribe past and future trends in the physician, \"mid-level,\" nursing, and pharmacist workforce.\n\n### **CHAPTER 8: PAINFUL VERSUS PAINLESS COST CONTROL**\n\n1. Give examples of medical interventions that lie on the steeper portions of the cost\u2013benefit curve, and p>interventions that lie on the flatter portions. Is the elimination of the latter painful or painless cost control?\n\n2. Give examples of painless cost control. Are these painless for everyone?\n\n#### **Discussion Topics**\n\n1. CABGville has four cardiac surgery units; one unit performs 300 coronary artery bypass graft (CABG) surgeries each year, and the other units perform an average of 40 per year. Cardiac surgeons can schedule a CABG anytime they wish. The small units have an operative mortality of 7% compared with 4% for the large unit. To control costs, the health planning council of CABGville closes the three less productive cardiac surgery units. Elective CABG surgeries now have a 1-month waiting list, and because of tight scheduling, surgeons are less likely to operate; the number of CABGs goes down from 420 to 340 per year; both the overall costs of CABG surgery and the unit cost per CABG operation drop, as does the mortality rate. Did CABGville achieve painful or painless cost control?\n\n2. Pretend that total US health care expenditures have been capped and are controlled by a health services commission. Because of tight budgetary constraints, the commission must decide whether to fund an all-out program of mammography or to limit mammography and finance in its place high-cost chemotherapy regimens for patients with metastatic breast cancer, treatments whose effectiveness has not been proven, but which might help certain subgroups of women. Under the first option, several thousand cases of early-stage breast cancer could be treated with curative surgery each year, but women currently suffering from advanced-stage breast cancer would receive no benefit. Which is the more painful cost control option from the point of view of women without breast cancer? From the perspective of women with metastatic breast cancer? From the perspective of society as a whole? Which of these two groups of women should have priority in this decision?\n\n### **CHAPTER 9: MECHANISMS FOR CONTROLLING COSTS**\n\n#### **Discussion Topics**\n\n1. You are chair of the health planning council of CABGville, a town that continues to have a health care cost crisis. The town has 30 physicians, each seeing 30 patients a day at a cost of $30 per visit. Total daily cost is 30 \u00d7 30 \u00d7 30 = $27,000. What methods are available to reduce the total cost of physician services? Would it work to reduce the fee per visit from $30 to $20? If an expenditure cap strategy (tying fees to volume) were used, how would it work?\n\n2. The CABGville health planning council changes the mode of physician reimbursement from fee-for-service to capitation: $20 per patient per month to PCPs, with 20 PCPs each having 2000 patients. (PCPs pay specialists from the $20 capitation.) Total cost per month = $800,000 (approximately $27,000 per day). How could the health planning council reduce the monthly cost? Could physician costs still increase despite this method of cost control? Why or why not?\n\n3. You have finished your residency in internal medicine and have the choice to work at Kaiser or at a private practice that is part of an IPA. You are particularly concerned about your ability to order laboratory tests and x-rays and to obtain specialty consultations. At Kaiser, you learn that you have freedom in ordering tests and obtaining consultations, but that patients may have to wait (except in urgent situations) because of the limited supply of such equipment as MRI scanners and of specialty appointments. At the IPA, you must request prior authorization for expensive diagnostic studies and for specialty consultations, but once prior authorization has been obtained, waiting periods are fairly short. Which work situation would you prefer, and which do you think has the better chance of controlling costs?\n\n4. What are the arguments pro and con patient cost sharing as a cost control strategy?\n\n5. You are the President of the United States, and your first term ends in a year. The cost-control mechanism you instituted 2 years ago, based on patient cost sharing and managed competition, has not worked, and the American people are upset about persistent health care inflation. You are preparing for a major television address on health care costs. What will you propose? Can you convince the public that yours is a painless cost-control strategy?\n\n### **CHAPTER 10: QUALITY OF HEALTH CARE**\n\n#### **Discussion Topics**\n\n1. Have you ever experienced or witnessed a medical care encounter of poor quality? What did you do about it? What should you have done?\n\n2. In the vignette about Shelley Rush, who do you think was responsible for the error in giving insulin to the wrong patient?\n\n3. In the vignette about Nina Brown, had the physician been working in a fee-for-service environment rather than a cost-conscious HMO, do you think he or she would have admitted Ms. Brown to the hospital?\n\n4. Reread the example of the 23-year-old graduate student whose x-ray report was lost. If you were the administrator of the hospital, what would you do to prevent such an error from taking place again? If you were the office manager of the internist's office that never received the x-ray report, what would you do to avoid a recurrence of this problem?\n\n5. What is wrong with the malpractice system? What would you do to fix it?\n\n### **CHAPTER 11: PREVENTION OF ILLNESS**\n\n1. Why did tuberculosis (TB) decline prior to the identification of the TB bacillus? Why did polio morbidity and mortality decline? Why did Hodgkin disease mortality fall in the late twentieth century?\n\n2. What are the first and the second epidemiologic revolutions?\n\n#### **Discussion Topics**\n\n1. Two people are campaigning for the consumer board of their group practice. The incumbent is running on a platform of charging tobacco users higher premiums than nonusers, because their use of tobacco costs the group practice more money. The opponent believes that society rather than the individual is responsible for tobacco addiction and that the group practice should become involved in social action against cigarette smoking. Conduct a debate between these two views.\n\n2. How do you explain the fact that a large number of heart attacks occur at early ages in people with cholesterol levels below the median level for the United States? That heart attacks seldom occur at these ages in Japan? What is the implication for primary prevention of coronary heart disease?\n\n3. You are named as head of the breast cancer prevention section of the US Centers for Disease Control and Prevention. What primary and secondary prevention programs would you favor to reduce the incidence of and mortality from breast cancer?\n\n### **CHAPTER 12: LONG-TERM CARE**\n\n1. What are activities of daily living and instrumental activities of daily living?\n\n2. What percentage of long-term care services are funded by which funding sources?\n\n3. Which long-term care services are covered by Medicare and which are not? Which are covered by Medicaid?\n\n#### **Discussion Topics**\n\n1. You are president of LTC Insurance Company and are testifying before a Senate committee on long-term care. You are asked two questions: Why do only a few million people carry private long-term care insurance? How do you answer the complaints that senior citizen advocacy groups make about the terms of private long-term care insurance policies? What do you say to the committee?\n\n2. Your mother's Alzheimer's disease is getting worse; she wanders around the neighborhood, sometimes unable to find her way home; she sleeps during the day and stays up most of the night; and she has become incontinent. Your father died 2 years ago. You and your spouse both work, you have three school-aged children, and you have an extra room in your home. The hospital social worker calls and says that your mother needs 24-hour-a-day help. Your choices are:\n\n(a) hiring a homemaker to live with your mother at $16,000 per year;\n\n(b) placing your mother in a nursing home whose bill will be paid by Medicaid;\n\n(c) taking your mother home with you. What do you decide?\n\nWhat reforms in the US long-term care system would have benefited you in this situation? How should such reforms be financed?\n\n### **CHAPTER 13: MEDICAL ETHICS AND RATIONING OF HEALTH CARE**\n\n#### **Discussion Topics**\n\n1. Pretend that the Lakeberg family discussed in this chapter belongs to an HMO, and that you are the HMO's medical director. The Lakeberg parents want surgery to separate the Siamese twins at the cost of $1 million. The list of benefits covered in the Lakebergs' HMO policy neither affirms nor denies their right to the surgery, so the responsibility to approve or deny the surgery falls on you. What do you decide? If you approve the surgery, who will end up paying for it? Is an ethical dilemma involved or not?\n\n2. You are Dr. Marco Intensivo, as described in the vignette in the section \"What is Rationing?\" What do you do?\n\n3. In the case of Mr. Olds and Mr. Younger described in the organ transplant section, which patient should receive the donor heart?\n\n4. You are the PCP for Rodolfo, a 58-year-old man who suffered a cerebral hemorrhage and has been in a persistent vegetative state for 18 months. He lives in a nursing home, requires tube feedings and round-the-clock nursing attention, and his care is paid for by Medicaid. Rodolfo's daughter is a nurse in the intensive care unit of your hospital. Rodolfo's wife is deeply religious and has faith that Rodolfo will get better.\n\nApproximately every 6 weeks, Rodolfo develops a urinary tract infection with septicemia and must be admitted to the hospital\u2014often to the ICU\u2014for treatment. Over the course of 2 years, Rodolfo's care has cost $260,000. The hospital ethics committee discussed the case and recommended that tube feedings be withdrawn, or that the next episode of septicemia not be treated, thereby allowing Rodolfo to die. When you discussed the ethics committee recommendations with the family, the daughter agreed but the wife demanded that everything possible be done to continue Rodolfo's life. As Rodolfo's physician, what do you do? Which ethical dilemmas are involved? Autonomy versus beneficence? Autonomy versus nonmaleficence? Autonomy versus distributive justice? Beneficence versus distributive justice? If Rodolfo's care were withdrawn, what would happen to the money saved?\n\n5. Evidence from public opinion polls suggests that people in the United States want the right to health care but don't want to pay for it.\n\nAt midnight, a new mother awakens to hear her 2-week-old infant scream. The mother and baby are Medicaid recipients. If she were experienced, the mother would know that the scream is normal, but she is frightened. She phones the emergency department and asks to bring the baby in to be seen. No amount of telephone advice seems to reassure her. Does the right to health care include society paying for her visit to the emergency department? Who is actually paying? Should the mother be advised to come into the emergency department if she is uninsured and wealthy? Uninsured and poor?\n\n6. In Oregon, the Medicaid program was extended to thousands of Oregonians who had previously been uninsured. To help pay for this extension, the breadth of services available to Medicaid recipients was reduced such that recipients lost access to some care that might have been beneficial. You are the Governor of Oregon and you have to testify in a lawsuit alleging that the program is unfair because it deprives Medicaid recipients of certain services enjoyed by privately insured people. What is your response?\n\n7. Should physicians be responsible to serve one master\u2014their patient\u2014or two masters\u2014their patient and the broader needs of society? In your discussion, draw from the examples of the Lake-bergs, Dr. Intensivo, and Rodolfo. How has the distribution system for organ transplantation tried to balance these two masters?\n\n### **CHAPTER 14: HEALTH CARE IN FOUR NATIONS**\n\n1. You are a secretary in a large company in Germany (Canada, United Kingdom, or Japan). How is your health care paid for? You become sick and are forced to retire from your job. How is your health care paid for in Germany (Canada, United Kingdom, or Japan)?\n\n2. If you developed a urinary tract infection, what would you do in Germany (Canada, United Kingdom, or Japan)? What if you needed cataract surgery? What if you had a sudden abdominal pain in the middle of the night? What if you developed leukemia and needed a bone marrow transplant? In each of these cases, which physician would care for you and where would you be cared for?\n\n3. You are a general practitioner in Germany (Canada, United Kingdom, or Japan). How are you paid? You are a specialist in Germany (Canada, United Kingdom, or Japan). How are you paid? You are a hospital administrator in Germany (Canada, UK, or Japan). How is your hospital paid?\n\n4. How are costs controlled in the four countries?\n\n### **CHAPTER 15: HEALTH CARE REFORM AND NATIONAL HEALTH INSURANCE**\n\n1. Describe how a government-financed national health insurance plan, an employer mandate plan, and an individual mandate plan would work.\n\n2. What is the difference between a social insurance and a public assistance approach to government-financed national health insurance? Use Medicare and Medicaid as examples.\n\n3. What are the main features of the 2010 Patient Protection and Affordable Care Act (ACA)?\n\n#### **Discussion Topics**\n\n1. You are the speech writer for two candidates for the Democratic presidential nomination. One candidate favors a mixed employer and individual mandate and the other a single-payer approach. What points would you have each candidate make about the strengths of his or her position and the weaknesses of the other candidate's position?\n\n2. Why do you think that there has been such a polarized debate over the ACA?\n\n### **CHAPTER 16: CONFLICT AND CHANGE IN AMERICA'S HEALTH CARE SYSTEM**\n\n1. Describe how the payers of health care services increased their power between 1945 and 1995.\n\n2. Describe changes in the relationships between physicians and insurance companies between 1945 and 1995.\n\n3. Describe the 1995\u20132000 backlash against managed care.\n\n4. Describe the recently growing power of specialty-oriented providers of care.\n\n#### **Discussion Topics**\n\n1. Discuss potential conflicts between the profit motive and the principles of beneficence and nonmaleficence in the following situations:\n\n(a) a private surgeon receiving fee-for-service reimbursement;\n\n(b) a primary physician in a small group practice that receives capitation payments covering primary care, laboratory, x-ray, and specialty referrals;\n\n(c) a physician who is the utilization manager of a large for-profit HMO receiving requests from her employed physicians to authorize expensive MRI scans for their patients;\n\n(d) the administrator of a nonprofit hospital who has calculated that a new cardiac surgery unit will be profitable even if only one surgery is performed each week;\n\n(e) the CEO of an HMO deciding whether to accept Medicaid patients, for whom the state government is paying premiums 30% lower than premiums paid for private patients.\n\nWhat changes in the organization of health care could be made that would minimize such conflicts?\n\n2. Discuss how health care is organized in your community\u2014who are the payers, insurers, and providers? To what degree has your local health care system moved from a dispersed set of institutions to a small number of vertically or virtually integrated health care conglomerates?\n\n3. Where in the health care system of the twenty-first century would you like to be\u2014as a provider and as a patient? What are yours fears and hopes for the future?\n\n## **Index**\n\nPage numbers followed by f refer to figures; page numbers followed by t refer to tables.\n\n**A**\n\nAccreditation Council for Graduate Medical Education (ACGME), ,\n\nActive practitioners in the U.S., , t\n\nActivities of daily living (ADL), , t\n\nAdequate access to care,\n\nAdequate scientific knowledge, t\n\nAgency for Health Care Policy and Research\/Agency for Health Care Research and Quality (AHRQ), ,\n\nAmbulatory care physicians, ,\n\nAmerican Association for Labor Legislation (AALL),\n\nAmerican Medical Association (AMA), ,\n\nAntismoking campaigns, \u2013140\n\nAutonomy, \u2013154\n\nnonmaleficence, comparison with,\n\n**B**\n\nBalanced Budget Act of 1997,\n\nBeneficence,\n\nBeveridge, William,\n\nBiomedical model, ,\n\nBlue Cross subscribers,\n\nBlue Cross, \u2013203\n\nBlue Shield,\n\nBreast cancer mortality rates, \u2013143\n\nBreast Cancer, \u2013143\n\nmultiple risk factors,\n\nBritish Medical Association (BMA),\n\nBritish National Health Service (NHS), \u201346, \u2013176\n\nreforms of, \u2013180\n\nBritish system\n\nof capitation payments,\n\nof health care, \u201346\n\n**C**\n\nCalifornia Medical Injury Compensation Reform Act,\n\nCanada's universal insurance program,\n\nCanadian family physicians,\n\nCanadian health care system,\n\nCanadian Hospital Insurance Act,\n\nCarve-outs,\n\nCHD. _See_ Coronary heart disease Chief organized purchaser, disinterest of,\n\nChronic disease prevention,\n\nmedical model,\n\nClinical practice guidelines, \u2013123\n\nClinton, Bill (U.S. President), health insurance plan of,\n\nCommercial insurers,\n\nCommodity scarcity through transplantation of organs, \u201359\n\nCommunity health centers, \u201362\n\nCommunity rating, . _See also_ Experience rating\n\nCommunity-based long-term care,\n\nCompetent health care providers, \u2013117\n\nCompetitive strategies\n\nfor cost control, \u2013106\n\nComputerized information systems,\n\nComputerized physician order entry (CPOE),\n\nConcerted action,\n\nContinuous quality improvement (CQI), ,\n\nCoronary artery bypass graft (CABG) surgery, \u2013120\n\nCoronary heart disease (CHD), , \u2013143\n\nage-adjusted mortality rates, \u2013138,\n\ndue to cigarette smoking, \u201340\n\ndue to hypertension, \u2013142\n\ndue to rich diet, \u2013141\n\nContinuous quality improvement (CQI) model,\n\nsystematically monitoring of health care providers, , t\n\nCQI. _See_ Continuous quality improvement\n\n_Curing Health Care_ ,\n\nCustodial services,\n\n**D**\n\nDepartment of Health and Human Services (U.S.), \u2013159\n\nDiagnosis-related group (DRG) method of payment, \u201340\n\nDispersed Model, \u201347, , , . _See also_\n\nRegionalized Model Distributive justice, \u2013155\n\nDRG. _See_ Diagnosis-related group\n\n**E**\n\nEarmarked health tax,\n\nEmployer mandate approach, ,\n\nEmployer mandate plans,\n\ncriticism of,\n\nEmployment-based private insurance, \u201310\n\nEmployment-based social insurance model,\n\nEmployment-based privately administered national health insurance proposal,\n\nEnd-of-life costs\n\nof patients in hospice programs,\n\nEnterprise liability,\n\nEthical dilemmas, \u2013157\n\nExperience rating, . _See also_ Community rating\n\nExperience-rated insurance, ,\n\nExplicit rationing,\n\n**F**\n\nFederal social insurance trust fund, \u201389\n\nFee-for-service payment,\n\nFee-for-service reimbursement, , , ,\n\nFinancially Neutral Clinical Decision Making,\n\nFinancing controls\n\nfor health care, \u2013106\n\nweaknesses,\n\nFinancing medical education,\n\nFirst epidemic revolution,\n\nFiscal reality,\n\nFiscal scarcity\n\nresource allocation, correlation with, \u2013159\n\nFrontier Nursing Service,\n\n**G**\n\nGatekeeping\n\nin primary care,\n\nGerman Cost Containment Act of 1977,\n\nGerman national health insurance system, f\n\nGood quality care,\n\nGovernment financed insurance, \u201316, f\n\nGovernment-financed national health insurance plans, \u2013190\n\npublic assistance (welfare) model,\n\nGPs and specialists\n\nBritish, pay for performance (P4P), \u2013178\n\nCanadian, fee-for-service basis,\n\nGerman, detailed fee schedule,\n\nJapanese, per diem hospital payment based on diagnosis,\n\nGriffiths, Martha, Michigan Representative,\n\nGuaranteed medical benefits,\n\n**H**\n\nHarvard Medical Practice study,\n\nHealth care \"report cards,\" 125\n\nHealth care financing ethics, \u2013166\n\nHealth care financing system, \u2013198\n\nHealth care financing,\n\nHealth care institutions,\n\nHealth care market, consolidation in,\n\nHealth care outcomes\n\norganization of health care systems and institutions,\n\nHealth care providers\n\nsocially useful cost savings, \u2013160\n\nHealth care quality, crossnational comparisons,\n\nHealth care resources, \u2013167\n\nHealth care sector\n\nof U.S. economy,\n\nHealth care system, \u20133,\n\nin the U.S.\n\nperformance analysis,\n\norganization of, \u201353\n\npublic's view of,\n\nquality of care, correlation with, \u2013120\n\ntraditional quality assurance, \u2013122\n\nweaknesses, understanding of, \u20133\n\nHealth care\n\nadministrative overheads of, \u201399\n\nbalance in levels of, \u201348, t\n\ncost control\n\nin Canada,\n\ncategories, t\n\nin Germany,\n\nin Japan,\n\npainless, \u2013102, t\n\nrequirement of,\n\nrequirements for,\n\nstrategies, \u2013101\n\nin United Kingdom,\n\ncost effectiveness\n\nprioritization and analysis of, \u2013101\n\ncost saving\n\nthrough disease prevention,\n\nthrough innovation,\n\ncost sharing, \u2013109\n\ncosts, description of,\n\ndeprived patients, ,\n\nexcess care,\n\npatients with, \u20132\n\nexpenditures, , t\n\nfinancial incentives, \u201355\n\nfinancing of\n\nin the U.S., , t\n\nmodes, \u201315\n\ngeneralism, role of, \u201354\n\nhistorical overview, t\n\nineffective, elimination of, \u201398\n\ninflation,\n\ncontrol of,\n\nneed and cost of, \u20136\n\npatient access to, ,\n\ngender and race factors, \u201326\n\npayment modes, \u201315\n\nphysician recommendations, implications of, \u20137\n\nrelation with health status, \u201328\n\nsocioeconomic status, influence of, \u201329\n\nresource input and outcomes, correlation in, \u201397\n\ntraditional structure of, \u201360\n\nHealth care, tensions, t\n\nHealth insurance premiums,\n\nHealth insurance\n\nin Canada, \u201373\n\ntax-financed, public, single-payer health care system,\n\nessence of,\n\nin Germany, \u2013171\n\nmerged social insurance and public assistance structure,\n\nhealth care services, implications of,\n\nin Japan, \u201382\n\nlack of, , \u201324\n\nfactors for, \u201319\n\nlimitations of,\n\nnonfinancial barriers, \u201326\n\nsource of, , t\n\nin United Kingdom, \u201376\n\nHealth Maintenance Organization Act,\n\nHealth maintenance organizations (HMO), ,\n\ncontracting of, \u2013205\n\ndecline of,\n\nIndependent practice associations (IPA) model, \u201367\n\nprepaid group practice, basis on, \u201363\n\nsecond generation, \u201367\n\nHealth maintenance,\n\nHealth plan employer data and information set (HEDIS),\n\nHealth policy\n\nabstract concepts in, \u2013216\n\ngoal of,\n\nconcerns of,\n\nHealth reform law, Massachusetts,\n\nHealth workers\n\nsupply of, \u201383\n\nunderrepresented minorities, representation of, \u201387, f\n\nwomen, \u201386, f\n\nHealth Commissioner projects, Limittown, U.S.A.,\n\nHeritage plan,\n\nHigh blood pressure, primary prevention,\n\nHigh-deductible health plan (HDHP),\n\nHigh-dose chemotherapy with autologous bone marrow transplantation (HDC-ABMT),\n\nHigh-quality health care, \u2013120\n\nHMO. _See_ Health maintenance organization Home care agencies,\n\nHome health services medicaid coverage of,\n\nHospital payment methods, \u201340\n\nHospital Quality Initiative,\n\nHSA. _See_ Health savings account Hybrid national health insurance proposals,\n\nin California,\n\n**I**\n\nIdeal long-term caregivers,\n\nIllegal drug use,\n\nIndependent practice associations (IPAs),\n\nIndiana Medical Malpractice Act,\n\nIndividual health care consumers,\n\nIndividual mandate health insurance, \u2013193\n\nIndividual mandates, \u2013194\n\nIndividual patients, maximizing care,\n\nIndividual physician report cards,\n\nIndividual private insurance, , f,\n\nInfant mortality\n\nrace, correlation with, \u201329, t\n\nInfectious disease mortality rates,\n\nInformal caregivers,\n\nIn-hospital medical errors,\n\nInstitute for Healthcare Improvement (IHI),\n\nInstrumental activities of daily living (IADLs),\n\nInsurance co-payments,\n\nInsurance deductibles,\n\nInsurers and providers of care, alliance of,\n\nInsurers,\n\nIntegrated organizations,\n\nIntegrated Healthcare Association (IHA) program,\n\nInvestor-owned \"for-profit\" status,\n\nIPA. _See_ Independent practice associations\n\n**J**\n\nJapan's community-based health insurance\/citizens' health insurance,\n\nJoint Commission on Accreditation of Hospitals\/Joint Commission,\n\n_Journal of the American Medical Association_ , \u201361\n\nJustice,\n\n**K**\n\nKaiser Health Plan, , \u201364\n\nKaiser\u2013Permanente medical care program, \u201365\n\nKennedy, Edward, Massachusetts Senator,\n\nKennedy-Griffiths Health Security Act of 1970,\n\nKnifeless' gamma ray surgery,\n\n**L**\n\nLCME. _See_ Licensing Council on Medical Education Licensing agencies,\n\nLicensing Council on Medical Education (LCME),\n\nLife-expectancy\n\nrace, correlation with, , t\n\nLong-term care policies,\n\nLong-term care,\n\nactivities requiring assistance, t\n\ndeinstitutionalizing,\n\ndirect out-of-pocket payments,\n\nfinancing of, \u2013151\n\nout-of-pocket expenses, ,\n\nLower-income people, nursing home care, ,\n\n**M**\n\nMacroallocation, ,\n\nMagic bullets, ,\n\nMalpractice liability system,\n\nnegative side effects on medical practice, \u2013129\n\nManaged care plans, , , ,\n\nMaximizing care for each patient, physicians' single-mindedness, \u2013167\n\nMayo clinic, , , ,\n\nMedicaid long-term coverage, \u2013148\n\nMedicaid public assistance model,\n\nMedicaid, , t\u201312t, , ,\n\nhealth care access through,\n\nMedicaid\/SCHIP (beneficiaries), 2007, , t\n\nMedical care\n\nin Canada, \u201374\n\ncosts of, influence of prevention,\n\nfinancial considerations and quality,\n\nin Germany,\n\nin Japan,\n\nin United Kingdom, \u201376\n\nMedical commons,\n\nMedical education, \u201375\n\nMedical ethics,\n\nprinciples of, \u2013154\n\nMedical injury, alternatives to jury trials,\n\nMedical insurance. _See_ Health insurance Medical negligence, , \u2013120\n\nMedical reimbursements,\n\nMedicare Advantage program, , ,\n\nMedicare coverage disparities, t,\n\nMedicare long-term coverage,\n\nMedicare Modernization Act of 2003,\n\nMedicare Part A, , t\n\nMedicare Part B, , t,\n\nMedicare Part D, \u201311, ,\n\nMedicare Prospective Payment System (diagnosis related groups [DRGs]) of 1983,\n\nMedicare, ,\n\nMedicare's budget,\n\nMedicine, commercialization of,\n\nMethods of payment, \u201332\n\nMicroallocation,\n\ndaily clinical decisions,\n\nMortality rates\n\nin the U.S.,\n\nMultidisciplinary group practice,\n\nMultispecialty group practice, \u201361\n\nMultispecialty groups,\n\n**N**\n\nNational Cholesterol Education Program,\n\nNational Committee for Quality Assurance (NCQA), ,\n\nNational health expenditures per capita, , f,\n\nNational Health Insurance (U.S.), \u2013199\n\nbenefit package,\n\ncost containment, \u2013197\n\npatient cost sharing, \u2013196\n\nNational Organ Transplantation Act of 1984,\n\nNHS. _See_ British National Health Service NIH cholesterol reduction strategy,\n\nNixon, U.S. President, \u2013191\n\nNo-fault malpractice reform,\n\nNonmaleficence, ,\n\nNurse practitioners, \u201380\n\nNurses\n\ndemand and need, \u201381\n\nsupply of, , f\n\nNursing homes, \u2013150\n\n**O**\n\nOmnibus Budget Reconciliation Act of 1987,\n\nOpen and closed medical care systems, role of ethical considerations,\n\nOregon Health Plan, \u201364\n\nOrgan allocation,\n\nOrganizing care, models of,\n\nOutcome measures,\n\nOutcomes,\n\nOut-of-pocket payments, , , , , f\n\nOveruse\u2013underuse spectrum,\n\n**P**\n\nPanel management\n\nin primary care, \u201352\n\nPatient-centered medical home, \u201352\n\nPatients' persistent financial barriers,\n\nPay for Performance (P4P), \u2013128\n\nPay for Reporting, \u2013127\n\nPaying physicians and hospitals\n\nin Canada, \u2013175\n\nin Germany,\n\nin Japan,\n\nin United Kingdom,\n\nPayments\n\nfor all services,\n\nper diem, ,\n\nper episode of illness, , \u201334\n\nper hospitalization episode, \u201340\n\nper institution,\n\nper patient\n\nto hospital,\n\nto physician, ,\n\nper procedure\n\nfor hospital,\n\nfor physician, \u201333\n\nper time,\n\nPCP. _See_ Primary care physician\n\nPeer review, \u2013122\n\ntheory of bad apples,\n\nPepper Commission of 1990,\n\nPharmaceutical industry (U.S.), \u2013210\n\nPharmacists,\n\nshortage of,\n\nsupply of, \u201381, f\n\nPharmacy technician,\n\nPhysician assistant education, \u201378\n\nPhysician assistants (PAs), \u201377\n\nPhysician entrepreneurship in Japan,\n\nPhysician organizations, funding of,\n\nPhysician payment methods, \u201333\n\nPhysician practices,\n\nPhysician Quality Reporting Initiative, ,\n\nPhysician\u2013industry relationships,\n\nPhysicians for National Health Program, ,\n\nPhysicians, \u201374\n\nfinancial incentives, \u201355\n\nin traditional fee-for-service, \u201360\n\nprofessionalism, \u201356\n\nsupply of\n\nrelation with mortality,\n\nPostdoctoral education, \u201376\n\nPower relationships, ,\n\nPPO. _See_ Preferred Provider Organization Practice organizations, patterns of care,\n\nPreferred Provider Organization (PPO), \u201333, \u201369\n\nPrepaid group practice, \u201363\n\nPrescription drug, efficacy and clinical trials of, \u2013211\n\nPrevention, strategies, \u2013136\n\nPrice controls, , , t, ,\n\nPrice, \u201397\n\nPrimary care physician (PCP), , , ,\n\nPrimary care physician,\n\nPrimary care trusts,\n\nPrimary prevention,\n\nthrough public health action,\n\nPrivate insurance,\n\nPrivate insurers,\n\nPrivate long-term care insurance,\n\nProcess measures,\n\nProcess of care,\n\nProfitability, \u2013210\n\nProfoundly ill people, medical care,\n\nPromotion of good health and the prevention of illness,\n\nProvider-insurer pact, \u2013202, \u2013206\n\nProviders,\n\nProviding or withholding of care,\n\nPurchaser dominance over health care,\n\nPurchasers,\n\nrevolt, \u2013205\n\n**Q**\n\nQuality improvement organizations (QIOs),\n\nQuality monitoring, contemporary approach,\n\nQuality of care,\n\nproposals for improvement, \u2013121\n\npublic reporting of, \u2013126\n\nQuantity,\n\n**R**\n\nRand Health Insurance Experiment, ,\n\nRationing\n\nin medical care, ,\n\nby medical effectiveness,\n\nfor society as a whole,\n\nrelationship to cost control,\n\nwithin one institution,\n\nRegionalized Model, , f. _See also_ Dispersed Model Registered nurse education,\n\nRegistered nurses, \u201378, ,\n\nRegulatory strategies for cost control,\n\nReimbursement controls for health care, , \u2013107\n\nRisk adjusted capitation, , ,\n\n**S**\n\nSalaried payment, , f\n\nSan Francisco, On Lok program,\n\nSan Joaquin Foundation for Medical Care, \u201366\n\nSCHIP. _See_ State Children's Health Insurance Program\n\nSecond epidemic revolution,\n\nSecondary care,\n\nSecondary prevention,\n\nSelective contracting,\n\nSelf-insurance placed employers,\n\nSickness funds, \u2013171\n\nSingle-payer detractors,\n\nSingle-payer proposals, \u2013197\n\nSingle-specialty groups,\n\nSkilled care versus custodial services,\n\nSmoking cessation, physician counseling,\n\nSocial insurance model, \u201314,\n\nSocial insurance,\n\nSocial\u2013ethical dilemma, \u2013156\n\nSociety-managed insurance plans,\n\nSpecialist physicians and specialty services, financial incentives,\n\nSpecialty service lines,\n\nSponsored collaboratives,\n\nStarfield, Barbara\n\nprimary care tasks, formulation of,\n\nState Children's Health Insurance Program (SCHIP), , , , , , ,\n\nStatin drugs, treatment for hyperlipidemia,\n\nSuppliers,\n\nSupply limits, \u2013202,\n\ncontrol of, \u2013112\n\n**T**\n\nTask Force on Organ Transplantation (1986),\n\nTax credits, \u2013192\n\nTertiary care, \u201344, , , \u2013219\n\nThree-tiered capitation, \u201336, f. _See also_ Two tiered capitation\n\nTobacco,\n\nTort reform,\n\nTraditional insurers,\n\nTruman, Harry S., U.S. President, ,\n\nTwo-tiered capitation, \u201336. _See also_ Three-tiered capitation\n\n**U**\n\nU.S. health care system\n\n1945\u20131970,\n\n1970s,\n\n1980s: purchasers' revolt, \u2013205\n\n1990s: provider\u2013insurer pact, breakup of, \u2013206\n\nmanaged care,\n\nnew millennium: re-emergence of provider power, \u2013207\n\nunstable power relationships,\n\nUnderinsurance, , t\n\neffects of,\n\nUnemployment benefits,\n\nUninsured people, , f, , f\n\nhealth outcomes, \u201323\n\nUnit of payment, , \u2013108,\n\nUM, relation with,\n\nUnited Network for Organ Sharing (UNOS),\n\nUnited States system\n\nof capitation payments, \u201336\n\nof health care,\n\nUnits of payment, \u201332\n\nUniversal health insurance through an employer mandate, , ,\n\nUniversal individual insurance proposals, ,\n\nUtilization (quantity) controls, \u2013112\n\nUtilization management (UM)\n\nin health care,\n\n**V**\n\nVertical integration, , f,\n\nVoluntary approach,\n\n**W**\n\nWagner\u2013Murray\u2013Dingell Bill, \u2013189\n\nWelfare benefits,\n\nWorld War II, rationing,\n\nWorthy, Joshua, \n","meta":{"redpajama_set_name":"RedPajamaBook"}}
+{"text":"\n\n\u00c9pict\u00e8te\n\nManuel\n\nLibrio\n\nJ'ai Lu\n\nFlammarion\n\n\u00a9 \u00c9ditions J'ai lu, 2014\n\n\u00a9 E.J.L, 2014 pour la s\u00e9lection\n\nD\u00e9p\u00f4t l\u00e9gal : janvier 2014\n\nLe livre a \u00e9t\u00e9 imprim\u00e9 sous les r\u00e9f\u00e9rences :   \nISBN : 9782290082751\n\nISBN num\u00e9rique : 9782290088074\n\nISBN PDF web : 9782290088166\n\nOuvrage compos\u00e9 et converti par PCA (44400 Rez\u00e9)\nPr\u00e9sentation de l'\u00e9diteur :\n\nPour atteindre le bonheur, tout est question d'attitude. Sur l'avis des autres, la richesse, la chance ou la mort, nous n'avons pas de prise. C'est donc aux op\u00e9rations de l'\u00e2me qu'il faut accorder tous nos soins, et apprendre \u00e0 jouir des choses mat\u00e9rielles sans nous y attacher. D\u00e9sirer que les choses arrivent comme elles arrivent, voil\u00e0 la clef pour \u00c9pict\u00e8te.\n\nEn illustrant cette voie de mani\u00e8re concr\u00e8te, il expose avec simplicit\u00e9 et sagesse une mani\u00e8re diff\u00e9rente de voir le monde, qui affranchit l'homme des angoisses et des pr\u00e9occupations de sa condition.\n\nCompil\u00e9 par Arrien, le Manuel est suivi de morceaux choisis parmi les Entretiens avec ce m\u00eame disciple : \u00ab \u00c0 ceux qui craignent la pauvret\u00e9 \u00bb, \u00ab Contre les gens querelleurs et m\u00e9chants \u00bb ou \u00ab Pour ceux qui parlent trop ais\u00e9ment d'eux-m\u00eames \u00bb...\n\n\u00c9PICT\u00c8TE (VERS 50 \u2013 120 AV. J.-C.)\n\nEsclave, puis affranchi dans des conditions mal connues, \u00c9pict\u00e8te, dont le nom signifie \u00ab homme achet\u00e9 \u00bb, v\u00e9cut \u00e0 Rome avant d'en \u00eatre chass\u00e9 sous Domitien, qui craignait l'influence des sto\u00efciens.\n\nIllustration de couverture : Portrait imaginaire d'\u00c9pict\u00e8te. Frontispice de l'Enchiridion d'\u00c9pict\u00e8te, traduit par Edward Ivie et imprim\u00e9 \u00e0 Oxford en 1751. Biblioth\u00e8que John Adams, Boston \nDANS LA M\u00caME S\u00c9RIE\n\nL'Art d'aimer, Librio no 11\n\nLe Banquet, Librio no 76\n\nLe Prince, Librio no 163\n\nDiscours de la m\u00e9thode, Librio no 299\n\nL'Utopie, Librio no 317\n\nDiscours sur l'origine et les fondements de l'in\u00e9galit\u00e9 parmi les hommes, Librio no 340\n\nLettres et maximes, Librio no 363\n\nSi la philosophie m'\u00e9tait cont\u00e9e, Librio no 403\n\nLe Bonheur, d\u00e9sesp\u00e9r\u00e9ment, Librio no 513\n\nFragments et aphorismes, Librio no 616\n\nApologie de Socrate, Librio no 635\n\nDe la vie heureuse et de la tranquillit\u00e9 de l'\u00e2me, Librio no 678\n\nNi Dieu, ni ma\u00eetre ! De Diderot \u00e0 Nietzsche, Librio no 812\n\nSur le mensonge, Librio no 1074\n\nGorgias, Librio no 1075\n\nL'Art d'avoir toujours raison, Librio no 1076\n\nPens\u00e9es, Librio no 1078\n\nDiscours de la servitude volontaire, Librio no 1084\n\nDu contrat social, Librio no 1085\n\nTrait\u00e9 sur la tol\u00e9rance, Librio no 1086\n\nEssai sur l'art de ramper, \u00e0 l'usage des courtisans, Librio no 1096\nManuel\n\nI. DISTINCTION ENTRE CE QUI D\u00c9PEND DE NOUS ET CE QUI NE D\u00c9PEND PAS DE NOUS\n\n1. Des choses les unes d\u00e9pendent de nous, les autres ne d\u00e9pendent pas de nous. Ce qui d\u00e9pend de nous, ce sont nos jugements, nos tendances, nos d\u00e9sirs, nos aversions, en un mot tout ce qui est op\u00e9ration de notre \u00e2me ; ce qui ne d\u00e9pend pas de nous, c'est le corps, la fortune, les t\u00e9moignages de consid\u00e9ration, les charges publiques, en un mot tout ce qui n'est pas op\u00e9ration de notre \u00e2me.\n\n2. Ce qui d\u00e9pend de nous est, de sa nature, libre, sans emp\u00eachement, sans contrari\u00e9t\u00e9 ; ce qui ne d\u00e9pend pas de nous est inconsistant, esclave, sujet \u00e0 emp\u00eachement, \u00e9tranger.\n\n3. Souviens-toi donc que si tu regardes comme libre ce qui de sa nature est esclave, et comme \u00e9tant \u00e0 toi ce qui est \u00e0 autrui, tu seras contrari\u00e9, tu seras dans le deuil, tu seras troubl\u00e9, tu t'en prendras et aux dieux et aux hommes ; mais si tu ne regardes comme \u00e9tant \u00e0 toi que ce qui est \u00e0 toi, et si tu regardes comme \u00e9tant \u00e0 autrui ce qui, en effet, est \u00e0 autrui, personne ne te contraindra jamais, personne ne t'emp\u00eachera, tu ne t'en prendras \u00e0 personne, tu n'accuseras personne, tu ne feras absolument rien contre ton gr\u00e9, personne ne te nuira ; tu n'auras pas d'ennemi, car tu ne souffriras rien de nuisible.\n\n4. Aspirant \u00e0 de si grands biens, songe qu'il ne faut pas te porter mollement \u00e0 les rechercher, qu'il faut renoncer enti\u00e8rement \u00e0 certaines choses et en ajourner d'autres quant \u00e0 pr\u00e9sent. Mais si outre ces biens tu veux encore le pouvoir et la richesse, peut-\u00eatre n'obtiendras-tu m\u00eame pas ces avantages parce que tu aspires en m\u00eame temps aux autres biens, et, en tout cas, ce qu'il y a de certain, c'est que tu manqueras les biens qui peuvent seuls nous procurer la libert\u00e9 et le bonheur.\n\n5. Ainsi, \u00e0 toute id\u00e9e rude, exerce-toi \u00e0 dire aussit\u00f4t : \u00ab Tu es une id\u00e9e, et tu n'es pas tout \u00e0 fait ce que tu repr\u00e9sentes. \u00bb Puis examine-la, applique les r\u00e8gles que tu sais, et d'abord et avant toutes les autres celle qui fait reconna\u00eetre si quelque chose d\u00e9pend ou ne d\u00e9pend pas de nous ; et si l'id\u00e9e est relative \u00e0 quelque chose qui ne d\u00e9pende pas de nous, sois pr\u00eat \u00e0 dire : \u00ab Cela ne me regarde pas. \u00bb\n\nII. APPLIQUER LA DISTINCTION AU D\u00c9SIR ET \u00c0 L'ACTION\n\n1. Souviens-toi que ce que le d\u00e9sir d\u00e9clare qu'il veut, c'est d'obtenir ce qu'il d\u00e9sire, que ce que l'aversion d\u00e9clare qu'elle ne veut pas, c'est de tomber dans ce qu'elle a en aversion ; et quand on n'obtient pas ce qu'on d\u00e9sire, on n'est pas heureux, quand on tombe dans ce qu'on a en aversion, on est malheureux. Si donc tu n'as d'aversion que pour ce qui est contraire \u00e0 la nature dans ce qui d\u00e9pend de toi, tu ne tomberas dans rien de ce que tu as en aversion ; mais si tu as de l'aversion pour la maladie, la mort ou la pauvret\u00e9, tu seras malheureux.\n\n2. Cesse donc de donner pour objet \u00e0 ton aversion rien de ce qui ne d\u00e9pend pas de nous, transporte-la sur ce qui est contraire \u00e0 la nature dans ce qui d\u00e9pend de nous. Quant au d\u00e9sir, supprime-le absolument pour le moment. En effet, si tu d\u00e9sires quelque chose qui ne d\u00e9pende pas de nous, infailliblement, tu ne seras pas heureux ; et quant aux choses qui d\u00e9pendent de nous, qu'il est beau de d\u00e9sirer, il n'en est aucune qui soit encore \u00e0 ta port\u00e9e. Borne-toi \u00e0 tendre vers les choses et \u00e0 t'en \u00e9loigner, mais l\u00e9g\u00e8rement, en faisant des r\u00e9serves, et sans ardeur.\n\nIII. CE QU'EST CE QUI EST D\u00c9SIR\u00c9\n\n\u00c0 propos de tout objet d'agr\u00e9ment, d'utilit\u00e9 ou d'affection, n'oublie pas de te dire en toi-m\u00eame ce qu'il est, \u00e0 commencer par les moins consid\u00e9rables. Si tu aimes une marmite, dis : \u00ab C'est une marmite que j'aime \u00bb ; alors, quand elle se cassera, tu n'en seras pas troubl\u00e9 : quand tu embrasses ton enfant ou ta femme, dis-toi que c'est un \u00eatre humain que tu embrasses ; et alors sa mort ne te troublera pas.\n\nIV. ENTREPRENDRE UNE ACTION EN PR\u00c9SERVANT SON CHOIX\n\nQuand tu entreprends quelque chose, rappelle-toi ce que c'est. Si tu t'en vas te baigner, repr\u00e9sente-toi ce qui arrive tous les jours au bain, les gens qui vous jettent de l'eau, qui vous poussent, qui vous injurient, qui vous volent ; tu seras plus s\u00fbr de toi en allant te baigner, si tu te dis aussit\u00f4t : \u00ab Je veux me baigner, mais je veux aussi conserver ma volont\u00e9 dans un \u00e9tat conforme \u00e0 la nature. \u00bb Et de m\u00eame en chaque occasion. Ainsi, s'il te survient au bain quelque contrari\u00e9t\u00e9, tu auras aussit\u00f4t pr\u00e9sent \u00e0 l'esprit : \u00ab Mais je ne voulais pas seulement me baigner, je voulais conserver aussi ma volont\u00e9 dans un \u00e9tat conforme \u00e0 la nature ; et je n'y r\u00e9ussirai pas, si je m'irrite de ce qui arrive tous les jours. \u00bb\n\nV. NOS JUGEMENTS NOUS TROUBLENT, NON LES CHOSES\n\nCe qui trouble les hommes, ce ne sont pas les choses, ce sont les jugements qu'ils portent sur les choses. Ainsi la mort n'a rien de redoutable, autrement elle aurait paru telle \u00e0 Socrate ; mais le jugement que la mort est redoutable, c'est l\u00e0 ce qui est redoutable. Ainsi donc quand nous sommes contrari\u00e9s, troubl\u00e9s ou pein\u00e9s, n'en accusons jamais d'autres que nous-m\u00eame, c'est-\u00e0-dire nos propres jugements. Il est d'un ignorant de s'en prendre \u00e0 d'autres de ses malheurs ; il est d'un homme qui commence \u00e0 s'instruire de s'en prendre \u00e0 lui-m\u00eame ; il est d'un homme compl\u00e8tement instruit de ne s'en prendre ni \u00e0 un autre ni \u00e0 lui-m\u00eame.\n\nVI. CE QUI EST \u00c0 TOI : L'USAGE DES REPR\u00c9SENTATIONS\n\nNe t'enorgueillis d'aucun avantage qui soit \u00e0 autrui. Si un cheval disait avec orgueil : \u00ab Je suis beau \u00bb, ce serait supportable ; mais toi, quand tu dis avec orgueil : \u00ab J'ai un beau cheval \u00bb, apprends que tu t'enorgueillis d'un avantage qui appartient au cheval. Qu'est-ce qui est donc \u00e0 toi ? L'usage de tes id\u00e9es. Quand tu en uses conform\u00e9ment \u00e0 la nature, alors enorgueillis-toi ; car tu t'enorgueilliras d'un avantage qui est \u00e0 toi.\n\nVII. LA VIE COMME NAVIGATION\n\nIl en est de la vie comme d'une navigation. Si l'on rel\u00e2che, et que l'on t'envoie faire de l'eau, accessoirement tu pourras sur ta route ramasser un coquillage ou un oignon, mais il faut toujours avoir l'esprit tendu vers le navire, te retourner sans cesse pour voir si le pilote ne t'appelle pas, et, s'il t'appelle, laisser tout cela pour ne pas te voir li\u00e9 et jet\u00e9 \u00e0 bord comme un mouton : de m\u00eame dans la vie, si au lieu d'un coquillage ou d'un oignon, tu as une femme et un enfant, rien n'emp\u00eache ; mais si le pilote t'appelle, cours au vaisseau, en laissant tout cela, sans te retourner. Si tu es vieux, ne t'\u00e9loigne pas trop du navire, pour ne pas risquer de manquer \u00e0 l'appel.\n\nVIII. D\u00c9SIRE QUE LES CHOSES ARRIVENT COMME ELLES ARRIVENT\n\nNe demande pas que ce qui arrive arrive comme tu d\u00e9sires ; mais d\u00e9sire que les choses arrivent comme elles arrivent, et tu seras heureux.\n\nIX. LE CORPS N'EST PAS UNE SOURCE DE CONTRARI\u00c9T\u00c9\n\nLa maladie est une contrari\u00e9t\u00e9 pour le corps, mais non pour la volont\u00e9, si elle ne veut pas. \u00catre boiteux est une contrari\u00e9t\u00e9 pour la jambe, mais non pour la volont\u00e9. Dis-toi la m\u00eame chose \u00e0 chaque incident ; tu trouveras que c'est une contrari\u00e9t\u00e9 pour autre chose, mais non pour toi.\n\nX. NOUS AVONS LA FORCE POUR R\u00c9SISTER AUX REPR\u00c9SENTATIONS TROUBLANTES\n\n\u00c0 chaque occasion qui se pr\u00e9sente, replie-toi sur toi-m\u00eame et cherche quelle facult\u00e9 tu as en toi-m\u00eame pour te conduire : si tu vois une belle femme, tu trouveras en toi la facult\u00e9 de la continence ; s'il se pr\u00e9sente une fatigue \u00e0 supporter, tu trouveras celle de l'endurance ; une injure, tu trouveras celle de la patience. Si tu prends cette habitude, tes id\u00e9es ne t'emporteront pas.\n\nXI\n\nNe dis jamais de quoi que ce soit : \u00ab Je l'ai perdu \u00bb, mais : \u00ab Je l'ai rendu. \u00bb Ton enfant est mort : il est rendu. Ta femme est morte : elle est rendue. \u00ab On m'a enlev\u00e9 mon bien. \u00bb \u2014 Eh bien ! il est rendu aussi. \u2014 \u00ab Mais c'est un sc\u00e9l\u00e9rat que celui qui me l'a enlev\u00e9. \u00bb \u2014 Eh ! que t'importe par qui celui qui te l'a donn\u00e9 l'a r\u00e9clam\u00e9 ? Tant qu'il te le laisse, occupe-t'en comme de quelque chose qui est \u00e0 autrui, ainsi que les passants usent d'une h\u00f4tellerie.\n\nXII\n\n1. Si tu veux faire des progr\u00e8s, laisse l\u00e0 toutes ces r\u00e9flexions, comme : \u00ab Si je n\u00e9glige ma fortune, je n'aurai pas de quoi manger \u00bb ; \u00ab Si je ne ch\u00e2tie pas mon esclave, il sera vicieux. \u00bb Il vaut mieux mourir de faim, exempt de peine et de crainte, que de vivre dans l'abondance et le trouble ; il vaut mieux que ton esclave soit vicieux, et que tu ne sois pas malheureux.\n\n2. Commence donc par les petites choses. On laisse couler ton huile ; on vole ton vin : dis-toi \u00ab C'est \u00e0 ce prix que se vend l'impassibilit\u00e9, c'est \u00e0 ce prix que se vend le calme \u00bb. On n'a rien pour rien. Quand tu appelles ton esclave, pense qu'il peut ne pas r\u00e9pondre \u00e0 ton appel, et, y r\u00e9pondant, ne rien faire de ce que tu veux, mais que sa situation n'est pas assez belle pour qu'il d\u00e9pende de lui que tu ne sois pas troubl\u00e9.\n\nXIII\n\nSi tu veux faire des progr\u00e8s, r\u00e9signe-toi \u00e0 passer pour un idiot et pour un imb\u00e9cile dans les choses du dehors, consens \u00e0 passer pour n'y rien entendre ; et si quelques-uns te croient quelque chose, d\u00e9fie-toi de toi-m\u00eame. Sache qu'il n'est pas facile de conserver sa volont\u00e9 dans un \u00e9tat conforme \u00e0 la nature, et en m\u00eame temps de veiller sur les choses du dehors ; mais n\u00e9cessairement, on ne peut s'occuper de l'un sans n\u00e9gliger l'autre.\n\nXIV\n\n1. Si tu veux que tes enfants, ta femme, tes amis vivent toujours, tu es un imb\u00e9cile ; tu veux que ce qui ne d\u00e9pend pas de toi, d\u00e9pende de toi ; tu veux que ce qui est \u00e0 autrui soit \u00e0 toi. Ainsi, si tu veux que ton esclave ne commette pas de fautes, tu es fou ; tu veux que le vice ne soit pas le vice, mais autre chose. Mais si tu veux ne pas manquer ce que tu d\u00e9sires, tu le peux ; applique-toi donc \u00e0 ce que tu peux.\n\n2. On est toujours le ma\u00eetre d'un homme, quand on a le pouvoir de lui donner ou de lui \u00f4ter ce qu'il veut ou ce qu'il ne veut pas. Si l'on veut \u00eatre libre, qu'on n'ait ni d\u00e9sir ni aversion pour rien de ce qui d\u00e9pend d'autrui ; sinon, il faut \u00eatre esclave.\n\nXV\n\nSouviens-toi que tu dois te comporter dans la vie comme dans un festin. Le plat qui circule arrive \u00e0 toi : \u00e9tends la main et prends avec discr\u00e9tion. Il passe plus loin : ne le retiens pas. Il n'est pas encore arriv\u00e9 : ne le devance pas de loin par tes d\u00e9sirs, attends qu'il arrive \u00e0 toi. Fais-en de m\u00eame pour des enfants, pour une femme, pour des charges publiques, pour de l'argent ; et tu seras digne de t'asseoir un jour \u00e0 la table des dieux. Mais si l'on te sert et que tu ne prennes rien, que tu d\u00e9daignes de prendre, alors tu ne seras pas seulement le convive des dieux, tu seras leur coll\u00e8gue. C'est en se conduisant ainsi que Diog\u00e8ne, qu'H\u00e9raclite et ceux qui leur ressemblent ont m\u00e9rit\u00e9 d'\u00eatre appel\u00e9s des hommes divins, comme ils l'\u00e9taient en effet.\n\nXVI\n\nQuand tu vois quelqu'un qui pleure, soit parce qu'il est en deuil, soit parce que son fils est au loin, soit parce qu'il a perdu ce qu'il poss\u00e9dait, prends garde de te laisser emporter par l'id\u00e9e que les accidents du dehors qui lui arrivent sont des maux. Rappelle-toi sur-le-champ que ce qui l'afflige ce n'est pas l'accident, qui n'en afflige pas d'autre que lui, mais le jugement qu'il porte sur cet accident. Cependant n'h\u00e9site pas \u00e0 lui t\u00e9moigner, au moins des l\u00e8vres, ta sympathie, et m\u00eame, s'il le faut, \u00e0 g\u00e9mir avec lui ; mais prends garde de g\u00e9mir du fond de l'\u00e2me.\n\nXVII\n\nSouviens-toi que tu es l'acteur d'un r\u00f4le, tel qu'il pla\u00eet \u00e0 l'auteur de te le donner : court, s'il l'a voulu court ; long, s'il l'a voulu long ; s'il veut que tu joues un r\u00f4le de mendiant, joue-le na\u00efvement ; ainsi d'un r\u00f4le de boiteux, de magistrat, de simple particulier. C'est ton fait de bien jouer le personnage qui t'est donn\u00e9 ; mais de le choisir, c'est le fait d'un autre.\n\nXVIII\n\nQuand un corbeau pousse un cri de mauvais augure, ne te laisse pas emporter par ton id\u00e9e ; distingue aussit\u00f4t en toi-m\u00eame, et dis : \u00ab Dans tout cela il n'y a point de pr\u00e9sage pour moi, il ne peut y en avoir que pour mon corps, ma fortune, ma r\u00e9putation, mes enfants, ma femme. Quant \u00e0 moi, tout est de bon augure, si je veux ; car quel que soit l'\u00e9v\u00e9nement, il d\u00e9pend de moi d'en tirer profit. \u00bb\n\nXIX\n\n1. Tu peux \u00eatre invincible, si tu ne t'engages dans aucune lutte, o\u00f9 il ne d\u00e9pend pas de toi d'\u00eatre vainqueur.\n\n2. Quand tu vois un homme rev\u00eatu d'honneurs extraordinaires ou d'un grand pouvoir ou de toute autre illustration, prends garde de le proclamer heureux et de te laisser emporter par ton id\u00e9e. Si la substance du bien est dans les choses qui d\u00e9pendent de nous, il n'y a pas de place pour l'envie ni pour la jalousie ; et toi-m\u00eame, tu ne voudras pas \u00eatre strat\u00e8ge, prytane ou consul, tu voudras \u00eatre libre. Or il n'y a qu'une route pour y arriver : m\u00e9priser ce qui ne d\u00e9pend pas de nous.\n\nXX\n\nSouviens-toi qu'on n'est pas outrag\u00e9 par celui qui injurie ou qui frappe, mais par le jugement qu'ils vous outragent. Quand quelqu'un te met en col\u00e8re, sache que c'est ton jugement qui te met en col\u00e8re. Efforce-toi donc avant tout de ne pas te laisser emporter par ton id\u00e9e ; si une fois tu gagnes du temps, quelque d\u00e9lai, tu seras plus facilement ma\u00eetre de toi.\n\nXXI\n\nAie tous les jours devant les yeux la mort, l'exil et tout ce qui para\u00eet effrayant, surtout la mort, et jamais tu ne penseras rien de bas, ni ne d\u00e9sireras rien avec exc\u00e8s.\n\nXXII\n\nSi tu d\u00e9sires \u00eatre philosophe, attends-toi d\u00e8s lors \u00e0 \u00eatre un objet de d\u00e9rision, \u00e0 \u00eatre en butte aux moqueries d'une foule de gens qui disent : \u00ab Il nous est revenu tout \u00e0 coup philosophe \u00bb et \u00ab D'o\u00f9 vient cet air renfrogn\u00e9 ? \u00bb Toi, n'aie pas l'air renfrogn\u00e9 ; mais attache-toi \u00e0 ce qui te para\u00eet le meilleur, avec la conviction que la divinit\u00e9 t'a assign\u00e9 ce poste : souviens-toi que si tu restes fid\u00e8le \u00e0 tes principes, ceux qui se moquaient d'abord de toi, t'admireront plus tard ; mais si tu es vaincu par leurs propos, tu te rendras doublement ridicule.\n\nXXIII\n\nS'il t'arrive de te tourner vers l'ext\u00e9rieur par complaisance pour quelqu'un, sois s\u00fbr que tu as perdu ton assiette. Contente-toi donc, partout, d'\u00eatre philosophe. Si de plus tu veux le para\u00eetre, parais-le \u00e0 toi-m\u00eame ; et c'est suffisant.\n\nXXIV\n\n1. Ne t'afflige pas par des raisonnements comme : \u00ab Je vivrai sans consid\u00e9ration et je ne serai rien nulle part. \u00bb Si le manque de consid\u00e9ration est un mal, tu ne peux souffrir de mal par le fait d'autrui, non plus que de honte. Est-ce que c'est quelque chose qui d\u00e9pend de toi, que d'obtenir une charge ou d'\u00eatre invit\u00e9 \u00e0 un grand repas ? nullement. Comment est-ce donc une humiliation ? Comment ne seras-tu rien nulle part, toi qui ne dois \u00eatre quelque chose que dans ce qui d\u00e9pend de toi, l\u00e0 o\u00f9 tu peux avoir le plus grand m\u00e9rite ?\n\n2. Mais tu ne viendras pas en aide \u00e0 tes amis. Qu'est-ce que tu dis l\u00e0, ne pas venir en aide ? Tu ne leur donneras pas de monnaie ? Tu ne les feras pas citoyens romains ? Et qui donc t'a dit que ce sont l\u00e0 des choses qui d\u00e9pendent de nous, et non d'autrui ? Qui est-ce qui peut donner \u00e0 un autre ce qu'il n'a pas lui-m\u00eame ? \u00ab Acquiers, dira l'un d'eux, pour que nous ayons. \u00bb\n\n3. Si je puis acqu\u00e9rir en restant discret, s\u00fbr, magnanime, montre-moi le moyen, et j'acquerrai. Si vous exigez que je perde les biens qui me sont propres pour vous acqu\u00e9rir ce qui n'est pas un bien, voyez vous-m\u00eames comme vous \u00eates injustes et d\u00e9raisonnables. Et que pr\u00e9f\u00e9rez-vous donc ? de l'argent qu'un ami loyal et r\u00e9serv\u00e9 ? Aidez-moi donc plut\u00f4t \u00e0 acqu\u00e9rir ce bien-l\u00e0, et n'exigez pas que je fasse ce qui me le fera perdre.\n\n4. \u00ab Mais, dira quelqu'un, ma patrie, je ne lui viendrai pas en aide, autant qu'il est en moi. \u00bb Encore une fois, quelle aide ? Elle ne te devra pas de portiques, de bains ? Et qu'est-ce que cela ? Tes concitoyens ne sont pas non plus chauss\u00e9s par l'armurier, ni arm\u00e9s par le cordonnier ; il suffit que chacun remplisse sa t\u00e2che. Si tu procurais \u00e0 la patrie quelque autre citoyen loyal et r\u00e9serv\u00e9, ne lui aurais-tu rendu aucun service ? \u2014 \u00ab C'est vrai. \u00bb \u2014 Eh bien ! alors, tu ne lui seras pas non plus inutile.\n\n5. \u00ab Quelle place aurai-je donc dans l'\u00c9tat ? \u2014 Celle que tu peux avoir en restant homme loyal et r\u00e9serv\u00e9. Mais si pour venir en aide \u00e0 ta patrie, tu perds ces biens, de quelle utilit\u00e9 peux-tu lui \u00eatre quand tu seras devenu impudent et d\u00e9loyal ? \u00bb\n\nXXV\n\n1. On t'a pr\u00e9f\u00e9r\u00e9 quelqu'un, soit pour l'inviter \u00e0 un repas, soit pour le saluer, soit pour l'appeler \u00e0 une d\u00e9lib\u00e9ration ? Si ce sont l\u00e0 des biens, tu dois te r\u00e9jouir de ce qu'il les a obtenus ; si ce sont des maux, ne t'afflige pas de n'en avoir pas ta part : souviens-toi que quand tu ne fais pas la m\u00eame chose que les autres pour avoir ce qui ne d\u00e9pend pas de nous, tu ne peux pas pr\u00e9tendre en avoir autant.\n\n2. Et comment celui qui ne fait pas une cour assidue \u00e0 un grand peut-il \u00eatre trait\u00e9 comme celui qui la fait ? celui qui ne lui fait pas cort\u00e8ge, comme celui qui le fait ? celui qui ne le loue pas, comme celui qui le loue ? Tu seras injuste et insatiable si, sans avoir pay\u00e9 le prix, tu veux recevoir pour rien ce qu'il vend.\n\n3. Voyons, combien se vend la laitue ? Supposons que ce soit une obole. Quand quelqu'un a de la laitue en donnant son obole et que toi tu n'en as pas en ne donnant pas la tienne, ne crois pas \u00eatre moins bien trait\u00e9 que celui qui en a. S'il a sa laitue, toi, tu as ton obole, que tu n'as pas donn\u00e9e.\n\n4. De m\u00eame ici. Quelqu'un ne t'a pas invit\u00e9 \u00e0 un repas ? C'est que tu n'as pas pay\u00e9 le prix auquel il vend son repas ; il le vend pour des compliments, il le vend pour des soins. Paye le prix auquel il vend, si tu y trouves un avantage ; mais si tu veux \u00e0 la fois ne pas payer et recevoir, tu es insatiable et imb\u00e9cile.\n\n5. N'as-tu donc rien \u00e0 la place du repas ? Oui, tu as quelque chose, tu as de ne pas louer qui tu ne veux pas, tu as de ne pas essuyer les insolences des esclaves qui gardent sa porte.\n\nXXVI\n\nOn peut reconna\u00eetre ce que veut la nature aux choses sur lesquelles nous ne diff\u00e9rons pas d'avis entre nous. Ainsi, quand l'esclave d'un autre casse sa coupe, nous avons aussit\u00f4t sur les l\u00e8vres : \u00ab Cela se voit tous les jours. \u00bb Sache donc que quand on cassera ta coupe, tu dois \u00eatre tel que tu es quand on casse celle d'un autre. Applique cette r\u00e9flexion \u00e0 des \u00e9v\u00e9nements plus importants. Quelqu'un perd son fils ou sa femme ? Il n'est personne qui ne dise : \u00ab C'est la condition de l'humanit\u00e9. \u00bb Mais quand on fait cette perte soi-m\u00eame, aussit\u00f4t de dire : \u00ab H\u00e9las ! que je suis malheureux ! \u00bb Il faudrait pourtant se rappeler ce qu'on \u00e9prouve en l'entendant dire d'un autre.\n\nXXVII\n\nComme on ne place pas de but pour qu'on le manque, de m\u00eame le mal de nature n'existe pas dans le monde.\n\nXXVIII\n\nSi on confiait ton corps au premier venu, tu serais indign\u00e9 ; et toi, quand tu confies ton \u00e2me au premier venu, pour qu'il la trouble et la bouleverse par ses injures, tu n'en as pas de honte ?\n\nXXIX\n\n1. Dans toute affaire, examine bien les ant\u00e9c\u00e9dents et les cons\u00e9quents, et alors entreprends. Sinon, tu seras d'abord plein de feu, parce que tu n'as pas r\u00e9fl\u00e9chi \u00e0 l'encha\u00eenement des choses ; et plus tard, quand quelques difficult\u00e9s se produiront, tu renonceras honteusement.\n\n2. Tu veux \u00eatre vainqueur aux jeux Olympiques ? Et moi aussi, de par les dieux ; car c'est une belle chose. Mais examine bien les ant\u00e9c\u00e9dents et les cons\u00e9quents, et alors entreprends. Il faut ob\u00e9ir \u00e0 une discipline, manger de force, t'abstenir de g\u00e2teau, faire des exercices forc\u00e9s, \u00e0 des heures r\u00e9gl\u00e9es, par le chaud, par le froid, ne boire ni eau fra\u00eeche ni vin indiff\u00e9remment, en un mot, te mettre entre les mains du dresseur comme entre celles d'un m\u00e9decin ; puis, dans l'ar\u00e8ne, il faut creuser des fosses, quelquefois se d\u00e9mettre un bras, se donner une entorse, avaler force poussi\u00e8re, quelquefois \u00eatre fouett\u00e9, et avec tout cela \u00eatre vaincu.\n\n3. Quand tu auras bien pes\u00e9 tout cela, si tu persistes, fais-toi athl\u00e8te. Sinon, tu seras comme les petits enfants qui jouent tant\u00f4t au lutteur, tant\u00f4t au gladiateur, qui tant\u00f4t sonnent de la trompette, tant\u00f4t d\u00e9clament ; de m\u00eame, tu seras tant\u00f4t athl\u00e8te, tant\u00f4t gladiateur, puis rh\u00e9teur, ensuite philosophe, et jamais rien du fond de l'\u00e2me ; tu imiteras comme un singe tout ce que tu verras faire, et chaque chose te plaira \u00e0 son tour. C'est qu'avant d'entreprendre tu n'as pas bien examin\u00e9, retourn\u00e9 la chose sous toutes ses faces ; tu vas au hasard et sans d\u00e9sirer vivement.\n\n4. C'est ainsi que certaines gens pour avoir vu un philosophe, pour avoir entendu parler comme parle Euphrate (et pourtant qui peut parler comme Euphrate ?), veulent aussi \u00eatre philosophes.\n\n5. Mais, pauvre homme, examine d'abord ce que c'est que d'\u00eatre philosophe ; ensuite \u00e9tudie ta propre nature, pour voir si tu es de force. Tu veux \u00eatre pentathle ou lutteur ? Consid\u00e8re tes bras, tes cuisses, examine tes reins. L'un est dou\u00e9 pour une chose, l'autre pour une autre.\n\n6. Crois-tu qu'en te faisant philosophe tu peux manger et boire de la m\u00eame mani\u00e8re, avoir les m\u00eames d\u00e9sirs, les m\u00eames aversions ? Il faut veiller, peiner, te s\u00e9parer des tiens, t'exposer au m\u00e9pris d'un petit esclave, aux ris\u00e9es des passants, avoir le dessous partout, en honneurs, en dignit\u00e9s, devant les juges, enfin en toute chose.\n\n7. P\u00e8se bien tout cela. Maintenant si tu tiens \u00e0 avoir en \u00e9change l'impassibilit\u00e9, la libert\u00e9, le calme, c'est bien ; sinon, retire-toi. Ne fais pas comme les enfants ; ne sois pas maintenant philosophe, ensuite percepteur, puis rh\u00e9teur, puis procurateur de C\u00e9sar. Tout cela ne saurait s'accorder. Il faut que tu sois un, ou vertueux ou vicieux ; il faut cultiver ou ton \u00e2me ou les choses du dehors, l'appliquer ou aux choses int\u00e9rieures ou aux choses ext\u00e9rieures, c'est-\u00e0-dire, rester ou philosophe ou non-philosophe.\n\nXXX\n\nPour faire son office, il faut se r\u00e9gler ordinairement sur les rapports de corr\u00e9lation. C'est ton p\u00e8re ; il t'est prescrit d'en prendre soin, de lui c\u00e9der en tout, de supporter ses injures, ses coups. \u2014 \u00ab Mais c'est un mauvais p\u00e8re. \u00bb \u2014 Est-ce avec un bon p\u00e8re que la nature t'a mis en rapport intime ? C'est avec un p\u00e8re. \u2014 \u00ab Mon fr\u00e8re me fait tort. \u00bb \u2014 Eh bien, alors observe les rapports qui sont \u00e9tablis entre toi et lui ; ne t'occupe pas de ce qu'il fait, mais de ce que tu dois faire pour que ta volont\u00e9 soit dans un \u00e9tat conforme \u00e0 la nature : un autre ne te nuira pas, si tu ne veux pas ; mais on t'aura nui, si tu juges qu'on te nuit. De m\u00eame avec les autres : si tu prends l'habitude de consid\u00e9rer les rapports de corr\u00e9lation qui sont entre toi et un autre en tant que voisin, concitoyen, pr\u00e9teur, tu trouveras quel est ton office.\n\nXXXI\n\n1. Sache que le fond de la pi\u00e9t\u00e9 envers les dieux, c'est d'en juger sainement, de penser qu'ils existent et qu'ils gouvernent l'univers avec sagesse et avec justice, et en cons\u00e9quence de te donner le r\u00f4le de leur ob\u00e9ir, de leur c\u00e9der et de les suivre en tout ce qui t'arrive, dans la pens\u00e9e que c'est arrang\u00e9 pour le mieux. Ainsi tu ne t'en prendras jamais aux dieux, et tu ne te plaindras pas d'en \u00eatre n\u00e9glig\u00e9.\n\n2. Or tu ne peux le faire qu'en \u00f4tant les biens et les maux de ce qui ne d\u00e9pend pas de nous pour les placer uniquement dans ce qui d\u00e9pend de nous. Si tu crois que quelque chose qui ne d\u00e9pend pas de nous est bon ou mauvais, infailliblement, toutes les fois que tu manqueras ce que tu veux et que tu tomberas dans ce que tu ne veux pas, tu t'en prendras aux auteurs responsables et tu les prendras en haine.\n\n3. En effet, tout \u00eatre anim\u00e9 est naturellement port\u00e9 \u00e0 fuir et \u00e0 \u00e9viter ce qui lui para\u00eet un mal et ce qui le cause, et d'autre part, \u00e0 rechercher et \u00e0 aimer ce qui lui para\u00eet un bien et ce qui le procure. Il est donc impossible \u00e0 celui qui croit qu'on lui nuit, d'aimer ce qui para\u00eet lui nuire, comme il est impossible d'aimer le dommage en lui-m\u00eame.\n\n4. De l\u00e0 les injures que le fils adresse au p\u00e8re, quand le p\u00e8re ne lui fait pas part de ce qui passe pour un bien. C'est ce qui fait que Polynice et \u00c9t\u00e9ocle sont devenus ennemis : ils croyaient que la royaut\u00e9 est un bien. C'est pourquoi le laboureur, le matelot, le marchand, ceux qui perdent leur femme ou leurs enfants, injurient les dieux. La pi\u00e9t\u00e9 est fond\u00e9e sur l'int\u00e9r\u00eat ; par cons\u00e9quent, quand on s'applique \u00e0 donner la direction qu'il faut \u00e0 ses d\u00e9sirs et \u00e0 ses aversions, on s'applique par l\u00e0 m\u00eame \u00e0 \u00eatre pieux.\n\n5. Quant aux libations, aux sacrifices, aux offrandes, il faut toujours suivre les lois de sa patrie, \u00eatre en \u00e9tat de puret\u00e9, n'avoir pas de nonchalance ni de n\u00e9gligence, ne pas rester trop en de\u00e7\u00e0 de ses moyens ni aller au-del\u00e0.\n\nXXXII\n\n1. Quand tu as recours \u00e0 la divination, souviens-toi que, si tu ne sais pas quel sera l'\u00e9v\u00e9nement, puisque tu viens aupr\u00e8s du devin pour l'apprendre, tu sais, avant de venir, de quelle nature sera cet \u00e9v\u00e9nement, si du moins tu es philosophe. Si c'est quelque chose qui ne d\u00e9pend pas de nous, il faut de toute n\u00e9cessit\u00e9 qu'il ne soit ni bon ni mauvais.\n\n2. N'aie donc, en te pr\u00e9sentant au devin, ni d\u00e9sir ni aversion ; ne tremble pas en approchant, sois convaincu que l'\u00e9v\u00e9nement quelconque qui sera annonc\u00e9 est chose neutre qui ne te regarde pas, que, quel qu'il puisse \u00eatre, il sera possible d'en tirer un bon parti, sans que personne au monde t'en emp\u00eache. Aie donc confiance en recourant aux conseils des dieux ; et quand tu auras re\u00e7u ces conseils, il ne te restera plus qu'\u00e0 ne pas oublier quels sont ceux qui te les ont donn\u00e9s et \u00e0 qui tu d\u00e9sob\u00e9irais, si tu ne les suivais pas.\n\n3. Maintenant ne consulte les devins, comme le voulait Socrate, que sur les choses o\u00f9 tout se rapporte \u00e0 l'issue, et pour lesquelles il n'y a ni raisonnement ni art quelconque qui donne le moyen de conna\u00eetre ce qu'on veut savoir ; ainsi, quand il faut se risquer pour un ami ou pour sa patrie, il ne faut pas demander au devin s'il faut se risquer. En effet, si le devin te d\u00e9clare que l'\u00e9tat des entrailles de la victime n'est pas favorable, il est \u00e9vident que cela pr\u00e9sage ou la mort ou une mutilation en quelque partie du corps ou l'exil, mais la raison prescrit, m\u00eame avec cette perspective, de venir au secours d'un ami et de se risquer pour sa patrie. Ob\u00e9is donc au plus grand devin, \u00e0 Apollon Pythien, qui chassa du temple celui qui n'\u00e9tait pas venu au secours de son ami, qu'on assassinait.\n\nXXXIII\n\n1. Retrace-toi d\u00e8s maintenant un genre de vie particulier, un plan de conduite, que tu suivras, et quand tu seras seul et quand tu te trouveras avec d'autres.\n\n2. Et d'abord garde ordinairement le silence, ou ne dis que ce qui est n\u00e9cessaire et en peu de mots. Il pourra arriver, mais rarement, que tu doives parler quand l'occasion l'exigera ; mais ne parle sur rien de frivole : ne parle pas de combats de gladiateurs, de courses du cirque, d'athl\u00e8tes, de boire et de manger, sujets ordinaires des conversations ; surtout ne parle pas des personnes, soit pour bl\u00e2mer, soit pour louer, soit pour faire des parall\u00e8les.\n\n3. Si tu le peux, ram\u00e8ne par tes discours les entretiens de ceux avec qui tu vis sur des sujets convenables. Si tu te trouves isol\u00e9 au milieu d'\u00e9trangers, garde le silence.\n\n4. Ne ris pas beaucoup, ni de beaucoup de choses, ni avec exc\u00e8s.\n\n5. Dispense-toi de faire des serments, en toute circonstance, si cela se peut, ou au moins dans la mesure du possible.\n\n6. Refuse de venir aux repas o\u00f9 tu te trouverais avec des \u00e9trangers qui ne sont pas philosophes ; et si l'occasion l'exige, fais bien attention \u00e0 ne pas tomber dans leurs mani\u00e8res. Souviens-toi que quand ton compagnon est sale, tu ne peux pas te frotter \u00e0 lui sans te salir, quelque propre que tu sois toi-m\u00eame.\n\n7. Ne prends pour les besoins du corps que ce qui est strictement n\u00e9cessaire, en fait de nourriture, de boisson, de v\u00eatement, de logement, de domestiques. Tout ce qui est d'ostentation et de luxe, supprime-le.\n\n8. Si l'on vient te dire qu'un tel dit du mal de toi, ne cherche point \u00e0 te justifier sur ce qu'on te rapporte ; r\u00e9ponds seulement : \u00ab Il faut qu'il ne soit pas au courant de ce qu'on peut encore dire sur mon compte ; autrement il ne se serait pas born\u00e9 l\u00e0. \u00bb\n\n9. Il n'est pas n\u00e9cessaire d'aller souvent au spectacle. S'il le faut, ne t'int\u00e9resse s\u00e9rieusement qu'\u00e0 toi-m\u00eame, c'est-\u00e0-dire, d\u00e9sire simplement que les choses arrivent comme elles arrivent et que celui-l\u00e0 soit vainqueur, qui est vainqueur ; ainsi tu ne seras pas contrari\u00e9. Abstiens-toi enti\u00e8rement de crier, de rire de tel acteur, de partager les passions des spectateurs. Quand le spectacle est termin\u00e9, ne parle pas beaucoup de ce qui s'est pass\u00e9, sauf en ce qui peut contribuer \u00e0 te rendre meilleur ; autrement il serait \u00e9vident que tu as \u00e9t\u00e9 frapp\u00e9 du spectacle.\n\n10. Ne te d\u00e9cide pas \u00e0 la l\u00e9g\u00e8re et facilement \u00e0 assister \u00e0 des lectures publiques. Quand tu y viens, garde une attitude grave et calme qui n'ait pourtant rien de d\u00e9sagr\u00e9able.\n\n11. Quand tu dois avoir affaire \u00e0 quelqu'un, particuli\u00e8rement \u00e0 quelqu'un de puissant, repr\u00e9sente-toi ce que Socrate ou Z\u00e9non aurait fait en pareil cas, et tu ne seras pas embarrass\u00e9 pour te comporter convenablement dans la circonstance.\n\n12. Quand tu fais des visites \u00e0 un homme puissant, repr\u00e9sente-toi d'avance que tu ne le trouveras pas chez lui, qu'on ne t'admettra pas, qu'on te fermera la porte sur le nez, qu'il ne se souciera pas de toi. Et si avec cela c'est ton office d'y aller, vas-y et supporte ce qui arrive, sans jamais te dire en toi-m\u00eame : \u00ab Ce n'\u00e9tait pas la peine ; \u00bb car cette r\u00e9flexion est d'un homme qui n'est pas philosophe et qui se met en col\u00e8re pour les choses du dehors.\n\n13. Dans la conversation, \u00e9vite de parler beaucoup et sans mesure de ce que tu fais ou des dangers que tu as courus. Si tu as du plaisir \u00e0 te souvenir des dangers auxquels tu as \u00e9t\u00e9 expos\u00e9, les autres n'ont pas autant de plaisir \u00e0 t'entendre raconter ce qui t'est arriv\u00e9.\n\n14. \u00c9vite aussi de chercher \u00e0 faire rire. On est induit par l\u00e0 \u00e0 glisser dans le genre de ceux qui ne sont pas philosophes, et en m\u00eame temps cela peut diminuer les \u00e9gards que les autres ont pour toi.\n\n15. Il est facile aussi de se laisser aller \u00e0 tenir des propos obsc\u00e8nes. Quand il arrive quelque chose de pareil, tu peux, si c'est \u00e0 propos, aller jusqu'\u00e0 faire des reproches \u00e0 celui qui se le permet ; sinon, t\u00e9moigne au moins par ton silence, ta rougeur, ton visage s\u00e9v\u00e8re, que cette conversation te d\u00e9pla\u00eet.\n\nXXXIV\n\nQuand une id\u00e9e de plaisir se pr\u00e9sente \u00e0 ton esprit, fais comme pour les autres, prends garde de te laisser emporter, diff\u00e8re d'agir, et obtiens de toi-m\u00eame quelque d\u00e9lai. Puis repr\u00e9sente-toi les deux moments, celui o\u00f9 tu jouiras du plaisir et celui o\u00f9, apr\u00e8s en avoir joui, tu te repentiras et t'accableras toi-m\u00eame de reproches ; mets en balance la joie que tu \u00e9prouveras \u00e0 t'abstenir et les f\u00e9licitations que tu t'adresseras. Si les circonstances exigent que tu agisses, fais attention \u00e0 ne pas te laisser vaincre par ce que la chose offre de doux, d'agr\u00e9able et d'attrayant : mets en balance l'avantage qu'il y a \u00e0 avoir conscience que tu as remport\u00e9 cette victoire.\n\nXXXV\n\nQuand tu fais quelque chose, apr\u00e8s avoir reconnu qu'il le faut faire, ne crains pas d'\u00eatre vu le faisant, quelque d\u00e9favorablement que le vulgaire en doive juger. Si tu as tort de le faire, \u00e9vite l'action elle-m\u00eame ; si tu as raison, pourquoi crains-tu ceux qui auront tort de te bl\u00e2mer ?\n\nXXXVI\n\nDe m\u00eame que les propositions \u00ab il fait jour \u00bb et \u00ab il fait nuit \u00bb ont une grande valeur pour une proposition disjonctive et n'ont pas de valeur pour une proposition copulative, ainsi dans un festin choisir la plus forte part peut avoir de la valeur pour le corps, mais n'a pas de valeur pour l'observation des pr\u00e9ceptes qui r\u00e8glent la mani\u00e8re dont on doit se conduire avec les autres dans un repas. Quand tu manges avec un autre, souviens-toi de ne pas consid\u00e9rer seulement la valeur de ce qu'on sert par rapport au corps, mais aussi de garder les \u00e9gards que l'on doit \u00e0 celui qui donne le festin.\n\nXXXVII\n\nQuand tu as pris un r\u00f4le au-dessus de tes forces, non seulement tu y as fait une pauvre figure, mais encore tu as laiss\u00e9 de c\u00f4t\u00e9 celui que tu aurais pu remplir.\n\nXXXVIII\n\nDe m\u00eame qu'en te promenant tu prends garde \u00e0 mettre le pied sur un clou ou \u00e0 te donner une entorse, de m\u00eame fais attention \u00e0 ne pas nuire \u00e0 la partie sup\u00e9rieure de ton \u00e2me. Si nous prenons cette pr\u00e9caution en chaque affaire, nous serons plus s\u00fbrs de nous en l'entreprenant.\n\nXXXIX\n\nLes exigences du corps sont la mesure de ce que chacun a besoin de poss\u00e9der, comme le pied est la mesure de la chaussure. Si tu t'en tiens l\u00e0, tu resteras dans la mesure ; si tu d\u00e9passes, infailliblement, tu ne feras plus que rouler dans le pr\u00e9cipice : de m\u00eame pour la chaussure ; si tu vas au-del\u00e0 de ce qu'il faut pour chausser ton pied, tu prends d'abord des chaussures dor\u00e9es, puis de pourpre, puis brod\u00e9es. Une fois qu'on a d\u00e9pass\u00e9 la mesure, il n'y a plus de limite.\n\nXL\n\nLes femmes aussit\u00f4t apr\u00e8s leur quatorzi\u00e8me ann\u00e9e, sont appel\u00e9es madame par les hommes ; alors elles commencent \u00e0 se parer et mettent l\u00e0 toutes leurs esp\u00e9rances. Il faut donc faire attention \u00e0 ce qu'elles sentent que rien ne peut leur attirer de la consid\u00e9ration que de para\u00eetre d\u00e9centes et r\u00e9serv\u00e9es.\n\nXLI\n\nC'est la marque d'un manque de disposition pour la vertu que de donner une grande place aux choses du corps, comme de donner beaucoup de temps \u00e0 faire de la gymnastique, \u00e0 manger, \u00e0 boire, \u00e0 excr\u00e9ter. Il ne faut faire tout cela qu'accessoirement, et appliquer toute son attention \u00e0 son esprit.\n\nXLII\n\nQuand on te maltraite ou qu'on t'injurie, souviens-toi que celui qui parle ou agit ainsi, croit que c'est son office. Il ne peut pas suivre ta mani\u00e8re de voir, il ne peut que suivre la sienne ; en sorte que s'il a tort, c'est pour lui qu'il y a dommage, puisque c'est lui qui est dans l'erreur. En effet, si l'on juge fausse une proposition copulative qui est vraie, il n'y a pas de dommage pour la proposition copulative, mais pour celui qui s'est tromp\u00e9. Si tu te fondes l\u00e0-dessus, tu seras indulgent pour celui qui te dit des injures. R\u00e9p\u00e8te chaque fois : \u00ab Il en a jug\u00e9 ainsi. \u00bb\n\nXLIII\n\nToute chose a deux anses, l'une, par o\u00f9 on peut la porter, l'autre, par o\u00f9 on ne le peut pas. Si ton fr\u00e8re a des torts, ne le prends pas par ce c\u00f4t\u00e9-l\u00e0, qu'il a des torts (c'est l'anse par o\u00f9 on ne peut porter) ; prends-le plut\u00f4t par cet autre c\u00f4t\u00e9, qu'il est ton fr\u00e8re, qu'il a \u00e9t\u00e9 nourri avec toi, et tu prendras la chose par o\u00f9 on peut la porter.\n\nXLIV\n\nCes raisonnements ne sont pas concluants : \u00ab Je suis plus riche que toi, donc, je te suis sup\u00e9rieur \u00bb ; \u00ab Je suis plus \u00e9loquent que toi, donc je te suis sup\u00e9rieur. \u00bb Mais ceux-ci sont plus concluants : \u00ab Je suis plus riche que toi, donc ma fortune est sup\u00e9rieure \u00e0 la tienne \u00bb ; \u00ab Je suis plus \u00e9loquent que toi, donc ma parole est sup\u00e9rieure \u00e0 la tienne. \u00bb Mais toi, tu n'es ni fortune ni parole.\n\nXLV\n\nQuelqu'un se baigne de bonne heure : ne dis pas que c'est mal ; dis que c'est de bonne heure. Quelqu'un boit beaucoup de vin : ne dis pas que c'est mal ; dis qu'il boit beaucoup de vin. Car avant d'avoir reconnu comment il en juge, d'o\u00f9 peux-tu savoir si c'est mal ? Ainsi il ne t'arrivera pas d'avoir des id\u00e9es \u00e9videntes de certaines choses et d'acquiescer \u00e0 d'autres.\n\nXLVI\n\n1. Ne te donne jamais pour philosophe et le plus souvent ne parle pas maximes devant ceux qui ne sont pas philosophes ; fais plut\u00f4t ce que les maximes prescrivent : ainsi, dans un repas, ne dis pas comment on doit manger, mais mange comme on le doit. Souviens-toi que Socrate s'\u00e9tait interdit toute ostentation, au point que des gens venaient le trouver pour se faire pr\u00e9senter par lui \u00e0 des philosophes ; et il les menait, tant il lui \u00e9tait \u00e9gal qu'on ne f\u00eet pas attention \u00e0 lui.2. Si, entre gens qui ne sont pas philosophes, la conversation tombe sur quelque maxime, garde le plus souvent le silence ; tu cours grand risque de rendre aussit\u00f4t ce que tu n'as pas encore dig\u00e9r\u00e9. Quand on te dit que tu ne sais rien, si tu n'en es pas piqu\u00e9, sache qu'alors tu commences \u00e0 \u00eatre philosophe. En effet, ce n'est pas en rendant leur herbe aux bergers, que les brebis leur montrent combien elles ont mang\u00e9 ; mais quand elles ont bien dig\u00e9r\u00e9 leur p\u00e2ture au dedans, elles produisent au dehors de la laine et du lait : de m\u00eame ne fais pas \u00e9talage des maximes devant ceux qui ne sont pas philosophes, mais commence par les dig\u00e9rer pour les produire en pratique.\n\nXLVII\n\nQuand tu es parvenu \u00e0 satisfaire \u00e0 peu de frais \u00e0 tous les besoins du corps, ne fais pas tes embarras, et si tu ne bois que de l'eau, ne dis pas \u00e0 tout propos que tu ne bois que de l'eau. Si tu veux t'endurcir \u00e0 la peine, fais-le pour toi et non pour les autres, ne tiens pas les statues embrass\u00e9es ; mais quand tu as soif, prends dans ta bouche un peu d'eau fra\u00eeche, rejette-la et n'en dis rien.\n\nXLVIII\n\n1. Conduite et caract\u00e8re de celui qui n'est pas philosophe : il n'attend pas de profit ni de dommage de lui-m\u00eame, mais de l'ext\u00e9rieur. Conduite et caract\u00e8re du philosophe : il n'attend de profit ni de dommage que de lui-m\u00eame.\n\n2. Signes de celui qui est en progr\u00e8s : il ne bl\u00e2me personne, il ne loue personne, il ne se plaint de personne, il n'accuse personne, il ne parle jamais de lui-m\u00eame comme de quelqu'un d'importance ou qui sait quelque chose. Quand il se sent contrari\u00e9 ou emp\u00each\u00e9, il ne s'en prend qu'\u00e0 lui-m\u00eame. Quand on le loue, il se moque \u00e0 part soi de celui qui le loue, et quand on le bl\u00e2me, il ne se justifie pas. Il fait comme les gens relevant de maladie qui se prom\u00e8nent avec pr\u00e9caution pour ne pas d\u00e9ranger ce qui se remet, avant que cela ait pris de la consistance.\n\n3. Il a supprim\u00e9 en lui tout d\u00e9sir, et il a transport\u00e9 toutes ses aversions sur ce qui est contraire \u00e0 la nature dans ce qui d\u00e9pend de nous. En toutes choses ses tendances sont mod\u00e9r\u00e9es. S'il para\u00eet b\u00eate ou ignorant, il ne s'en inqui\u00e8te pas. En un mot il se d\u00e9fie de lui-m\u00eame comme d'un ennemi dont on craint les pi\u00e8ges.\n\nXLIX\n\nQuand un homme est tout fier de pouvoir comprendre et expliquer les livres de Chrysippe, dis en toi-m\u00eame : \u00ab Si Chrysippe avait \u00e9crit clairement, cet homme n'aurait pas de quoi se vanter. Pour moi, qu'est-ce que je veux ? conna\u00eetre la nature et la suivre. Je cherche donc quel en est l'interpr\u00e8te ; j'apprends que c'est Chrysippe et je vais \u00e0 lui. Mais je ne comprends pas ce qu'il a \u00e9crit ; alors je cherche quelqu'un qui me l'explique. Jusque-l\u00e0 il n'y a rien de bien extraordinaire. Mais quand j'ai trouv\u00e9 l'interpr\u00e8te, reste \u00e0 mettre en pratique les pr\u00e9ceptes, et c'est cela seulement qui est beau. Mais si c'est pr\u00e9cis\u00e9ment l'explication des pr\u00e9ceptes que j'admire, n'est-il pas arriv\u00e9 que je suis devenu grammairien au lieu de philosophe ? Seulement : au lieu d'Hom\u00e8re j'explique Chrysippe. Aussi quand on me dit : \"Explique-moi Chrysippe\", si je rougis, c'est plut\u00f4t de ne pas pouvoir montrer une conduite qui soit semblable et conforme \u00e0 ses pr\u00e9ceptes. \u00bb\n\nL\n\nObserve tout ce qu'enseigne la philosophie comme des lois que tu ne peux violer sans impi\u00e9t\u00e9. Quoi qu'on dise de toi, ne t'en inqui\u00e8te pas ; cela ne d\u00e9pend plus de toi.\n\nLI\n\n1. Combien de temps encore diff\u00e8res-tu de te juger propre \u00e0 ce qu'il y a de meilleur et de ne d\u00e9sob\u00e9ir \u00e0 rien de ce que la raison prescrit ? Tu as re\u00e7u les maximes envers lesquelles il fallait s'engager, et tu t'es engag\u00e9. Quel ma\u00eetre attends-tu donc encore pour lui transf\u00e9rer le soin de t'amender ? Tu n'es plus un jeune homme, tu es un homme fait. Si tu t'abandonnes maintenant \u00e0 la n\u00e9gligence et \u00e0 la paresse, si tu introduis sans cesse d\u00e9lais sur d\u00e9lais, si tu remets d'un jour \u00e0 l'autre de faire attention \u00e0 toi-m\u00eame, tu ne t'apercevras pas que tu ne fais pas de progr\u00e8s, et tu ne seras jamais philosophe de ta vie, y compris le moment de ta mort.\n\n2. Prends donc d\u00e8s maintenant le parti de vivre en homme fait et qui est en progr\u00e8s, que tout ce qui t'est d\u00e9montr\u00e9 bon soit pour toi une loi inviolable. S'il se pr\u00e9sente quelque chose qui soit p\u00e9nible ou agr\u00e9able, avantageux ou nuisible \u00e0 ta consid\u00e9ration, souviens-toi que le jour de la lutte est venu, que tu es maintenant dans l'ar\u00e8ne d'Olympie, que tu ne peux plus diff\u00e9rer et qu'il ne tient qu'\u00e0 un seul jour, \u00e0 une seule action que tes progr\u00e8s soient assur\u00e9s ou compromis \u00e0 tout jamais.\n\n3. Si Socrate est devenu ce qu'il a \u00e9t\u00e9, c'est qu'en toute rencontre il ne faisait attention qu'\u00e0 la raison. Quant \u00e0 toi, si tu n'es pas encore Socrate, tu dois vivre comme si tu voulais \u00eatre Socrate.\n\nLII\n\n1. La premi\u00e8re partie de la philosophie et la plus essentielle, c'est de mettre en pratique les maximes, par exemple de ne pas mentir ; la seconde, ce sont les d\u00e9monstrations, par exemple, d'o\u00f9 vient qu'il ne faut pas mentir ; la troisi\u00e8me est celle qui confirme et \u00e9claircit les d\u00e9monstrations elles-m\u00eames ; par exemple d'o\u00f9 vient que c'est une d\u00e9monstration ? Qu'est-ce qu'une d\u00e9monstration ? Qu'est-ce que cons\u00e9quence, incompatibilit\u00e9, vrai, faux ?\n\n2. Ainsi donc, la troisi\u00e8me partie est n\u00e9cessaire \u00e0 cause de la seconde, et la seconde \u00e0 cause de la premi\u00e8re ; mais la plus n\u00e9cessaire, celle au-del\u00e0 de laquelle on ne peut plus remonter, c'est la premi\u00e8re. Nous, nous agissons au rebours. Nous nous arr\u00eatons \u00e0 la troisi\u00e8me partie ; toute notre \u00e9tude est pour elle, et nous n\u00e9gligeons compl\u00e8tement la premi\u00e8re. Aussi nous mentons, mais nous savons sur le bout du doigt comment on d\u00e9montre qu'il ne faut pas mentir.\n\nLIII\n\nIl faut \u00eatre pr\u00eat \u00e0 dire en toute rencontre\n\n1. Emm\u00e8ne-moi, Jupiter, et toi, Destin\u00e9e, l\u00e0 o\u00f9 vous avez arr\u00eat\u00e9 que je dois aller. Je vous suivrai sans h\u00e9siter et quand m\u00eame j'aurais la folie de ne pas le vouloir, je ne vous en suivrai pas moins.\n\n2. Quiconque se soumet de bonne gr\u00e2ce \u00e0 la n\u00e9cessit\u00e9 est sage \u00e0 notre avis et sait les choses divines.\n\n3. Mais, Criton, si telle est la volont\u00e9 des dieux, qu'elle s'accomplisse.\n\n4. Anytus et M\u00e9litus peuvent me tuer, ils ne peuvent pas me nuire.\nEntretiens   \n(extraits)\n\nLe combat n'est pas \u00e9gal entre une jolie fille  \net un jeune apprenti philosophe\n\nLivre premier\n\nII. COMMENT ON PEUT CONSERVER SA DIGNIT\u00c9 EN TOUTE CHOSE\n\nPour l'\u00eatre dou\u00e9 de la vie et de la raison, il n'y a d'impossible \u00e0 supporter que ce qui est contre la raison, mais tout ce qui est conforme \u00e0 la raison se peut supporter. Les coups par eux-m\u00eames ne sont point impossibles \u00e0 supporter. \u2014 Comment cela ? \u2014 Vois comme les Lac\u00e9d\u00e9moniens se laissent battre de verges, sachant que cela est conforme \u00e0 la raison. La pendaison elle-m\u00eame se peut supporter. Lorsque quelqu'un croit qu'elle est conforme \u00e0 la raison, il s'en va et se pend. En un mot, si nous y faisons attention, nous trouverons que l'\u00eatre dou\u00e9 de la vie ne souffre de rien tant que de ce qui n'est pas raisonnable ; et qu'en revanche il n'est attir\u00e9 par rien autant que par ce qui est raisonnable.\n\nMais ce qui para\u00eet raisonnable ou d\u00e9raisonnable \u00e0 l'un, ne le para\u00eet pas \u00e0 l'autre. Il en est de cela comme du bien et du mal, de l'utile et du nuisible. Et c'est pour ce motif surtout que nous avons besoin d'instruction pour apprendre \u00e0 mettre d'accord avec la nature, dans chaque cas particulier, notre notion a priori du raisonnable et du d\u00e9raisonnable.\n\nOr, pour juger de ce qui est conforme ou contraire \u00e0 la raison, nous ne nous bornons pas \u00e0 appr\u00e9cier les objets ext\u00e9rieurs, nous tenons compte encore de notre dignit\u00e9 personnelle. L'un, en effet, trouve conforme \u00e0 la raison de pr\u00e9senter le pot de chambre \u00e0 quelqu'un, parce qu'il ne voit qu'une chose : que, s'il ne le pr\u00e9sente point, il recevra des coups et ne recevra pas de nourriture ; tandis que s'il le pr\u00e9sente, il n'aura \u00e0 supporter rien de f\u00e2cheux ni de p\u00e9nible. L'autre, non seulement trouve intol\u00e9rable de le pr\u00e9senter lui-m\u00eame, mais encore ne saurait souffrir qu'un autre le lui pr\u00e9sente. Si tu me fais cette question : \u00ab Pr\u00e9senterai-je ou non le pot de chambre ? \u00bb Je te dirai que recevoir de la nourriture vaut mieux que n'en pas recevoir, et qu'il y a plus de d\u00e9sagr\u00e9ment \u00e0 \u00eatre frapp\u00e9 de verges qu'\u00e0 ne pas l'\u00eatre ; de sorte que, si tu calcules d'apr\u00e8s cela ce qui te convient, va pr\u00e9senter le pot de chambre. \u2014 Mais la chose est indigne de moi. \u2014 C'est \u00e0 toi de faire entrer cela en ligne de compte, et non pas \u00e0 moi, car tu es le seul qui sache combien tu t'estimes, et combien tu veux te vendre. Chacun se vend un prix diff\u00e9rent.\n\nAussi quand Florus demanda \u00e0 Agrippinus s'il devait descendre sur la sc\u00e8ne avec N\u00e9ron pour y jouer un r\u00f4le lui aussi, \u00ab Descends-y \u00bb fut la r\u00e9ponse. Et \u00e0 cette question : \u00ab Pourquoi, toi, n'y descends-tu pas ? \u00bb Il r\u00e9pondit : \u00ab Parce que, moi, dit-il, je ne me demande m\u00eame pas si je dois le faire. \u00bb C'est, qu'en effet, celui qui s'abaisse \u00e0 d\u00e9lib\u00e9rer sur de pareilles choses et qui p\u00e8se les objets ext\u00e9rieurs avant de se d\u00e9cider, touche de bien pr\u00e8s \u00e0 ceux qui oublient leur dignit\u00e9 personnelle.\n\nQue me demandes-tu en effet ? Qui vaut le mieux de la mort ou de la vie ? Je te r\u00e9ponds, la vie. De la souffrance ou du plaisir ? Je te r\u00e9ponds, le plaisir. \u2014 Mais si je ne joue pas la trag\u00e9die, dis-tu, j'aurai la t\u00eate coup\u00e9e. \u2014 Va donc, et joue la trag\u00e9die. Pour moi, je ne la jouerai pas. \u2014 Pourquoi ? \u2014 Parce que toi, tu ne te regardes que comme un des fils de la tunique. \u2014 Que veux-tu dire ? \u2014 Que d\u00e8s lors, il te faut chercher \u00e0 ressembler aux autres hommes, de m\u00eame qu'aucun fil ne demande \u00e0 \u00eatre sup\u00e9rieur aux autres fils. Mais moi, je veux \u00eatre le morceau de pourpre, cette petite partie brillante qui donne aux autres l'\u00e9clat et la beaut\u00e9. Que me dis-tu donc de ressembler aux autres ? Comment serais-je pourpre alors ?\n\nC'est ce qu'avait bien vu Priscus Helvidius ; et il agit comme il avait vu. \u2014 Vespasien lui avait envoy\u00e9 dire de ne pas aller au s\u00e9nat : \u2014 Il est en ton pouvoir, lui r\u00e9pondit-il, de ne pas me laisser \u00eatre du s\u00e9nat ; mais tant que j'en serai, il faut que j'y aille. \u2014 Eh bien ! Vas-y, lui dit l'empereur, mais tais-toi. \u2014 Ne m'interroge pas, et je me tairai. \u2014 Mais il faut que je t'interroge. \u2014 Et moi, il faut que je dise ce qui me semble juste. \u2014 Si tu le dis, je te ferai mourir. \u2014 Quand t'ai-je dit que j'\u00e9tais immortel ? Tu rempliras ton r\u00f4le, et je remplirai le mien. Ton r\u00f4le est de faire mourir ; le mien est de mourir sans trembler. Ton r\u00f4le est d'exiler, le mien est de partir sans chagrin. \u00c0 quoi servit cette conduite de Priscus, seul comme il \u00e9tait ? Mais en quoi la pourpre sert-elle au manteau ? Que fait-elle autre chose que de ressortir sur lui en sa qualit\u00e9 de pourpre, et d'y \u00eatre, pour le reste, un sp\u00e9cimen de beaut\u00e9 ? Un autre homme, si C\u00e9sar, dans de pareilles circonstances, lui avait dit de ne pas aller au s\u00e9nat, aurait r\u00e9pondu : \u00ab Je te remercie de m'\u00e9pargner. \u00bb Mais C\u00e9sar n'aurait pas emp\u00each\u00e9 un tel homme d'y aller, sachant bien qu'il y devait rester immobile comme une cruche, ou que, s'il y parlait, il dirait ce qu'il savait d\u00e9sir\u00e9 de l'empereur, et que m\u00eame il rench\u00e9rirait encore dessus.\n\nDe m\u00eame cet athl\u00e8te qui \u00e9tait en danger de mourir, si on ne lui coupait pas les parties sexuelles. Son fr\u00e8re vint le trouver (l'athl\u00e8te \u00e9tait philosophe) et lui dit : \u00ab Eh bien ! fr\u00e8re, que vas-tu faire ? coupons cette partie, et retournons encore au gymnase. \u00bb Mais celui-ci refusa, tint bon, et mourut. Quelqu'un demandait \u00e0 quel titre il avait agi ainsi : \u00e0 titre d'athl\u00e8te ou \u00e0 titre de philosophe ? \u2014 \u00c0 titre d'homme, r\u00e9pondit \u00c9pict\u00e8te ; au titre d'un homme qui avait \u00e9t\u00e9 proclam\u00e9 \u00e0 Olympie apr\u00e8s y avoir combattu, d'un homme qui avait pass\u00e9 sa vie sur ce terrain-l\u00e0, et non \u00e0 se faire parfumer d'odeurs chez Baton. Un autre se serait fait couper jusqu'\u00e0 la t\u00eate m\u00eame, s'il avait pu vivre sans t\u00eate. Voil\u00e0 ce que c'est que le sentiment de notre dignit\u00e9. Voil\u00e0 la force qu'il a chez ceux qui ont l'habitude de le faire entrer en ligne de compte dans leurs d\u00e9lib\u00e9rations. \u2014 Va donc, \u00c9pict\u00e8te : fais-toi raser. \u2014 Si je suis philosophe, je r\u00e9ponds : \u00ab Je ne me ferai pas raser. \u00bb \u2014 Mais je t'enl\u00e8verai la t\u00eate. \u2014 Enl\u00e8ve-la, si cela te semble bon.\n\nQuelqu'un lui demandait : Comment sentirons-nous ce qui est conforme \u00e0 notre dignit\u00e9 ? \u2014 Comment le taureau, dit-il, \u00e0 l'approche du lion, sent-il seul la force qui est en lui, et se jette-t-il en avant pour le troupeau tout entier ? Il est \u00e9vident que d\u00e8s le premier instant, avec la force dont il est dou\u00e9, se trouve en lui le sentiment de cette force. Eh bien ! de m\u00eame chez nous, nul de ceux qui seront ainsi dou\u00e9s ne restera sans le savoir. Mais ce n'est pas en un jour que se fait le taureau, non plus que l'homme d'\u00e9lite ; il faut s'exercer et se former \u00e0 grand-peine, et ne pas s'\u00e9lancer \u00e0 l'\u00e9tourdie vers ce qui n'est pas de notre comp\u00e9tence.\n\nVois seulement \u00e0 quel prix tu vends ton libre arbitre. Au moins, mon ami, vends-le cher. \u2014 Ce prix \u00e9lev\u00e9 et exceptionnel convient peut-\u00eatre \u00e0 d'autres (diras-tu), \u00e0 Socrate et \u00e0 ceux qui lui ressemblent ? \u2014 Pourquoi donc, puisque nous naissons tous semblables \u00e0 lui, un si petit nombre plus tard lui sont-ils semblables ? \u2014 Tous les chevaux deviennent-ils donc rapides, et tous les limiers bons chasseurs ? \u2014 Eh bien ! parce que je suis d'une nature ingrate, faut-il me refuser \u00e0 tout effort ? \u00e0 Dieu ne plaise ! \u00c9pict\u00e8te n'est pas sup\u00e9rieur \u00e0 Socrate, mais qu'il ne lui soit pas inf\u00e9rieur, et cela me suffit. Je ne deviendrai pas non plus un Milon, et cependant je ne n\u00e9glige pas mon corps ; un Cr\u00e9sus non plus, et cependant je ne n\u00e9glige pas ma fortune. Il n'y a aucune autre chose en un mot, dont nous nous refusions \u00e0 prendre soin, parce que nous y d\u00e9sesp\u00e9rons du premier rang.\n\nVIII. LES TALENTS DES IGNORANTS NE SONT PAS SANS P\u00c9RILS\n\nAutant il y a de mani\u00e8res de varier les propositions \u00e9quivalentes, autant il y en a de varier dans nos raisonnements la forme des \u00e9pich\u00e9r\u00e8mes et des enthym\u00e8mes ; comme dans celui-ci, par exemple : Si tu m'as emprunt\u00e9 et ne m'as pas rendu, tu me dois de l'argent ; or, tu ne m'as ni emprunt\u00e9 ni rendu, tu ne me dois donc pas d'argent. Et c'est ce qu'il n'appartient \u00e0 personne plus qu'au philosophe de faire habilement. Car si l'enthym\u00e8me est un syllogisme incomplet, il est \u00e9vident que celui qui est exerc\u00e9 au syllogisme complet ne sera pas moins habile \u00e0 l'incomplet. Pourquoi donc ne pas nous exercer en ce genre, seuls ou avec d'autres ? \u2014 Parce que aujourd'hui que nous ne nous y exer\u00e7ons pas, et que, autant que nous le pouvons, rien ne nous distrait de l'\u00e9tude de la morale, nous ne faisons cependant pas de progr\u00e8s dans la vertu. \u00c0 quoi ne devrions-nous pas nous attendre alors, si nous y ajoutions cette distraction ? d'autant plus que ce ne serait pas seulement une distraction des choses plus n\u00e9cessaires, mais encore une cause non commune de pr\u00e9somption et d'orgueil. C'est une grande puissance, en effet, que l'art d'argumenter et de persuader, surtout quand il se fortifie par la pratique et qu'il emprunte au style un certain prestige. De plus, toute puissance, en g\u00e9n\u00e9ral, est dangereuse aux mains des ignorants et des faibles, car elle les porte \u00e0 s'enorgueillir et \u00e0 faire les fiers. Comment, en effet, persuader au jeune homme qui se distingue par ces talents que ce n'est pas lui qui doit leur appartenir, mais eux qui doivent lui appartenir \u00e0 lui ? Ne foule-t-il pas aux pieds toutes ces observations ? Et ne s'en va-t-il pas tout fier et tout plein de lui-m\u00eame, repoussant quiconque s'attacherait \u00e0 lui, pour lui repr\u00e9senter ce qu'il quitte, et o\u00f9 il va \u00e0 la d\u00e9rive ?\n\n\u2014 Mais quoi ! Platon n'\u00e9tait-il pas philosophe ? \u2014 Eh bien ! Hippocrate n'\u00e9tait-il pas m\u00e9decin ? Et tu vois comment sait parler Hippocrate. Or, est-ce en tant que m\u00e9decin qu'Hippocrate parle ainsi ? Pourquoi donc confonds-tu des choses qui se trouvent dans le m\u00eame homme \u00e0 des titres diff\u00e9rents ? Si Platon avait \u00e9t\u00e9 beau ou fort, me faudrait-il rester l\u00e0 \u00e0 me fatiguer pour devenir beau ou fort moi aussi, comme si cela \u00e9tait n\u00e9cessaire pour \u00eatre philosophe, parce qu'un philosophe aurait \u00e9t\u00e9 \u00e0 la fois beau et philosophe ? Ne veux-tu donc pas voir et distinguer ce que les gens sont en tant que philosophes, et ce qui est chez eux \u00e0 d'autres titres ? Si, par exemple, moi j'\u00e9tais philosophe, faudrait-il donc que vous, vous devinssiez boiteux comme moi ? Mais quoi ! est-ce que je pr\u00e9tends supprimer ces talents ? \u00e0 Dieu ne plaise ! pas plus que la facult\u00e9 de voir. Mais cependant si tu me demandes quel est le bien de l'homme, je ne puis te r\u00e9pondre que ceci : une certaine fa\u00e7on d'user des id\u00e9es.\n\nXXI. CONTRE CEUX QUI VEULENT SE FAIRE ADMIRER\n\nLorsque quelqu'un dans cette vie est ce qu'il doit \u00eatre, il ne s'extasie pas devant les choses du dehors. Homme, que souhaites-tu qu'il t'arrive ? Pour moi il me suffit que mes d\u00e9sirs et mes aversions soient conformes \u00e0 la nature ; que, dans mes vouloirs ou dans mes refus, dans mes projets, dans mes efforts, dans mes jugements, je sais que je suis n\u00e9 pour \u00eatre. Pourquoi marches-tu aussi raide que si tu avais aval\u00e9 une broche ? \u00ab Je veux que tous ceux qui se trouvent sur mon chemin m'admirent et me suivent en criant : \"Quel grand philosophe !\" \u00bb \u2014 Eh ! qui sont ces gens dont tu veux te faire admirer ? Ne sont-ce pas ceux dont tu as l'habitude de dire qu'ils sont fous ? Et c'est par des fous que tu veux \u00eatre admir\u00e9 !\n\nLivre deuxi\u00e8me\n\nIV. SUR UN HOMME QUI AVAIT \u00c9T\u00c9 SURPRIS EN ADULT\u00c8RE\n\nUn jour qu'il soutenait que l'homme \u00e9tait n\u00e9 pour l'honn\u00eatet\u00e9, et que m\u00e9conna\u00eetre ce principe c'\u00e9tait m\u00e9conna\u00eetre le caract\u00e8re essentiel de l'humanit\u00e9, survint un de nos pr\u00e9tendus lettr\u00e9s, qui avait \u00e9t\u00e9 autrefois surpris \u00e0 Rome en adult\u00e8re. Que faisons-nous, dit alors \u00c9pict\u00e8te, lorsque, renon\u00e7ant \u00e0 cette honn\u00eatet\u00e9 pour laquelle nous sommes n\u00e9s, nous nous attaquons \u00e0 la femme de notre voisin ? Ce que nous faisons ? Nous perdons et d\u00e9truisons... Quoi donc ? Notre honn\u00eatet\u00e9, notre retenue, notre puret\u00e9. Est-ce l\u00e0 tout ? Ne d\u00e9truisons-nous pas encore les rapports de bon voisinage ? Et l'amiti\u00e9 ? Et la soci\u00e9t\u00e9 civile ? Quel r\u00f4le nous donnons-nous \u00e0 nous-m\u00eames ? \u00d4 homme, quelles relations entretiendrai-je avec toi ? des relations de voisin ? d'ami ? De quoi, enfin ? de citoyen ? Quelle confiance puis-je avoir en toi ? Si tu \u00e9tais un vase en si piteux \u00e9tat, que tu ne pusses servir \u00e0 rien, on te jetterait dehors, sur un tas de fumier, et personne ne t'y ramasserait. Si tu es un homme, et que tu ne puisses jouer aucun des r\u00f4les de l'homme, que ferons-nous de toi ? Car, si tu ne peux \u00eatre \u00e0 ta place comme ami, y pourras-tu \u00eatre comme esclave ? Mais l\u00e0 encore, qui se fiera \u00e0 toi ? Et tu ne veux pas qu'on te jette toi aussi sur un tas de fumier, comme un vase inutile, aussi sale que le fumier !\n\nPuis tu viendras dire : \u00ab Quoi ! personne ne fait cas de moi qui suis un lettr\u00e9 ! \u00bb C'est que tu es un m\u00e9chant, dont il n'y a rien \u00e0 faire. C'est comme si les gu\u00eapes s'indignaient de ce qu'on ne fait pas cas d'elles, de ce qu'on les fuit, et de ce qu'on les frappe et les abat, quand on le peut ! Tu as un dard qui porte le chagrin et la douleur partout o\u00f9 il frappe. Que veux-tu que nous fassions de toi ? Il n'y a pas de place o\u00f9 te mettre. \u00ab Comment ! dis-tu. Est-ce que la nature n'a pas fait les femmes communes \u00e0 tous ? \u00bb Et moi je te dis : Le cochon de lait lui aussi est commun \u00e0 tous les invit\u00e9s. Mais, quand il a \u00e9t\u00e9 partag\u00e9, avise-toi d'aller prendre de force la part de ton voisin, ou de la lui d\u00e9rober ; ou bien encore, mets la main dans son assiette pour go\u00fbter de ce qui est dedans, et, si tu ne peux lui enlever sa viande, tra\u00eene tes doigts dans sa graisse, et l\u00e8che-les. Quel honn\u00eate convive ! Quel disciple de Socrate \u00e0 table ! Le th\u00e9\u00e2tre lui aussi n'est-il pas commun \u00e0 tous les citoyens ! Eh bien ! lorsqu'ils sont assis, va t'aviser de chasser l'un d'eux de sa place. C'est de cette fa\u00e7on-l\u00e0 que les femmes sont communes. Lorsque le l\u00e9gislateur, comme un ma\u00eetre de maison, les a partag\u00e9es entre tous, toi, plut\u00f4t que de chercher \u00e0 en avoir ta part \u00e0 toi, aimeras-tu mieux voler la part de ton voisin et y porter la dent ? \u2014 Mais je suis un lettr\u00e9, dis-tu, et je comprends Arch\u00e9d\u00e9mus ! \u2014 Eh bien ! toi qui comprends Arch\u00e9d\u00e9mus, sois d\u00e9bauch\u00e9, sois sans honneur ; au lieu d'\u00eatre un homme, sois un loup ou un singe. Car en quoi diff\u00e8res-tu d'eux ?\n\nXV. SUR LES GENS QUI PERSISTENT OBSTIN\u00c9MENT DANS CE QU'ILS ONT D\u00c9CID\u00c9\n\nIl est des gens qui, pour avoir entendu dire qu'il faut \u00eatre ferme, que notre facult\u00e9 de juger et de vouloir est de sa nature ind\u00e9pendante et libre, que tout le reste, pouvant \u00eatre entrav\u00e9 ou contraint, est esclave et ne nous appartient pas, s'imaginent qu'ils doivent persister obstin\u00e9ment dans toutes les d\u00e9cisions qu'ils ont pu prendre. Mais, avant tout, il faut que ta d\u00e9cision soit saine. Je veux que ton corps ait de la force, mais une force due \u00e0 la sant\u00e9 et au travail. Si la force que tu m'\u00e9tales est celle de la fr\u00e9n\u00e9sie, et si tu t'en vantes, je te dirai : \u00ab Mon ami, cherche un m\u00e9decin ; ce n'est pas l\u00e0 de la force, mais un manque de force \u00e0 un autre point de vue. \u00bb Tel est au moral l'\u00e9tat de ceux qui comprennent mal les pr\u00e9ceptes dont nous parlions. C'est ainsi qu'un de mes amis r\u00e9solut, sans aucun motif, de se laisser mourir de faim. Je l'appris quand il y avait d\u00e9j\u00e0 trois jours qu'il s'abstenait de manger ; j'allai le trouver, et lui demandai ce qu'il y avait. \u2014 Je l'ai r\u00e9solu, me dit-il. \u2014 Mais quel est le motif qui t'y a pouss\u00e9 ? Car, si ta r\u00e9solution est raisonnable, nous allons nous asseoir pr\u00e8s de toi, et t'aider \u00e0 sortir de cette vie ; mais, si elle est d\u00e9raisonnable, changes-en. \u2014 Il faut \u00eatre ferme dans ses d\u00e9cisions. \u2014 Que dis-tu l\u00e0, mon ami ? Il faut \u00eatre ferme, non dans toutes ses d\u00e9cisions, mais dans celles qui sont raisonnables. Quoi ! si, par un caprice, tu avais d\u00e9cid\u00e9 qu'il faisait nuit, tu ne changerais pas, tu persisterais en disant : \u00ab Je persiste dans mes d\u00e9cisions ! \u00bb Que fais-tu, mon ami ? Il ne faut pas persister dans toutes. Ne consentiras-tu pas \u00e0 poser d'abord solidement ta base et tes fondements, \u00e0 examiner si ta d\u00e9cision est bonne ou mauvaise, avant de lui faire porter le poids de ta fermet\u00e9 et de ta constance ? Si les fondements que tu poses sont d\u00e9fectueux et sans solidit\u00e9, plus ce que tu y \u00e9tabliras sera fort et massif, plus ce sera prompt \u00e0 s'\u00e9crouler. Vas-tu, sans aucune raison, nous enlever un homme que la vie a fait notre ami et notre compagnon, notre concitoyen dans la grande comme dans la petite patrie ? Tu commets un meurtre, tu tues un homme qui n'a fait aucun mal, et tu dis : \u00ab Je suis ferme dans mes d\u00e9cisions ! \u00bb Mais, s'il te venait l\u00e0 volont\u00e9 de me tuer, serait-ce un devoir pour toi d'\u00eatre ferme dans ta d\u00e9cision ?\n\nNotre homme se laissa dissuader, mais non sans peine ; et, de nos jours, il en est plus d'un qu'on ne peut faire changer. Aussi, crois-je savoir aujourd'hui ce que j'ignorais auparavant, le sens de ce dicton : \u00ab On ne persuade pas plus un sot qu'on ne le brise. \u00bb Dieu me pr\u00e9serve d'avoir pour ami un philosophe qui ne soit qu'un sot ! Il n'y a rien de plus difficile \u00e0 manier. \u00ab J'ai d\u00e9cid\u00e9 \u00bb dit-il ! Mais les fous aussi d\u00e9cident ; et plus ils persistent dans leurs d\u00e9cisions erron\u00e9es, plus pr\u00e9cis\u00e9ment ils ont besoin d'ell\u00e9bore. Ne consentiras-tu pas \u00e0 te conduire comme un malade, \u00e0 appeler le m\u00e9decin ? \u00ab Je suis malade, ma\u00eetre (lui dit-on) : viens \u00e0 mon secours ; examine ce que je dois faire ; je n'ai, moi, qu'\u00e0 t'ob\u00e9ir. \u00bb De m\u00eame ici : \u00ab Je ne sais pas ce que je dois faire (devrait-on lui dire) ; je suis venu pour l'apprendre. \u00bb Au lieu de cela, on lui dit : \u00ab Parle-moi d'autre chose ; quant \u00e0 cette question-l\u00e0, je suis d\u00e9cid\u00e9. \u00bb \u2014 Et de quelle autre chose veux-tu qu'on te parle ? Car qu'y a-t-il de plus important et de plus utile que de te convaincre qu'il ne suffit pas d'avoir d\u00e9cid\u00e9 et de ne point varier dans sa d\u00e9cision ? C'est le d\u00e9ploiement de force d'un fou et non pas d'un homme de bon sens. \u2014 Je suis r\u00e9solu \u00e0 mourir, si tu veux me contraindre \u00e0 cela ! \u2014 Pourquoi, mon ami ? Qu'est-il arriv\u00e9 ? \u2014 Je l'ai d\u00e9cid\u00e9 ! \u2014 Je suis bien heureux que tu n'aies pas d\u00e9cid\u00e9 de me tuer ! \u2014 Je ne veux pas de ton argent ! \u2014 Pourquoi ? \u2014 Je l'ai d\u00e9cid\u00e9. \u2014 Sache donc que la force que tu d\u00e9ploies pour refuser, rien ne garantit que tu ne la d\u00e9ploieras pas un jour pour prendre avec aussi peu de raison, et que tu ne diras pas encore : \u00ab J'ai d\u00e9cid\u00e9. \u00bb Dans le corps d'un malade qu'assi\u00e8gent les rhumatismes, les humeurs se portent tant\u00f4t sur un point, tant\u00f4t sur un autre ; de m\u00eame une \u00e2me faible se porte d'un c\u00f4t\u00e9 sans savoir pourquoi ; puis, quand \u00e0 cette inclinaison et \u00e0 ce mouvement vient s'ajouter la force, il n'y a plus contre le mal qui en r\u00e9sulte ni secours ni rem\u00e8de.\n\nXVIII. COMMENT IL FAUT LUTTER CONTRE LES ID\u00c9ES DANGEREUSES\n\nToute habitude, tout talent, se forment et se fortifient par les actions qui leur sont analogues : marchez, pour \u00eatre marcheur ; courez, pour \u00eatre coureur. Voulez-vous savoir lire ? Lisez. Savoir \u00e9crire ? \u00c9crivez. Passez trente jours de suite sans lire, \u00e0 faire tout autre chose, et vous saurez ce qui en arrivera. Restez couch\u00e9 dix jours, puis levez-vous, et essayez de faire une longue route, et vous verrez comme vos jambes seront fortes. Une fois pour toutes, si vous voulez prendre l'habitude d'une chose, faites cette chose ; si vous n'en voulez pas prendre l'habitude, ne la faites pas, et habituez-vous \u00e0 faire quoi que ce soit plut\u00f4t qu'elle. Il en est de m\u00eame pour l'\u00e2me : lorsque vous vous emportez, sachez que ce n'est pas l\u00e0 le seul mal qui vous arrive, mais que vous augmentez en m\u00eame temps votre disposition \u00e0 la col\u00e8re : c'est du bois que vous mettez dans le feu. Lorsque vous avez succomb\u00e9 aux attraits de la chair avec quelqu'un, ne vous dites pas qu'il n'y a l\u00e0 qu'une d\u00e9faite, mais que vous avez du m\u00eame coup aliment\u00e9, fortifi\u00e9 votre penchant au plaisir. Il est impossible, en effet, que les actes en analogie avec quelque habitude et quelque disposition, ne les fassent point na\u00eetre, si elles n'existent pas avant, et ne les d\u00e9veloppent point, ne les fortifient point, dans l'autre cas.\n\nC'est certainement ainsi, au dire des philosophes, que se forment jour \u00e0 jour nos maladies morales. Convoitez une fois de l'argent, et qu'il vous arrive ensuite un raisonnement qui vous fasse sentir votre mal, votre convoitise cesse, et votre partie ma\u00eetresse est r\u00e9tablie dans son premier \u00e9tat ; mais que rien ne vienne la gu\u00e9rir, elle ne redeviendra pas ce qu'elle \u00e9tait ; bien loin de l\u00e0, qu'une apparition du m\u00eame genre l'excite une seconde fois, et la convoitise s'allumera en elle bien plus vite que la premi\u00e8re. Que ceci se reproduise d'une mani\u00e8re suivie, le calus se forme \u00e0 jamais, et la cupidit\u00e9 devient en nous une maladie durable. Celui qui a eu la fi\u00e8vre, et qui a cess\u00e9 de l'avoir, n'est pas dans le m\u00eame \u00e9tat qu'avant de l'avoir eue, \u00e0 moins qu'il n'ait \u00e9t\u00e9 gu\u00e9ri compl\u00e8tement. La m\u00eame chose arrive pour les maladies de l'\u00e2me. Elles y laissent des traces, des meurtrissures, qu'il faut faire dispara\u00eetre compl\u00e8tement ; sinon, pour peu qu'on re\u00e7oive encore quelque coup \u00e0 la m\u00eame place, ce ne sont plus des meurtrissures, ce sont des plaies qui se produisent. Si donc tu ne veux pas \u00eatre enclin \u00e0 la col\u00e8re, n'en entretiens pas en toi l'habitude ; ne lui donne rien pour l'alimenter. Calme ta premi\u00e8re fureur, puis compte les jours o\u00f9 tu ne te seras pas emport\u00e9. \u00ab J'avais l'habitude de m'emporter tous les jours, diras-tu ; maintenant c'est un jour sur deux, puis ce sera un sur trois, et apr\u00e8s cela un sur quatre. \u00bb Si tu passes ainsi trente jours, fais un sacrifice \u00e0 Dieu. L'habitude, en effet, commence par s'affaiblir, puis elle dispara\u00eet enti\u00e8rement. Si tu peux te dire : \u00ab Voici un jour que je ne me suis pas afflig\u00e9 ; en voici deux ; puis voici deux mois, voici trois mois ; j'ai veill\u00e9 sur moi, quand il s'est pr\u00e9sent\u00e9 des choses qui pouvaient me contrarier \u00bb, sache que tout va bien chez toi. Si je puis me dire : \u00ab Aujourd'hui, \u00e0 la vue d'un beau gar\u00e7on ou d'une belle femme, je ne me suis pas dit : \"Pl\u00fbt aux dieux qu'on couch\u00e2t avec elle !\" ni \"Bienheureux son mari !\" (car celui qui dit cela, dit aussi : \"Bienheureux son amant !\"). Je ne me suis pas non plus repr\u00e9sent\u00e9 tout ce qui s'ensuit, cette femme pr\u00e8s de moi, se mettant nue, se couchant \u00e0 mes c\u00f4t\u00e9s \u00bb, je me caresse la t\u00eate, et je me dis : \u00ab C'est bien, \u00c9pict\u00e8te ! Tu es venu \u00e0 bout d'un beau sophisme, d'un sophisme bien plus beau que celui qu'on nomme le Dominateur. \u00bb Et si cette femme ne demandait pas mieux, si elle me faisait des signes, si elle venait vers moi, si elle me touchait et se mettait tout pr\u00e8s de moi, et que je me dominasse encore et triomphasse d'elle, ce serait venir \u00e0 bout d'un sophisme bien au-dessus du Menteur et de l'Endormi. Voil\u00e0 ce dont on a le droit d'\u00eatre fier, et non pas d'avoir propos\u00e9 le Dominateur !\n\nMais comment en arriver l\u00e0 ? Veuille te plaire \u00e0 toi-m\u00eame ; veuille \u00eatre beau aux yeux de Dieu ; veuille vivre pur avec toi-m\u00eame qui resteras par, et avec Dieu. Puis, quand il se pr\u00e9sentera \u00e0 toi quelque apparition de ce genre, Platon te dit : \u00ab Recours aux sacrifices expiatoires ; recours, en suppliant, aux temples des dieux tut\u00e9laires ; mais il te suffira de te retirer dans la soci\u00e9t\u00e9 de quelqu'un des sages, et de rester avec lui en te comparant \u00e0 lui ; qu'il soit un de ceux qui vivent, ou un de ceux qui sont morts. \u00bb Va vers Socrate, vois-le, couch\u00e9 pr\u00e8s d'Alcibiade, triompher de sa beaut\u00e9 en se jouant ; songe quelle grande victoire, quelle victoire olympique, il e\u00fbt alors conscience d'avoir remport\u00e9e. Fut-il en ce moment beaucoup au-dessous d'Hercule ? De par tous les dieux ! on put, \u00e0 bon droit, le saluer de ces paroles : \u00ab Salut, \u00f4 l'homme incroyable ! \u00bb Ceux que tu as vaincus, ce ne sont pas ces mis\u00e9rables histrions ou h\u00e9ros du pancrace, ni ces gens bons \u00e0 une seule lutte qui sont de la m\u00eame famille que les autres ! Si tu te repr\u00e9sentes tout cela, tu triompheras de l'apparition, et tu ne seras pas entra\u00een\u00e9 par elle. Commence par r\u00e9sister \u00e0 son impression trop vive, et dis : \u00ab Attends-moi un peu, id\u00e9e ; laisse-moi voir qui tu es et sur quoi tu portes. Laisse-moi te juger. \u00bb Puis ne la laisse pas faire de progr\u00e8s, et retrace \u00e0 ton imagination tout ce qui la suit ; sinon, elle va t'entra\u00eener partout o\u00f9 elle voudra. Appelle bien plut\u00f4t \u00e0 sa place quelque autre id\u00e9e honn\u00eate et noble, et chasse ainsi l'image impure. Si tu t'habitues \u00e0 ce genre de lutte, tu verras ce que deviendront tes \u00e9paules, tes tendons et tes muscles ; mais pour aujourd'hui, ils n'existent qu'en parole, et rien de plus.\n\nVoil\u00e0 le v\u00e9ritable lutteur : c'est celui qui s'exerce \u00e0 combattre ces id\u00e9es. R\u00e9siste, \u00f4 malheureux ! ne te laisse pas entra\u00eener ! Importante est la lutte, et elle est le fait d'un Dieu : il s'agit de la royaut\u00e9, de la libert\u00e9, de la vie heureuse et calme. Souviens-toi de Dieu, appelle-le \u00e0 ton secours et \u00e0 ton aide, comme dans la temp\u00eate les navigateurs appellent les Dioscures. Est-il, en effet, temp\u00eate plus terrible que celle qui na\u00eet de ces id\u00e9es, dont la force nous jette hors de notre raison ? La temp\u00eate elle-m\u00eame, en effet, qu'est-elle autre chose qu'une id\u00e9e ? Enl\u00e8ve la crainte de la mort, et am\u00e8ne-nous tous les tonnerres et tous les \u00e9clairs que tu voudras, et tu verras quel calme et quelle tranquillit\u00e9 il y aura dans notre \u00e2me. Mais, si tu te laisses vaincre une fois, en te disant que tu vaincras demain, et que demain ce soit la m\u00eame chose, sache que tu en arriveras \u00e0 \u00eatre si malade et si faible qu'\u00e0 l'avenir tu ne t'apercevras m\u00eame plus de tes fautes, mais que tu seras toujours pr\u00eat \u00e0 trouver des excuses \u00e0 tes actes. Tu confirmeras ainsi la v\u00e9rit\u00e9 de ce vers d'H\u00e9siode :\n\n\u00ab L'homme irr\u00e9solu lutte toute sa vie contre le malheur. \u00bb\n\nXXIV. \u00c0 QUELQU'UN QU'IL N'ESTIMAIT PAS\n\nQuelqu'un lui dit un jour : \u2014 Je suis venu souvent vers toi dans le d\u00e9sir de t'entendre, et jamais tu ne m'as r\u00e9pondu. Aujourd'hui, au moins, si faire se peut, dis-moi quelque chose, je t'en conjure. \u2014 Ne crois-tu pas, lui dit \u00c9pict\u00e8te, qu'il y a l'art de parler, comme il y a l'art de telle autre chose ? Ceux qui poss\u00e9deront cet art parleront en gens qui s'y connaissent, et en ignorants, ceux qui ne le poss\u00e9deront pas. \u2014 Je le crois. \u2014 Eh bien ! ceux qui en parlant se font du bien \u00e0 eux-m\u00eames et peuvent en faire aux autres, ne sont-ils pas ceux qui parlent en s'y connaissant ? Et ceux, au contraire, qui se font du tort \u00e0 eux-m\u00eames et aux autres, ne sont-ils pas ceux qui ne se connaissent pas \u00e0 cet art de parler ? Or, il est facile de trouver des gens qui se font du bien en parlant, et d'autres qui se font du tort. \u00c0 leur tour, ceux qui \u00e9coutent tirent-ils tous quelque profit de ce qu'ils \u00e9coutent ?\n\nEt ne peut-on pas, parmi eux aussi, trouver des gens qui profitent, et des gens qui p\u00e2tissent ? \u2014 Oui, parmi eux aussi. \u2014 Eh bien ! l\u00e0 aussi tous ceux qui \u00e9coutent en s'y connaissant ne sont-ils pas ceux qui profitent, tandis que tous ceux qui \u00e9coutent en ne s'y connaissant point, p\u00e2tissent ? \u2014 D'accord. \u2014 N'y a-t-il pas alors un art d'\u00e9couter, comme il y a un art de parler ? \u2014 Il semble que oui. \u2014 Si tu le veux bien, pense encore \u00e0 ceci. \u00c0 qui appartient-il, suivant toi, de faire de la musique ? \u2014 Au musicien. \u2014 Faire une statue comme elle doit \u00eatre faite, \u00e0 qui crois-tu encore que cela appartienne ? \u2014 Au statuaire. \u2014 Et pour la regarder en connaisseur, crois-tu qu'il n'y ait besoin d'aucune science ? \u2014 Il y en a besoin. \u2014 Eh bien ! s'il faut un homme exerc\u00e9 pour parler comme on le doit, ne vois-tu pas qu'il faut aussi un homme exerc\u00e9 pour \u00e9couter avec profit ? Ne parlons pour le moment, si tu le veux, ni de perfection ni de profit complet, car tous les deux nous sommes \u00e0 grande distance de quoi que ce soit de ce genre. Mais voici, ce me semble, une chose que tout le monde m'accordera : c'est que, pour \u00e9couter un philosophe, on a besoin de quelque pr\u00e9paration. N'est-ce pas vrai ?\n\nDe quoi donc te parlerai-je ? Sur quel sujet peux-tu m'\u00e9couter ? Sur le bien et le mal ? Mais de qui ? Du cheval ? \u2014 Non. \u2014 Du b\u0153uf ? \u2014 Non. \u2014 De qui donc ? De l'homme ? \u2014 Oui. \u2014 Savons-nous donc ce que c'est que l'homme, quelle est sa nature, quelle est son intelligence ? Avons-nous les oreilles familiaris\u00e9es avec cette question, au moins dans une certaine mesure ? Comprends-tu ce que c'est que la nature ? Ou pourras-tu me suivre dans une certaine mesure, si je te le dis ? Puis me servirai-je avec toi de d\u00e9monstrations ? Et comment le ferai-je ? Car te rends-tu au moins compte de ce que c'est qu'une d\u00e9monstration, de la mani\u00e8re dont elle se fait, des moyens qu'elle emploie, des cas o\u00f9 il y a semblant de d\u00e9monstration, sans d\u00e9monstration r\u00e9elle ? Sais-tu, en effet, ce que c'est que la v\u00e9rit\u00e9, ce que c'est que l'erreur, ce que c'est que cons\u00e9quence, opposition, d\u00e9saccord, contradiction ? Puis te pousserai-je vers la philosophie ? Comment le ferai-je ? En te montrant les oppositions et les divergences de la plupart des hommes sur le bien et le mal, l'utile et le nuisible ? Mais tu ne sais m\u00eame pas ce que c'est qu'opposition ! Montre-moi donc ce \u00e0 quoi je puis arriver en causant avec toi. Donne-moi le d\u00e9sir de le faire. Que la brebis aper\u00e7oive une herbe qui lui convient, cela lui donne l'envie d'en manger ; mais place aupr\u00e8s d'elle une pierre ou du pain, elle y sera indiff\u00e9rente. Il y a de m\u00eame en nous une certaine propension naturelle \u00e0 parler, quand celui qui doit nous entendre nous fait l'effet de quelqu'un, quand il a en lui-m\u00eame quelque chose qui nous y invite ; mais, quand il n'est l\u00e0 pr\u00e8s de nous que comme une pierre ou comme une botte de foin, quelle envie peut-il donner \u00e0 un homme ? Est-ce que la vigne dit \u00e0 l'ouvrier des champs : \u00ab Cultive-moi ? \u00bb Non ; mais, rien qu'\u00e0 la voir, il est clair que celui qui la cultivera s'en trouvera bien ; et elle invite ainsi d'elle-m\u00eame \u00e0 la cultiver. Un petit enfant, charmant et vif, ne vous donne-t-il pas l'envie de jouer avec lui, de marcher avec lui sur les mains, de balbutier avec lui ? Mais qui a jamais l'id\u00e9e de jouer avec un \u00e2ne ou de braire avec lui ? C'est que, si petit qu'il soit, il n'est jamais qu'un \u00e2non.\n\n\u2014 Pourquoi donc ne me dis-tu rien ? \u2014 Je ne puis te dire qu'une chose, c'est que l'homme qui ignore ce qu'il est et pourquoi il est n\u00e9, qui ne sait ni ce qu'est ce monde o\u00f9 il est, ni ce que sont ses compagnons, ni ce qui est bon, ni ce qui est mauvais, ni ce qui est beau, ni ce qui est laid, qui ne comprend ni un raisonnement, ni une d\u00e9monstration, ni ce que c'est que la v\u00e9rit\u00e9, ni ce que c'est que l'erreur, et qui ne sait pas les distinguer, ne se conformera \u00e0 la nature ni dans ses d\u00e9sirs, ni dans ses craintes, ni dans ses vouloirs, ni dans ses entreprises, ni dans ses affirmations, ni dans ses n\u00e9gations, ni dans ses doutes. En somme, il s'en ira \u00e0 droite et \u00e0 gauche sourd et aveugle ; on le prendra pour quelqu'un, et il ne sera personne. Est-ce en effet la premi\u00e8re fois qu'il en est ainsi ? Est-ce que, depuis que la race humaine existe, toutes nos fautes et tous nos malheurs ne sont pas d\u00e8s ce moment venus de notre ignorance ? Pourquoi Agamemnon et Achille se sont-ils disput\u00e9s ? N'est-ce point faute de savoir ce qui est utile et ce qui est nuisible ? L'un ne dit-il pas qu'il est utile de rendre Chrys\u00e9is \u00e0 son p\u00e8re, et l'autre que cela est funeste ? L'un ne dit-il pas qu'il doit recevoir la r\u00e9compense qui a \u00e9t\u00e9 donn\u00e9e \u00e0 un autre ; et l'autre, qu'il ne le doit pas ? N'est-ce pas pour cela qu'ils ont oubli\u00e9 qui ils \u00e9taient, et pourquoi ils \u00e9taient venus l\u00e0 ? Homme, pourquoi es-tu venu ? pour gagner des ma\u00eetresses ? ou pour combattre ? \u2014 Pour combattre. \u2014 Qui ? les Troyens ou les Grecs ? \u2014 Les Troyens. \u2014 Eh bien ! laisseras-tu l\u00e0 Hector pour tirer l'\u00e9p\u00e9e contre le roi ? Et toi, mon cher, oublieras-tu ton r\u00f4le de roi, toi \u00e0 qui les peuples sont confi\u00e9s, \u00e0 qui tant d'int\u00e9r\u00eats sont remis ; et te disputeras-tu pour une femme avec le plus vaillant de tes alli\u00e9s, que tu devrais entourer de toute sorte d'attentions et d'\u00e9gards ? Seras-tu au-dessous de l'habile grand-pr\u00eatre, qui a toute esp\u00e8ce de soins pour les grands guerriers ? Vois-tu ce que peut produire l'ignorance de ce qui est vraiment utile ?\n\n\u2014 Mais, moi, dis-tu, je suis riche ! \u2014 Es-tu donc plus riche qu'Agamemnon ? \u2014 Mais, moi, je suis beau ! \u2014 Es-tu donc plus beau qu'Achille ? \u2014 J'ai de plus une chevelure magnifique ! \u2014 Est-ce qu'Achille n'en avait pas une plus belle encore, et une blonde ? Et il ne la peignait ni ne l'arrangeait avec \u00e9l\u00e9gance ! \u2014 Mais, de plus, je suis fort ! \u2014 Peux-tu donc soulever une pierre telle que celle que soulevait Hector ou Ajax ? \u2014 Mais, de plus, je suis de noble race ! \u2014 As-tu donc une d\u00e9esse pour m\u00e8re ? As-tu pour p\u00e8re un fils de Jupiter ? Et de quoi tout cela servait-il \u00e0 Achille, quand il \u00e9tait assis \u00e0 pleurer pour une femme ? \u2014 Mais je suis orateur ! \u2014 Est-ce qu'il ne l'\u00e9tait pas lui aussi ? Ne sais-tu pas comment il s'est tir\u00e9 d'affaire avec les plus habiles parleurs de la Gr\u00e8ce, Ulysse et Ph\u00e9nix ? Comment il les a r\u00e9duits au silence ?\n\nVoil\u00e0 tout ce que je puis te dire, et encore sans plaisir. Pourquoi ? parce que tu ne m'as pas inspir\u00e9. Que puisse en effet regarder en toi qui m'excite, comme la vue d'un cheval de bonne race excite un \u00e9cuyer ? Ton corps ? Mais tu en as soin d'une fa\u00e7on honteuse. Tes habits ? Mais eux aussi sont ceux d'un d\u00e9bauch\u00e9. Ta tournure ? Ton regard ? Rien. Quand tu voudras entendre parler un philosophe, ne lui dis pas : \u00ab Tu ne me dis rien \u00bb ; borne-toi \u00e0 lui montrer que tu es digne de l'entendre, que tu as ce qu'il faut pour cela ; et tu verras quelles paroles tu lui inspireras.\n\nLivre troisi\u00e8me\n\nIV. CONTRE CEUX QUI, AU TH\u00c9\u00c2TRE, DONNENT DES MARQUES INCONVENANTES DE FAVEUR\n\nUn procurateur de l'\u00c9pire avait favoris\u00e9 un histrion d'une mani\u00e8re inconvenante, et le public lui avait dit des injures ; il \u00e9tait venu alors raconter ces injures \u00e0 \u00c9pict\u00e8te, et il s'indignait contre ceux qui les lui avaient adress\u00e9es. \u2014 Qu'ont-ils fait de mal ? lui dit celui-ci. Ils ont donn\u00e9 des marques de leur faveur, tout comme toi. \u2014 Mais peut-on en donner de pareilles ? dit notre homme. \u2014 Quand ils te voyaient, r\u00e9pliqua \u00c9pict\u00e8te, toi leur magistrat, toi l'ami et le procurateur de C\u00e9sar, t\u00e9moigner ainsi ta faveur, ne pouvaient-ils pas de m\u00eame t\u00e9moigner la leur ? Car, si l'on ne doit pas t\u00e9moigner ainsi sa faveur, commence par ne pas t\u00e9moigner la tienne ; ou, si on le doit, pourquoi leur en veux-tu de t'avoir imit\u00e9 ? Qui la multitude peut-elle imiter, si ce n'est vous qui \u00eates au-dessus d'elle ? Et, quand elle va au th\u00e9\u00e2tre, sur qui a-t-elle les yeux, si ce n'est sur vous ? \u00ab Vois, dit-on, comme l'intendant de C\u00e9sar regarde le spectacle ! Il a cri\u00e9 ! Je crierai donc, moi aussi. Il tr\u00e9pigne d'enthousiasme ! Je tr\u00e9pignerai donc aussi. Ses esclaves, assis \u00e0 ses c\u00f4t\u00e9s, poussent des clameurs ! Moi, je n'ai pas d'esclaves ; je vais \u00e0 moi seul, si je le puis, en pousser autant que tous. \u00bb Il te fallait savoir, quand tu es entr\u00e9 au th\u00e9\u00e2tre, que tu y entrais pour servir de r\u00e8gle et d'exemple aux autres, sur la mani\u00e8re dont on doit regarder. Pourquoi donc t'ont-ils injuri\u00e9 ? parce que tout homme hait ce qui le contrarie. Ces gens voulaient qu'un tel f\u00fbt couronn\u00e9 ; toi tu voulais que ce f\u00fbt un autre : ils te contrariaient, tu les contrariais. Tu t'es trouv\u00e9 le plus fort ; ils ont fait ce qu'ils pouvaient faire : ils ont injuri\u00e9 qui les contrariait. Que voudrais-tu donc ? que tu fisses ce que tu veux, et que ces gens ne pussent m\u00eame pas dire ce qu'ils veulent ? Qu'y a-t-il d'\u00e9tonnant qu'ils aient agi ainsi ? Les laboureurs n'injurient-ils pas Jupiter, quand il les contrarie ? Les matelots ne l'injurient-ils pas aussi ? Cesse-t-on jamais d'injurier C\u00e9sar ? Eh bien ! est-ce que Jupiter ne le sait pas ? Est-ce que les paroles qu'on a dites ne sont pas rapport\u00e9es \u00e0 C\u00e9sar ? Que fait-il donc ? Il sait que, s'il punissait tous ceux qui l'injurient, il n'aurait plus sur qui r\u00e9gner.\n\nQue conclure de l\u00e0 ? Que tu devais te dire, en arrivant au th\u00e9\u00e2tre, non pas : \u00ab Il faut que Sophron soit couronn\u00e9 \u00bb ; mais : \u00ab J'aurai soin dans cette occasion que ma volont\u00e9 soit conforme \u00e0 la nature. Personne ne m'est plus cher que moi-m\u00eame. Il serait donc ridicule de me nuire \u00e0 moi-m\u00eame, pour faire triompher l'un des com\u00e9diens. Quel est donc celui que je veux voir vainqueur ? Celui qui le sera. De cette fa\u00e7on celui qui vaincra sera toujours celui que j'aurai voulu. \u00bb \u00ab Mais je veux, dis-tu, que la couronne soit \u00e0 Sophron ! \u00bb Fais c\u00e9l\u00e9brer alors dans ta maison tous les jeux que tu voudras, et proclame le vainqueur aux jeux N\u00e9m\u00e9ens, aux Pythiens, aux Isthmiques et aux Olympiques. Mais en public pas d'empi\u00e9tements : ne t'arroge pas ce qui appartient \u00e0 tous. Sinon, supporte les injures ; car, lorsque tu agis comme la multitude, tu te mets toi-m\u00eame \u00e0 son niveau.\n\nV. CONTRE CEUX QUI PARTENT PARCE QU'ILS SONT MALADES\n\n\u2014 Je suis malade ici, dit quelqu'un ; je veux m'en retourner chez moi. \u2014 Est-ce que chez toi tu ne seras plus malade ? Ne veux-tu pas te demander si tu ne fais pas ici quelque chose qui serve \u00e0 l'am\u00e9lioration de ta facult\u00e9 de juger et de vouloir ? Car, si tu ne fais pas de progr\u00e8s, c'est inutilement, en effet, que tu es venu. Va-t'en, et occupe-toi de ta maison. Car, si ta partie ma\u00eetresse ne peut \u00eatre conforme \u00e0 la nature, ton champ du moins le pourra ; tu augmenteras tes \u00e9cus ; tu soigneras ton vieux p\u00e8re ; tu vivras sur la place publique ; tu seras magistrat ; et, corrompu, tu feras en homme corrompu quelqu'une des choses qui sont la cons\u00e9quence de ce titre. Mais si tu avais la conscience de t'\u00eatre d\u00e9livr\u00e9 de quelques opinions mauvaises, et de les avoir remplac\u00e9es par d'autres ; si tu avais fait passer ton \u00e2me de l'amour des choses qui ne rel\u00e8vent pas de ton libre arbitre \u00e0 l'amour de celles qui en rel\u00e8vent ; si, quand tu dis : \u00ab H\u00e9las ! \u00bb tu ne le disais ni \u00e0 cause de ton p\u00e8re, ni \u00e0 cause de ton fr\u00e8re, mais \u00e0 cause de ton moi, est-ce que alors tu te pr\u00e9occuperais encore de la maladie ? Ne sais-tu pas, en effet, qu'il faut que la maladie et la mort viennent nous saisir au milieu de quelque occupation ? Elles saisissent le laboureur \u00e0 son labour et le marin sur son navire. Que veux-tu \u00eatre en train de faire quand elles te prendront ? Car il faut qu'elles te prennent en train de faire quelque chose. Si tu sais quelque chose de meilleur que ceci \u00e0 faire au moment o\u00f9 elles te prendront, fais-le.\n\nPour moi, puisse-t-il m'arriver d'\u00eatre pris par elles ne m'occupant d'autre chose que de ma facult\u00e9 de juger et de vouloir, pour que, soustraite aux troubles, aux entraves, \u00e0 la contrainte, elle soit pleinement libre ! Voil\u00e0 les occupations o\u00f9 je veux qu'elles me trouvent, afin de pouvoir dire \u00e0 Dieu : \u00ab Est-ce que j'ai transgress\u00e9 tes ordres ? Est-ce que j'ai mal us\u00e9 des facult\u00e9s que tu m'avais donn\u00e9es ? Mal us\u00e9 de mes sens ? De mes notions a priori ? T'ai-je jamais rien reproch\u00e9 ? Ai-je jamais bl\u00e2m\u00e9 ton gouvernement ? J'ai \u00e9t\u00e9 malade, parce que tu l'as voulu. Les autres aussi le sont, mais moi je l'ai \u00e9t\u00e9 sans m\u00e9contentement. J'ai \u00e9t\u00e9 pauvre, parce que tu l'as voulu, mais je l'ai \u00e9t\u00e9, content de l'\u00eatre. Je n'ai pas \u00e9t\u00e9 magistrat, parce que tu ne l'as pas voulu ; mais aussi je n'ai jamais d\u00e9sir\u00e9 de magistrature. M'en as-tu jamais vu plus triste ? Ne me suis-je pas toujours pr\u00e9sent\u00e9 \u00e0 toi le visage radieux, n'attendant qu'un ordre, qu'un signe de toi ? Tu veux que je parte aujourd'hui de ce grand spectacle du monde ; je vais en partir. Je te rends gr\u00e2ce, sans r\u00e9serve, de m'y avoir admis avec toi, de m'avoir donn\u00e9 d'y contempler tes \u0153uvres et d'y comprendre ton gouvernement. \u00bb Que ce soit l\u00e0 ce que je pense, \u00e9crive ou lise, au moment o\u00f9 me prendra la mort !\n\n\u2014 Mais, dans ma maladie, ma m\u00e8re ne me tiendra pas la t\u00eate ! \u2014 Va-t'en donc pr\u00e8s de ta m\u00e8re, car tu m\u00e9rites bien qu'on te tienne la t\u00eate, quand tu es malade. \u2014 Mais chez moi j'\u00e9tais couch\u00e9 dans un lit \u00e9l\u00e9gant ! \u2014 Va donc trouver ton lit ; tu m\u00e9rites de t'y coucher en bonne sant\u00e9. Ne te prive pas de ce que tu peux te procurer l\u00e0-bas.\n\nEt que dit Socrate ? \u00ab Comme un autre, dit-il, est heureux des progr\u00e8s qu'il fait faire \u00e0 son champ, et tel autre \u00e0 son cheval, ainsi moi je suis heureux chaque jour quand je sens les progr\u00e8s que je fais. \u00bb \u2014 En quoi donc \u00e9taient ces progr\u00e8s ? Dans l'art des jolies phrases ? \u2014 Tais-toi, mon cher ! \u2014 Dans l'\u00e9tude de la Logique ? \u2014 Que dis-tu l\u00e0 ? \u2014 Je ne vois pourtant pas autre chose dont s'occupent les philosophes. \u2014 N'est-ce donc rien \u00e0 tes yeux que de n'adresser jamais de reproches \u00e0 personne, ni \u00e0 la divinit\u00e9, ni \u00e0 l'homme ? Que de ne bl\u00e2mer personne ? Que d'avoir toujours le m\u00eame visage, en sortant comme en rentrant ? C'\u00e9tait l\u00e0 ce que savait faire Socrate ; et jamais cependant il ne se vanta de savoir ou d'enseigner quelque chose. Si quelqu'un lui demandait l'art des jolies phrases ou la science de la Logique, il le conduisait \u00e0 Protagoras ou \u00e0 Hippias, comme il aurait conduit \u00e0 un jardinier celui qui serait venu lui demander des l\u00e9gumes.\n\nOr, quel est celui de vous qui a de pareils principes ? Si vous les aviez, vous seriez heureux d'\u00eatre malades, d'\u00eatre pauvres, et m\u00eame de mourir. S'il est quelqu'un de vous qui soit amoureux d'une jolie fille, il sait que je dis vrai.\n\nX. COMMENT DOIT-ON SUPPORTER LES MALADIES ?\n\nQuand vient le moment d'appliquer quelques-uns de nos principes, il faut toujours les avoir l\u00e0 pr\u00e9sents : \u00e0 table, ceux qui sont pour la table ; aux bains, ceux qui sont pour le bain ; au lit, ceux qui sont pour le lit.\n\nQue tes yeux trop faibles ne donnent jamais entr\u00e9e au sommeil, avant que tu n'aies pass\u00e9 en revue toutes tes actions de la journ\u00e9e. Quelle loi ai-je viol\u00e9e ? Quel acte ai-je fait ? \u00c0 quel devoir ai-je failli ? Pars de l\u00e0 et continue. Puis, si tu as fait du mal, reproche-le-toi ; si tu as fait du bien, sois-en content.\n\nVoil\u00e0 des vers qu'il faut retenir pour les mettre en pratique, et non pas pour les d\u00e9biter \u00e0 haute voix, comme on d\u00e9bite le P\u00e9an \u00e0 Apollon !\n\nDans la fi\u00e8vre \u00e0 son tour, ayons pr\u00e9sents les principes qui sont faits pour elle, bien loin de les laisser de c\u00f4t\u00e9 tous en masse et de les oublier, parce que nous avons la fi\u00e8vre. \u00ab M'arrive ce qui voudra, t'\u00e9cries-tu, si je m'occupe encore de philosophie ! Je m'en irai quelque part, o\u00f9 je ne songerai qu'aux soins de mon corps, et o\u00f9 la fi\u00e8vre ne me viendra plus ! \u00bb Mais qu'est-ce que s'occuper de philosophie ? N'est-ce pas se pr\u00e9parer contre les \u00e9v\u00e9nements ? Ne comprends-tu pas alors que tes paroles reviennent \u00e0 dire : \u00ab M'arrive ce qui voudra, si je me pr\u00e9pare encore \u00e0 supporter avec calme les \u00e9v\u00e9nements ! \u00bb C'est comme si quelqu'un renon\u00e7ait au jeu du pancrace, parce qu'il y aurait re\u00e7u des coups. Encore est-il tout loisible dans ce cas de cesser la lutte et de ne plus \u00eatre battu ; tandis que nous, si nous cessons de nous occuper de philosophie, qu'est-ce que nous y gagnerons ? Que doit donc dire le philosophe, \u00e0 chaque chose p\u00e9nible qui lui arrive ? Voil\u00e0 ce \u00e0 quoi je me suis pr\u00e9par\u00e9, ce en vue de quoi je me suis exerc\u00e9. Dieu te dit : \u00ab Donne-moi une preuve que tu t'es pr\u00e9par\u00e9 \u00e0 la lutte suivant toutes les r\u00e8gles, que tu t'es nourri comme on doit le faire, que tu as fr\u00e9quent\u00e9 le gymnase, que tu as \u00e9cout\u00e9 les le\u00e7ons du ma\u00eetre. \u00bb Vas-tu maintenant mollir \u00e0 l'instant d\u00e9cisif ? Voici le moment d'avoir la fi\u00e8vre ; qu'elle vienne, et sois convenable. Voici le moment d'avoir soif ; aie soif, et sois convenable. Voici le moment d'avoir faim ; aie faim, et sois convenable. Cela ne d\u00e9pend-il pas de toi ? Quelqu'un peut-il t'en emp\u00eacher ? Le m\u00e9decin t'emp\u00eachera de boire ; mais il ne peut t'emp\u00eacher d'\u00eatre convenable en ayant soif. Il t'emp\u00eachera de manger, mais il ne peut t'emp\u00eacher d'\u00eatre convenable en ayant faim.\n\n\u2014 Mais, en cet \u00e9tat, je ne puis pas \u00e9tudier ! \u2014 \u00c0 quelle fin \u00e9tudies-tu donc, esclave ? N'est-ce pas pour arriver au calme ? \u00e0 la tranquillit\u00e9 ? N'est-ce pas pour te mettre et te maintenir en conformit\u00e9 avec la nature ? Or, quand tu as la fi\u00e8vre, qui t'emp\u00eache de mettre cet accord entre la nature et ta partie ma\u00eetresse ? C'est ici le moment de faire tes preuves ; c'est ici l'\u00e9preuve du philosophe ; car la fi\u00e8vre fait partie de la vie, comme la promenade, les travers\u00e9es, les voyages par terre. Est-ce que tu lis en te promenant ? \u2014 Non. \u2014 Eh bien, c'est la m\u00eame chose quand tu as la fi\u00e8vre. Si tu restes convenable, en te promenant, tu es ce que doit \u00eatre un promeneur ; si tu es convenable, en ayant la fi\u00e8vre, tu es ce que doit \u00eatre un fi\u00e9vreux. Qu'est-ce donc qu'\u00eatre convenable en ayant la fi\u00e8vre ? C'est de ne t'en prendre ni \u00e0 Dieu ni aux hommes ; c'est de ne pas te d\u00e9soler de ce qui arrive ; c'est d'attendre dignement et convenablement la mort ; c'est de faire tout ce que l'on t'ordonne ; c'est de ne pas t'effrayer de ce que va dire le m\u00e9decin, quand il arrive, et de ne pas te r\u00e9jouir outre mesure, quand il te dit : \u00ab Tu te portes bien. \u00bb Qu'est-ce l\u00e0, en effet, te dire de bon ? Car, lorsque tu te portais bien, qu'y avait-il l\u00e0 de bon pour toi ? C'est encore de ne pas te d\u00e9sesp\u00e9rer, quand il te dit : \u00ab Tu te portes mal. \u00bb Qu'est-ce, en effet, que se mal porter ? Approcher du moment o\u00f9 l'\u00e2me se s\u00e9pare du corps. Qu'y a-t-il donc l\u00e0 de terrible ? Est-ce que, si tu n'en approches pas maintenant, tu n'en approcheras pas plus tard ? Est-ce encore que le monde doit \u00eatre boulevers\u00e9 par ta mort ? Pourquoi donc flattes-tu le m\u00e9decin ? Pourquoi lui dis-tu : \u00ab Si tu le veux, ma\u00eetre, je serai en bonne sant\u00e9 \u00bb ? Pourquoi lui donner un motif de porter haut la t\u00eate ? Pourquoi ne pas l'estimer juste ce qu'il vaut ? Le cordonnier est pour mon pied, le charpentier pour ma maison, et le m\u00e9decin, \u00e0 son tour, pour mon mis\u00e9rable corps, c'est-\u00e0-dire pour quelque chose qui n'est pas \u00e0 moi, pour un \u00eatre mort-n\u00e9. Voil\u00e0 ce qu'a \u00e0 faire le fi\u00e9vreux ; et, s'il le fait il est ce qu'il doit \u00eatre. La t\u00e2che du philosophe, en effet, n'est pas de sauvegarder les choses du dehors, son vin, son huile, son corps, mais de sauvegarder sa partie ma\u00eetresse. Comment se conduira-t-il vis-\u00e0-vis les choses du dehors ? Il s'en occupera dans la mesure que la raison comporte. Et alors quand aura-t-il encore \u00e0 s'effrayer ? Quand aura-t-il encore \u00e0 se mettre en col\u00e8re ? Quand aura-t-il encore \u00e0 trembler pour des choses qui ne sont pas \u00e0 lui, et qui ne m\u00e9ritent pas qu'il en fasse cas ? Voici, en effet, les deux pens\u00e9es qu'il faut avoir toujours pr\u00e9sentes : c'est qu'en dehors de notre libre arbitre, il n'y a rien de bon ni de mauvais, et qu'il ne faut pas vouloir conduire les \u00e9v\u00e9nements, mais les suivre. Mon fr\u00e8re ne devait pas se conduire ainsi avec moi. Oui ; mais c'est \u00e0 lui d'y voir ; et quant \u00e0 moi, de quelque fa\u00e7on qu'il se soit conduit, j'agirai envers lui comme je le dois. Car voil\u00e0 ce qui me regarde, tandis que l'autre chose ne me regarde pas ; voil\u00e0 ce que nul ne peut emp\u00eacher, tandis qu'on peut emp\u00eacher l'autre chose.\n\nXII. DE L'EXERCICE\n\nIl ne faut nous exercer \u00e0 rien qui soit extraordinaire et contre nature ; autrement, nous qui nous disons philosophes, nous ne diff\u00e9rerons pas des faiseurs de tours. Il est difficile, en effet, de danser sur la corde ; et non seulement cela est difficile, mais cela est encore dangereux. Est-ce une raison cependant pour que nous aussi nous apprenions \u00e0 danser sur la corde, \u00e0 y \u00e9lever en l'air une branche de palmier, \u00e0 y tenir embrass\u00e9es des statues ? Pas le moins du monde. Tout ce qui est difficile et p\u00e9rilleux n'est pas un bon objet d'exercice ; il n'y a de tel que ce qui nous conduit au but qui est propos\u00e9 \u00e0 nos efforts. Quel est donc le but propos\u00e9 \u00e0 nos efforts ? De n'\u00eatre jamais entrav\u00e9 dans ce que l'on d\u00e9sire ou cherche \u00e0 \u00e9viter. Et qu'est-ce que n'y \u00eatre pas entrav\u00e9 ? C'est ne jamais manquer ce qu'on d\u00e9sire, ne jamais tomber dans ce qu'on veut \u00e9viter. C'est l\u00e0 le seul but en vue duquel nous devions nous exercer. Car, sache-le, comme ce n'est que par un exercice s\u00e9rieux et soutenu qu'on peut arriver \u00e0 ne jamais manquer ce qu'on d\u00e9sire, \u00e0 ne jamais tomber dans ce qu'on veut \u00e9viter, tu ne saurais, si tu te laisses aller \u00e0 t'exercer \u00e0 des choses ext\u00e9rieures qui ne rel\u00e8vent pas de ton libre arbitre, arriver \u00e0 ne jamais manquer ce que tu d\u00e9sires, \u00e0 ne jamais tomber dans ce que tu veux \u00e9viter. Et, comme la force de l'habitude est souveraine, et que ce n'est qu'aux choses du dehors que nous sommes habitu\u00e9s \u00e0 appliquer notre puissance de d\u00e9sirer ou de fuir, il nous faut donc opposer \u00e0 cette habitude une habitude contraire, opposer l'exercice le plus soutenu l\u00e0 o\u00f9 la s\u00e9duction des apparences sensibles est la plus grande.\n\nJe penche vers la volupt\u00e9 : je vais me jeter du c\u00f4t\u00e9 contraire, et cela avec exc\u00e8s, afin de m'exercer. J'ai le travail en aversion : je vais habituer et accoutumer ma pens\u00e9e \u00e0 n'avoir plus jamais d'aversion pour lui et ce qui lui ressemble. Qu'est-ce, en effet, que s'exercer ? C'est s'appliquer \u00e0 ne jamais rien d\u00e9sirer, et \u00e0 n'avoir d'aversion que pour des choses qui rel\u00e8vent de notre libre arbitre, et s'y appliquer de pr\u00e9f\u00e9rence l\u00e0 o\u00f9 il nous est le plus difficile de r\u00e9ussir. D'o\u00f9 il r\u00e9sulte que les choses contre lesquelles on doit s'exercer le plus varient avec chacun. Or, \u00e0 quoi bon pour cela \u00e9lever en l'air une branche de palmier, et promener partout une tente de cuir, un mortier et un pilon ? Homme, si tu es prompt \u00e0 la col\u00e8re, exerce-toi \u00e0 supporter les injures, et \u00e0 ne pas t'irriter des outrages. Et tes progr\u00e8s iront si loin ainsi, que tu te diras, si quelqu'un te frappe : \u00ab Suppose que tu as voulu embrasser une statue. \u00bb Puis exerce-toi \u00e0 bien te comporter en face du vin, ce qui n'est pas t'exercer \u00e0 en boire beaucoup (comme plus d'un le fait malheureusement), mais, avant tout, \u00e0 t'en abstenir ; exerce-toi apr\u00e8s cela \u00e0 te passer de femme et de friandises. Ensuite, pour t'\u00e9prouver, si une heureuse occasion se pr\u00e9sente, va de toi-m\u00eame au p\u00e9ril, afin de savoir si les sens triompheront de toi comme auparavant. Mais, au d\u00e9but, fuis loin des tentations trop fortes. Le combat n'est pas \u00e9gal entre une jolie fille et un jeune apprenti philosophe : \u00ab Cruche et pierre, dit-on, ne peuvent aller ensemble. \u00bb\n\nApr\u00e8s le d\u00e9sir et l'aversion, la seconde chose qu'il nous faut travailler c'est notre fa\u00e7on de vouloir les choses ou de les repousser. Il faut que ces volont\u00e9s soient conformes \u00e0 la raison, qu'elles ne soient \u00e0 contresens ni du moment ni du lieu, qu'elles ne violent enfin aucune convenance de ce genre.\n\nLa troisi\u00e8me chose \u00e0 travailler est l'assentiment que nous donnons \u00e0 ce qui persuade et entra\u00eene. Socrate disait que l'on ne pouvait vivre sans examiner ; de m\u00eame, on ne doit accepter aucune apparence sans l'examiner. On doit lui dire : \u00ab Attends ; laisse-moi voir qui tu es, d'o\u00f9 tu viens \u00bb ; comme les gardes de nuit disent : \u00ab Montre-moi le signe convenu. \u00bb As-tu re\u00e7u de la nature le signe que doit avoir toute id\u00e9e pour se faire accepter ?\n\nEn dernier lieu, il faut nous exercer aussi \u00e0 tout ce que les ma\u00eetres de gymnastique prescrivent au corps, pourvu que cela tende \u00e0 nous exercer au sujet du d\u00e9sir et de l'aversion. Mais, si ce qu'ils prescrivent ne tend qu'\u00e0 la montre, c'est l'affaire de l'homme qui se penche au-dehors pour chercher autre chose, et appeler des spectateurs auxquels il entendra dire : \u00ab Quel grand homme ! \u00bb Aussi Apollonius disait-il avec raison : \u00ab Veux-tu t'exercer ? Quand il fait chaud et que tu as soif, mets dans ta bouche une gorg\u00e9e d'eau fra\u00eeche, puis rejette-la, et ne le conte \u00e0 personne. \u00bb\n\nXIII. QU'EST-CE QUE C'EST QUE L'ABANDON ? ET QU'EST-CE QUI EST ABANDONN\u00c9 ?\n\n\u00catre abandonn\u00e9, c'est se trouver sans appui. Un homme qui est seul n'est pas dans l'abandon pour cela ; par contre, on peut \u00eatre au milieu de beaucoup d'autres, et n'en \u00eatre pas moins abandonn\u00e9. C'est pour cela que, quand nous perdons un fr\u00e8re, un fils, un ami qui \u00e9tait notre appui, nous disons que nous restons abandonn\u00e9s, bien que souvent nous soyons \u00e0 Rome, en face d'une si grande foule, au milieu de tant d'autres habitants, et parfois m\u00eame que nous ayons \u00e0 nous un si grand nombre d'esclaves. Car celui-l\u00e0 se dit abandonn\u00e9, qui, dans sa pens\u00e9e, se trouve priv\u00e9 d'appui, \u00e0 la merci de qui veut lui nuire. C'est pour cela qu'en voyage nous ne nous disons jamais plus abandonn\u00e9s qu'au moment o\u00f9 nous tombons dans une troupe de voleurs ; car ce n'est pas la pr\u00e9sence d'un homme qui nous sauve de l'abandon, mais la pr\u00e9sence d'un homme s\u00fbr, honn\u00eate, et pr\u00eat \u00e0 nous venir en aide. Si la solitude suffisait \u00e0 faire l'abandon, il faudrait dire que Jupiter est dans l'abandon lors de l'embrasement du monde, et qu'il y g\u00e9mit ainsi sur lui-m\u00eame : \u00ab Malheureux que je suis ! je n'ai plus avec moi Junon, ni Minerve, ni Apollon ; je n'ai plus, enfin, ni fr\u00e8res, ni fils, ni petit-fils, ni parent d'aucune sorte. \u00bb C'est pourtant l\u00e0 ce que quelques-uns disent qu'il fait, quand il est seul lors de cet embrasement. C'est qu'ils ne comprennent pas comment on peut vivre seul ; et il faut avouer qu'ils partent d'un principe naturel, car la nature nous a faits pour vivre en soci\u00e9t\u00e9, pour nous aimer les uns les autres, pour \u00eatre heureux de nous trouver avec des hommes. Mais cependant il faut que chacun ait en lui les moyens de pouvoir se suffire, et de pouvoir vivre seul ; de m\u00eame que Jupiter vit seul, jouissant tranquillement de lui-m\u00eame, songeant \u00e0 la fa\u00e7on dont il gouverne, et tout entier aux pens\u00e9es qui conviennent \u00e0 sa divinit\u00e9. Il faut que nous aussi, \u00e0 son exemple, nous puissions converser avec nous-m\u00eames ; nous passer des autres ; n'avoir besoin d'aucune distraction ; r\u00e9fl\u00e9chir au gouvernement divin et \u00e0 nos rapports avec le reste du monde ; songer \u00e0 la conduite que nous avons tenue en face des \u00e9v\u00e9nements, et \u00e0 celle que nous tenons aujourd'hui ; chercher quelles sont les choses qui nous g\u00eanent encore, comment on peut y porter rem\u00e8de, comment on peut les faire dispara\u00eetre ; et, si quelque c\u00f4t\u00e9 en nous a besoin d'un perfectionnement, le lui donner conform\u00e9ment \u00e0 la raison.\n\nVoyez quelle large paix C\u00e9sar semble nous avoir faite : plus de guerres, plus de combats, plus de grandes troupes de voleurs, plus de pirates. On peut se mettre en route \u00e0 toute heure ; on peut naviguer de l'orient \u00e0 l'occident. Mais C\u00e9sar a-t-il pu nous garantir \u00e9galement de la fi\u00e8vre ? des naufrages ? des incendies ? des tremblements de terre ? de la foudre ? Allons plus loin : de l'amour ? Il ne le peut. De la douleur ? Il ne le peut. De la jalousie ? Il ne le peut. Il ne peut rien contre aucune de ces choses. Or, la philosophie s'engage \u00e0 nous garantir de celles-l\u00e0 aussi. Et que nous dit-elle \u00e0 cet effet ? \u00ab \u00d4 hommes, si vous vous attachez \u00e0 moi, en quelque lieu que vous soyez, et quel que soit votre sort, il n'y aura pour vous ni douleur, ni col\u00e8re, ni contrainte, ni entraves ; vous serez affranchis de tout, vous serez libres partout. \u00bb Celui qui jouit de cette paix, que C\u00e9sar n'a pas promulgu\u00e9e, car comment le pourrait-il faire, mais qu'a promulgu\u00e9e Dieu lui-m\u00eame avec l'aide de la raison, a-t-il donc besoin d'autre chose, quand il est seul ? Il n'a qu'\u00e0 ouvrir les yeux et qu'\u00e0 se dire : \u2014 Maintenant rien de mauvais ne peut m'arriver ; il n'y a pour moi ni voleurs, ni tremblement de terre ; partout la paix et la tranquillit\u00e9. Il n'est pas une route, pas une ville, pas un compagnon de voyage, pas un voisin, pas un associ\u00e9 qui puisse m'\u00eatre fatal. Il est quelqu'un qui prend soin de me fournir ma nourriture et mes v\u00eatements ; il est quelqu'un qui m'a donn\u00e9 mes sens et mes notions a priori. Lorsqu'il ne me fournit pas ce qui m'est n\u00e9cessaire, c'est qu'il me sonne la retraite, qu'il ouvre la porte, et qu'il me dit : \u00ab Viens. \u00bb \u2014 O\u00f9 cela ? \u2014 Vers rien qui soit \u00e0 craindre ; vers ce dont tu es sorti ; vers des amis, vers des parents, vers les \u00e9l\u00e9ments. Tout ce qu'il y avait de feu en toi s'en ira vers le feu ; tout ce qu'il y avait de terre, vers la terre ; tout ce qu'il y avait d'air, vers l'air ; tout ce qu'il y avait d'eau, vers l'eau. Il n'y a pas de Pluton, pas d'Ach\u00e9ron, pas de Cocyte, pas de Phl\u00e9g\u00e9ton en feu ; non : tout est peupl\u00e9 de dieux et de G\u00e9nies. Quand on peut se dire tout cela, quand on a devant ses yeux le soleil, la lune et les astres, quand on a la jouissance de la terre et de la mer, on n'est pas plus abandonn\u00e9 que l'on n'est sans appui. \u2014 Mais quoi ! si quelqu'un me surprenait seul et me tuait ! \u2014 Imb\u00e9cile ! ce ne serait pas toi qu'il tuerait, ce serait ton corps !\n\nQu'est-ce donc que l'abandon ? Qu'est-ce donc que le d\u00e9nuement ? Pourquoi nous faire inf\u00e9rieurs aux enfants ? Quand on les laisse seuls, que font-ils ? Ils prennent des coquilles et de la terre, et font des maisons, qu'ils renversent ensuite pour en faire d'autres. De cette fa\u00e7on les moyens de passer le temps ne leur manquent jamais. Vais-je donc, moi, si vous faites voile au loin, m'asseoir en pleurant, parce que vous m'aurez laiss\u00e9 seul et dans l'abandon ? Est-ce que je n'ai pas comme eux des coquillages ? Est-ce que je n'ai pas de la terre ? Et, quand ils agissent ainsi faute d'avoir la raison, nous qui avons la raison serons-nous malheureux par elle ?\n\nToute grande puissance est un p\u00e9ril au d\u00e9but. Il faut en porter le poids suivant ses forces, mais d'une mani\u00e8re conforme \u00e0 la nature... mais non pas pour le poitrinaire. \u00c9tudie-toi parfois \u00e0 te conduire comme si tu \u00e9tais malade, pour savoir un jour te conduire comme un homme bien portant. Je\u00fbne, bois de l'eau, interdis-toi toute esp\u00e8ce de d\u00e9sir, pour savoir un jour d\u00e9sirer conform\u00e9ment \u00e0 la raison. Et, quand tu d\u00e9sireras conform\u00e9ment \u00e0 la raison, quand le bien sera ainsi en toi, tes d\u00e9sirs seront bons. Mais ce n'est pas l\u00e0 ce que nous faisons : d\u00e8s le premier jour nous pr\u00e9tendons vivre comme des sages et servir l'humanit\u00e9. Eh ! Comment la sers-tu ? Que fais-tu ? Quels services, en effet, as-tu commenc\u00e9 par te rendre \u00e0 toi-m\u00eame ? Tu veux les exhorter au bien ! Mais t'y es-tu exhort\u00e9 toi-m\u00eame ? Tu veux leur \u00eatre utile ! Montre-leur par ton propre exemple quels hommes la philosophie sait faire, et ne bavarde pas inutilement. Par ta fa\u00e7on de manger, sois utile \u00e0 ceux qui mangent avec toi ; par ta fa\u00e7on de boire, \u00e0 ceux qui y boivent : c\u00e8de-leur ; fais abn\u00e9gation de toi-m\u00eame ; supporte tout d'eux ; sois-leur utile ainsi, et ne crache pas sur eux.\n\nXVI. QU'IL FAUT Y REGARDER \u00c0 DEUX FOIS AVANT DE SE LAISSER ENTRA\u00ceNER \u00c0 UNE LIAISON\n\nDe deux choses l'une : ou celui qui se laisse entra\u00eener souvent \u00e0 causer, \u00e0 d\u00eener, et g\u00e9n\u00e9ralement \u00e0 vivre avec d'autres, leur deviendra semblable ; ou il les convertira \u00e0 ses m\u0153urs. Placez, en effet, un charbon \u00e9teint aupr\u00e8s d'un charbon allum\u00e9, le premier \u00e9teindra le second, ou le second allumera le premier. En face d'un semblable p\u00e9ril, il faut y regarder \u00e0 deux fois avant de se laisser entra\u00eener \u00e0 de pareilles liaisons avec les hommes ordinaires ; il faut se rappeler qu'on ne saurait se frotter \u00e0 un individu barbouill\u00e9 de suie, sans attraper soi-m\u00eame de la suie. Que feras-tu, en effet, s'il te parle de gladiateurs, de chevaux, d'athl\u00e8tes, ou, ce qui est encore pis, s'il te parle des hommes ; s'il te dit : \u00ab Un tel est un m\u00e9chant homme ; un tel est honn\u00eate ; ceci a \u00e9t\u00e9 bien fait ; cela l'a \u00e9t\u00e9 mal \u00bb ? Et si c'est un moqueur, un persifleur, une mauvaise langue ? Avez-vous donc les ressources du musicien, qui, d\u00e8s qu'il a pris sa lyre, et qu'il en a touch\u00e9 les cordes, reconna\u00eet celles qui ne sont pas justes, et accorde son instrument ? Avez-vous donc le talent de Socrate, qui, dans toute liaison, savait amener \u00e0 ses sentiments celui avec qui il vivait ? Et d'o\u00f9 vous viendrait ce talent ? Forc\u00e9ment, ce serait vous qui seriez entra\u00een\u00e9s par les hommes ordinaires.\n\nEt pourquoi sont-ils plus forts que vous ? Parce que toutes ces sottises, c'est avec conviction qu'ils les disent ; tandis que vous, toutes ces belles choses, c'est des l\u00e8vres seulement que vous les dites. Aussi sont-elles dans votre bouche sans force et sans vie ; aussi prend-on en d\u00e9go\u00fbt les exhortations qu'on vous entend faire, et la mis\u00e9rable vertu que vous vantez \u00e0 tort et \u00e0 travers. C'est l\u00e0 ce qui fait que les hommes ordinaires vous battent. Car partout la conviction est forte, partout la conviction est invincible. Jusqu'au moment donc o\u00f9 tous ces beaux principes seront profond\u00e9ment grav\u00e9s en vous, et o\u00f9 vous serez devenus assez forts pour n'avoir rien \u00e0 craindre, je vous conseille d'y regarder \u00e0 deux fois avant de descendre au milieu des hommes ordinaires ; autrement, tout ce que dans l'\u00e9cole vous aurez \u00e9crit en vous, s'y fondra jour \u00e0 jour comme la cire au soleil. Tenez-vous donc bien loin du soleil, tant que vos principes seront de cire. C'est pour cela encore que les philosophes nous conseillent de quitter notre patrie, parce que les vieilles habitudes nous entra\u00eenent, et ne nous permettent pas de prendre d'autres plis ; parce que aussi nous ne savons pas r\u00e9sister \u00e0 ceux qui disent, en nous rencontrant : \u00ab Regarde donc ! Un tel est philosophe, lui qui \u00e9tait ceci et cela. \u00bb C'est ainsi encore que les m\u00e9decins envoient dans un autre pays, et sous un autre ciel, ceux qui sont malades depuis longtemps ; et ils ont raison ! Vous aussi, inoculez-vous d'autres m\u0153urs, gravez profond\u00e9ment en vous les principes, exercez-vous \u00e0 les appliquer. Ce n'est pas l\u00e0 ce que vous faites : vous allez d'ici au spectacle, aux combats de gladiateurs, aux galeries des athl\u00e8tes, au cirque ; puis de l\u00e0 ici, et d'ici l\u00e0, toujours de m\u00eame. Point de noble habitude en vous, point d'application, point de s\u00e9v\u00e9rit\u00e9 pour vous-m\u00eames, point d'attention \u00e0 vous dire : \u00ab Quel usage fais-je des objets qui se pr\u00e9sentent \u00e0 mes sens ? Est-il conforme \u00e0 la nature ou lui est-il contraire ? Comment suis-je vis-\u00e0-vis d'eux ? Comme je dois \u00eatre ou comme je ne dois pas \u00eatre ? Dis-je bien aux choses qui ne rel\u00e8vent pas de mon libre arbitre, que je n'ai rien \u00e0 faire d'elles ? \u00bb \u2014 Tant que ce n'est pas encore l\u00e0 ce que vous \u00eates, fuyez vos anciennes habitudes, fuyez les hommes ordinaires, si vous voulez jamais commencer \u00e0 \u00eatre quelque chose.\n\nXXIII. CONTRE CEUX QUI LISENT OU DISCUTENT PAR D\u00c9SIR DE SE MONTRER\n\nCommence par te demander ce que tu veux \u00eatre ; puis, apr\u00e8s cela, fais ce que veut ton m\u00e9tier. Car, dans les autres parties, c'est presque toujours ainsi que nous voyons les choses se passer. Ceux qui se destinent \u00e0 l'ar\u00e8ne commencent par d\u00e9cider ce qu'ils veulent \u00eatre, puis, apr\u00e8s cela, ils agissent en cons\u00e9quence. Si tu veux fournir la grande course, voici ta nourriture, voici tes promenades, voici tes frictions, voici tes exercices ; si tu ne veux courir que le stade, tout cela changera ; si tu veux \u00eatre pentathle, tout changera encore. Tu trouveras la m\u00eame chose dans les arts. Si tu veux \u00eatre charpentier, voici ce que tu auras \u00e0 faire ; si tu veux \u00eatre fondeur, voil\u00e0. Car, si nous ne rapportons pas chacune de nos actions \u00e0 un but, nous agissons au hasard ; et, si nous la rapportons \u00e0 un autre but que celui qu'il faudrait, nous nous \u00e9garons.\n\nReste \u00e0 d\u00e9terminer le but g\u00e9n\u00e9ral et les buts particuliers. Le premier, c'est d'agir comme un homme. Qu'est-ce que cela implique ? De ne pas agir comme un mouton, tout en \u00e9tant bon, ni comme un m\u00e9chant, \u00e0 la fa\u00e7on des b\u00eates fauves. Quant aux buts particuliers, ils varient avec la profession de chacun, et avec la vie qu'il a choisie.\n\nQue le musicien agisse comme un musicien ; le charpentier, comme un charpentier ; le philosophe, comme un philosophe ; l'orateur, comme un orateur. Lors donc que tu nous dis : \u00ab Venez ici, et entendez-moi vous faire une lecture \u00bb, prends garde d'abord d'agir ainsi sans but ; puis, si tu trouves un but \u00e0 ton acte, prends garde qu'il ne soit pas celui qu'il faut. Cherches-tu \u00e0 \u00eatre utile ? Ou ne cherches-tu que des \u00e9loges ?\n\nD\u00e8s que l'on parle ainsi, on entend le personnage nous dire : \u00ab Que m'importent les \u00e9loges de la multitude ! \u00bb Et il a raison. Car ces \u00e9loges ne sont rien non plus pour le musicien, en tant que musicien ; pour le g\u00e9om\u00e8tre, en tant que g\u00e9om\u00e8tre. Tu veux donc \u00eatre utile ! Mais \u00e0 quoi ? Dis-le-nous, pour que nous aussi nous courions t'entendre. Et maintenant ; quelqu'un peut-il faire profiter les autres, s'il n'a pas commenc\u00e9 par profiter lui-m\u00eame ? Non. Celui qui n'est pas charpentier ne peut nous aider \u00e0 devenir charpentier, ni celui qui n'est pas cordonnier, \u00e0 devenir cordonnier.\n\nVeux-tu donc savoir si tu as profit\u00e9 ? Philosophe, apporte-nous ici tes principes. Que se propose-t-on, quand on d\u00e9sire une chose ? \u2014 De ne pas la manquer. \u2014 Et quand on cherche \u00e0 l'\u00e9viter ? \u2014 De ne pas y tomber. \u2014 Eh bien ! nous, r\u00e9alisons-nous ce que nous nous proposons dans ces deux cas ? Dis-moi la v\u00e9rit\u00e9. Si tu me trompes, je te dirai : \u00ab Tel jour, parce qu'on avait \u00e9t\u00e9 moins empress\u00e9 \u00e0 venir t'entendre, moins empress\u00e9 \u00e0 t'acclamer, tu t'es retir\u00e9 tout honteux. Tel autre, parce que tu avais \u00e9t\u00e9 applaudi, tu te promenais par l'assembl\u00e9e, en disant \u00e0 chacun : \"Comment m'as-tu trouv\u00e9 ? \u2014 Admirable, ma\u00eetre, par mon salut ! \u2014 Et comme j'ai dit ce passage ! \u2014 Lequel ? \u2014 Celui o\u00f9 j'ai fait le portrait de Pan et des Nymphes. \u2014 Merveilleusement.\" \u00bb Et tu viendras me dire que tu ne d\u00e9sires et ne redoutes rien que conform\u00e9ment \u00e0 la nature ! Va-t'en le faire accroire \u00e0 un autre. L'autre jour n'as-tu pas lou\u00e9 tel individu contrairement \u00e0 ce que tu en pensais ? N'as-tu pas adul\u00e9 le fils de tel s\u00e9nateur ? Voudrais-tu donc que tes enfants lui ressemblassent ? \u2014 \u00c0 Dieu ne plaise ! \u2014 Pourquoi donc tant de flatteries et tant d'attentions pour lui ? \u2014 C'est un jeune homme merveilleusement dou\u00e9, et un auditeur tr\u00e8s intelligent. \u2014 Comment le sais-tu ? \u2014 Il m'admire. \u2014 Tu nous as dit ta vraie raison. Mais que te figures-tu donc ? Crois-tu que ces gens-l\u00e0 ne te m\u00e9prisent pas en secret ? Quand un homme qui a la conscience de n'avoir jamais rien dit ni rien pens\u00e9 de bon, trouve un philosophe qui lui dit : \u00ab Quelle nature d'\u00e9lite ! Quelle honn\u00eatet\u00e9 ! Quelle puret\u00e9 ! \u00bb que crois-tu qu'il se dise, si ce n'est : \u00ab Voici un homme qui a besoin de moi ? \u00bb Si je me trompe, dis-moi ce qu'il a fait qui soit l'\u0153uvre d'une nature d'\u00e9lite. Voici ce qu'il a fait : il a \u00e9t\u00e9 assidu pr\u00e8s de toi pendant un certain temps. Il t'a \u00e9cout\u00e9 parler ; il t'a \u00e9cout\u00e9 lire. Mais en est-il plus modeste ? A-t-il fait un retour sur lui-m\u00eame ? A-t-il le sentiment de sa mis\u00e8re ? S'est-il d\u00e9pouill\u00e9 de sa pr\u00e9somption ? Cherche-t-il un ma\u00eetre ? \u2014 Il en cherche un, dis-tu. \u2014 Pour lui enseigner comment il faut vivre ? Non pas, sot que tu es ; mais pour lui enseigner comment il faut parler ; car c'est pour ta fa\u00e7on de parler qu'il t'admire. \u00c9coute ce qu'il dit : \u00ab Voici un homme qui \u00e9crit avec la derni\u00e8re habilet\u00e9, beaucoup mieux que Dion. \u00bb C'est l\u00e0 tout. Dit-il : \u00ab Voici un homme plein de retenue et de probit\u00e9, un homme que rien ne trouble \u00bb ? S'il parlait ainsi, je lui dirais : \u00ab Puisque cet homme est si probe, qu'est-ce donc en lui que la probit\u00e9 ? \u00bb Et, s'il ne pouvait me le dire, j'ajouterais : \u00ab Commence par apprendre ce que tu dis ; et ne parle qu'apr\u00e8s. \u00bb Et c'est dans cette triste situation d'esprit, c'est quand tu t'extasies devant ceux qui t'applaudissent, c'est quand tu comptes tes auditeurs, que tu pr\u00e9tends \u00eatre utile aux autres ! \u2014 Aujourd'hui, dis-tu, j'ai eu beaucoup plus d'auditeurs ! \u2014 Oui, beaucoup. Cinq cents, ce me semble. \u2014 Vous ne savez ce que vous dites ! Mettez-en mille. \u2014 Jamais Dion n'en a eu autant. \u2014 Et comment les aurait-il ? Puis, comme ils \u00e9coutent ma parole ! C'est que le beau, monsieur, agit jusque sur les pierres elles-m\u00eames ! \u2014 Et c'est l\u00e0 le langage d'un philosophe ! Ce sont l\u00e0 les sentiments du futur bienfaiteur de l'humanit\u00e9 ! C'est l\u00e0 l'homme qui a \u00e9cout\u00e9 la raison, qui a lu les livres socratiques comme on lit des livres socratiques, et non pas comme on lit des livres de Lysias ou d'Isocrate ! Au lieu de lire : \u00ab Je me suis souvent demand\u00e9 avec surprise par quels raisonnements... \u00bb C'est ceci qu'il faut lire : \u00ab Par quelle raison... ? \u00bb Car cet ouvrage-ci vaut mieux que l'autre. Et ces livres socratiques, les avez-vous lus d'une autre fa\u00e7on qu'on ne lit des chansonnettes ? Si vous les lisiez comme il faut, vous ne vous attacheriez pas \u00e0 toutes ces frivolit\u00e9s ; mais vous fixeriez plut\u00f4t votre attention sur ceci : \u00ab Anytus et Melytus peuvent me tuer ; ils ne peuvent me nuire \u00bb ; et sur ceci encore : \u00ab Je suis de nature \u00e0 ne m'attacher qu'\u00e0 une seule chose en moi, \u00e0 la raison qui, bien consid\u00e9r\u00e9e, me para\u00eet la meilleure. \u00bb Aussi, quelqu'un a-t-il jamais entendu dire \u00e0 Socrate : \u00ab Je sais et j'enseigne ? \u00bb Loin de l\u00e0 : il avait pour chacun un ma\u00eetre \u00e0 qui l'adresser. Les gens venaient donc le prier de les pr\u00e9senter \u00e0 des philosophes ; et il les y menait et les recommandait. Est-ce que cela n'est pas vrai ? Est-ce qu'il leur disait, en les reconduisant : \u00ab Viens m'entendre parler aujourd'hui dans la maison de Codratus \u00bb ? Eh ! pourquoi irais-je t'entendre ? Veux-tu me montrer que tu sais disposer les mots \u00e9l\u00e9gamment ? Tu sais les disposer, \u00f4 homme ! Mais quel bien cela te fait-il ? \u2014 Applaudis-moi. \u2014 Qu'entends-tu par t'applaudir ? \u2014 Dis-moi : \u00ab Ah ! \u00bb et \u00ab C'est merveilleux ! \u00bb \u2014 Eh bien ! je le dis. Mais, si les applaudissements doivent porter sur quelque chose que les philosophes placent dans la cat\u00e9gorie du bien, qu'est-ce que j'ai \u00e0 applaudir en toi ? Si c'est une bonne chose que de bien parler, prouve-le-moi, et je t'applaudirai. \u2014 Quoi donc ! serait-ce qu'il doit m'\u00eatre d\u00e9sagr\u00e9able d'entendre bien parler ? \u2014 \u00c0 Dieu ne plaise ! Il ne m'est pas d\u00e9sagr\u00e9able non plus d'entendre jouer de la lyre ; mais est-ce une raison pour que je doive me tenir l\u00e0 debout \u00e0 jouer de la lyre ? \u00c9coute ce que dit Socrate : \u00ab Hommes, il ne convient pas \u00e0 mon \u00e2ge de me pr\u00e9senter devant vous en arrangeant mes discours, comme le fait un jeune homme. \u00bb Il dit comme le fait un jeune homme. C'est qu'en r\u00e9alit\u00e9, c'est une jolie chose que de savoir choisir et disposer ses mots, que de savoir apr\u00e8s cela les lire ou les d\u00e9biter avec gr\u00e2ce, que de s'interrompre enfin au milieu de sa lecture pour s'\u00e9crier : \u00ab Par votre salut ! ce sont l\u00e0 des choses que peu de gens peuvent comprendre. \u00bb\n\nEst-ce que le philosophe prie les gens de venir l'entendre ? Est-ce que par le seul fait de son existence il n'attire pas \u00e0 lui, comme le soleil, comme la nourriture, ceux \u00e0 qui il doit \u00eatre utile ? Quel est le m\u00e9decin qui prie les gens de se faire soigner par lui ? J'entends dire, il est vrai, qu'aujourd'hui \u00e0 Rome les m\u00e9decins prient les malades de venir \u00e0 eux ; mais, de mon temps, c'\u00e9tait eux qu'on priait. Je t'en prie, viens apprendre que tu n'es pas en bon \u00e9tat, que tu t'occupes de tout autre chose que ce dont tu dois t'occuper, que tu te trompes sur les biens et sur les maux, que tu es malheureux, que tu es infortun\u00e9. La charmante pri\u00e8re ! Et cependant, si la parole du philosophe n'a pas r\u00e9ellement ces effets, elle n'est qu'une parole morte, et c'est un mort qui parle. Rufus avait l'habitude de dire : \u00ab S'il vous reste assez de libert\u00e9 d'esprit pour m'applaudir, c'est que je ne dis rien qui vaille. \u00bb Il parlait de telle fa\u00e7on que nous, qui \u00e9tions assis l\u00e0, nous croyions chacun lui avoir \u00e9t\u00e9 d\u00e9nonc\u00e9s ; tant il mettait le doigt sur ce qui \u00e9tait, tant il nous pla\u00e7ait \u00e0 chacun nos mis\u00e8res sous les yeux.\n\nHommes, c'est la maison d'un m\u00e9decin que l'\u00e9cole d'un philosophe. Avant d'en sortir, il vous faut, non pas jouir, mais souffrir ; car vous n'y entrez pas bien portants, mais l'un avec une \u00e9paule d\u00e9mise, l'autre avec un abc\u00e8s, celui-ci avec une fistule, celui-l\u00e0 avec des maux de t\u00eate. Et moi, vais-je m'asseoir l\u00e0 \u00e0 vous d\u00e9biter de belles sentences et de belles paroles, pour que vous partiez m'ayant applaudi, mais en remportant, l'un son \u00e9paule telle qu'il l'avait apport\u00e9e, l'autre sa t\u00eate dans le m\u00eame \u00e9tat, celui-ci sa fistule, celui-l\u00e0 son abc\u00e8s ? Et ce serait pour cela que les jeunes gens se d\u00e9rangeraient ! Ils quitteraient leurs parents, leurs amis, leur famille, leur h\u00e9ritage, pour venir te dire bravo ! pendant que tu leur d\u00e9bites de belles paroles ! Est-ce l\u00e0 ce que faisait Socrate, ce que faisait Z\u00e9non, ce que faisait Cl\u00e9anthe ?\n\n\u2014 Mais quoi ! l'exhortation n'est-elle pas un genre oratoire sp\u00e9cial ? \u2014 Qui dit le contraire ? C'est ainsi qu'il y a le genre de la r\u00e9futation, et celui de l'enseignement. Mais qui donc a jamais parl\u00e9 d'un quatri\u00e8me genre apr\u00e8s ceux-l\u00e0, le genre de l'ostentation ? En quoi consiste le genre de l'exhortation ? \u00c0 pouvoir montrer \u00e0 un individu ou \u00e0 plusieurs dans quelle m\u00eal\u00e9e ils se trouvent emport\u00e9s, et comment ils sont sans cesse en qu\u00eate de tout autre chose que ce qu'ils veulent. Car ce qu'ils veulent, c'est ce qui conduit au bonheur, et ils le cherchent o\u00f9 il n'est pas. Et pour faire cette d\u00e9monstration, il te faudrait commencer par disposer un millier de si\u00e8ges, et inviter les gens \u00e0 venir t'entendre, puis, \u00e9l\u00e9gamment drap\u00e9 dans ta robe ou dans ton manteau, te jucher sur des coussins, et raconter de l\u00e0 la mort d'Achille ! Cessez, par tous les dieux ! de d\u00e9shonorer, autant qu'il est en vous, de grands noms et de grandes choses. On dirait que les exhortations ne sont jamais plus efficaces que lorsque l'orateur laisse voir \u00e0 ses auditeurs qu'il a besoin d'eux !\n\nEt qui, dis-moi, en t'entendant lire ou parler, a con\u00e7u des inqui\u00e9tudes sur lui-m\u00eame ou est descendu au fond de son c\u0153ur ? Qui a dit, en sortant : \u00ab Le philosophe a bien mis le doigt sur mes plaies ; je ne dois plus me conduire ainsi \u00bb ? Personne ; mais, quand tu as eu du succ\u00e8s, l'un dit : \u00ab Il a bien parl\u00e9 de Xerx\u00e8s ! \u00bb l'autre : \u00ab Non, mais du combat des Thermopyles. \u00bb Est-ce donc l\u00e0 l'auditoire d'un philosophe ?\n\nXXVI. \u00c0 CEUX QUI CRAIGNENT LA PAUVRET\u00c9\n\nN'as-tu pas honte d'avoir moins de courage et moins de c\u0153ur que les esclaves fugitifs ? En quel \u00e9tat fuient-ils, quand ils abandonnent leurs ma\u00eetres ? Quels domaines, quels serviteurs ont-ils pour se rassurer ? Ils d\u00e9robent le peu qu'il leur faut pour les premiers jours, puis ils se lancent \u00e0 travers les terres, et m\u00eame \u00e0 travers les mers, se procurant habilement les moyens de subsister : aujourd'hui celui-ci, demain celui-l\u00e0. Et qui d'entre eux est jamais mort de faim ? Mais toi, tu trembles de manquer du n\u00e9cessaire ; et te voil\u00e0 passant tes nuits \u00e0 veiller ! Malheureux, es-tu donc si aveugle ? Ne vois-tu pas le chemin ? Et ne sais-tu pas o\u00f9 nous conduit le manque du n\u00e9cessaire ? O\u00f9 nous conduit-il donc ? O\u00f9 nous conduit la fi\u00e8vre, o\u00f9 nous conduit une pierre qui nous tombe sur la t\u00eate : \u00e0 la mort. N'est-ce pas ce que tu as dit cent fois toi-m\u00eame \u00e0 tes amis ? Ne l'as-tu pas lu cent fois ? Ne l'as-tu pas \u00e9crit cent fois aussi ? \u00c0 combien de reprises ne t'es-tu pas vant\u00e9 d'attendre la mort avec calme ?\n\n\u2014 Mais les miens mourront de faim ! \u2014 Eh bien ! Est-ce que la faim les conduit ailleurs que toi ? Est-ce que la descente n'est pas la m\u00eame pour eux ? Est-ce qu'en bas ils ne trouveront pas les m\u00eames choses ? Ne peux-tu donc pas, sans t'effrayer du d\u00e9nuement et de la disette, fixer un \u0153il calme sur le lieu o\u00f9 doivent descendre les plus riches, les magistrats les plus \u00e9lev\u00e9s, les rois et les tyrans eux-m\u00eames ? Peut-\u00eatre y descendras-tu d'inanition ; ils y descendront, eux, crevant d'indigestion et d'ivresse. Mais ne sera-ce pas toute la diff\u00e9rence ? Que de mendiants n'as-tu pas vus arriver \u00e0 la vieillesse ! Combien m\u00eame \u00e0 l'extr\u00eame vieillesse ! Ces gens transis de froid et le jour et la nuit, ces gens qui gisent sur le sol, et qui ne mangent que bien juste leur n\u00e9cessaire, ces gens-l\u00e0 arrivent presque \u00e0 ne pouvoir mourir. Ne peux-tu donc pas faire un m\u00e9tier ? Ne peux-tu pas \u00eatre copiste ? \u00catre pr\u00e9cepteur ? Garder la porte d'autrui ? \u2014 Mais c'est une honte, d'en venir \u00e0 cette extr\u00e9mit\u00e9 ! \u2014 Eh bien ! commence par apprendre o\u00f9 est la honte, et alors seulement dis-toi philosophe. Pour le moment, ne permets m\u00eame pas \u00e0 un autre de t'appeler de ce nom.\n\nEst-ce que c'est une honte pour toi que ce qui n'est pas ton \u0153uvre, que ce dont tu n'es pas l'auteur, que ce qui t'arrive par hasard, comme le mal de t\u00eate, comme la fi\u00e8vre ? Si tes parents \u00e9taient pauvres, ou si, riches, ils ont laiss\u00e9 leur h\u00e9ritage \u00e0 d'autres, ou si encore, de leur vivant, ils ne te donnent rien, est-ce une honte pour toi ? Est-ce l\u00e0 ce que tu as appris chez les philosophes ? Ne leur as-tu pas entendu dire que ce qui est bl\u00e2mable est seul honteux, et que ce qui est bl\u00e2mable c'est ce qui est digne de bl\u00e2me ? Et qui peux-tu bl\u00e2mer de ce qui n'est pas son \u0153uvre, de ce qu'il n'a pas fait lui-m\u00eame ? Est-ce donc toi qui as fait ton p\u00e8re tel qu'il est ? Ou bien t'est-il possible de le corriger ? Est-ce l\u00e0 une chose qui soit en ta puissance ? Eh bien ! dois-tu vouloir ce qui n'est pas en ta puissance ? ou rougir quand tu n'y r\u00e9ussis pas ? Est-ce la philosophie qui t'a fait prendre cette habitude d'avoir les yeux sur les autres, et de ne rien attendre de toi-m\u00eame ? G\u00e9mis donc, lamente-toi, et ne mange qu'en tremblant de n'avoir pas de quoi vivre demain. Tremble que tes esclaves ne te volent, ne s'enfuient ou ne meurent. Que ce soit l\u00e0 ta vie, et qu'elle ne cesse jamais, puisque c'est de nom seulement que tu t'es approch\u00e9 de la philosophie, puisque tu d\u00e9shonores son enseignement autant qu'il t'est possible de le faire, toi qui montres qu'il est sans utilit\u00e9 et sans profit pour ceux qui l'ont re\u00e7u. Jamais tu n'as souhait\u00e9 le calme, la tranquillit\u00e9, l'impassibilit\u00e9 ; jamais tu ne t'es attach\u00e9 \u00e0 personne pour y arriver ; mais que de gens auxquels tu t'es attach\u00e9 par amour pour les syllogismes ! Jamais pour aucune des choses qui apparaissaient \u00e0 tes sens tu ne t'es demand\u00e9 \u00e0 toi-m\u00eame : \u00ab Pourrai-je, ou ne pourrai-je pas supporter cela ? Que me reste-t-il \u00e0 faire ? \u00bb Mais, comme si tout ce qui est \u00e0 toi \u00e9tait en bon \u00e9tat et \u00e0 l'abri de tout p\u00e9ril, tu t'occupais de ce qui ne doit venir qu'apr\u00e8s tout le reste, de l'immutabilit\u00e9 ! Et qu'avais-tu donc \u00e0 rendre immuable ? Ta l\u00e2chet\u00e9, ta couardise, ton admiration pour les riches, tes d\u00e9sirs avort\u00e9s, tes efforts inutiles pour \u00e9viter les choses ? Voil\u00e0 ce que tu voulais mettre \u00e0 l'abri de tout p\u00e9ril !\n\nNe devais-tu pas commencer par acqu\u00e9rir ce que la raison te conseillait, puis songer alors seulement \u00e0 mettre tes acquisitions en s\u00fbret\u00e9 ? Qui as-tu vu construire un couronnement autour de sa maison, sans placer ce couronnement sur un mur ? Quel est le portier que l'on \u00e9tablit o\u00f9 il n'y a pas de porte ? Ta pr\u00e9occupation \u00e0 toi, c'est d'\u00eatre capable de d\u00e9montrer ; mais de d\u00e9montrer quoi ? Ta pr\u00e9occupation, c'est de ne pas te laisser entra\u00eener par les sophismes ; mais entra\u00eener loin de quoi ? Montre-moi d'abord ce qui est l'objet de tes soins, ce que tu mesures, ou ce que tu p\u00e8ses ; puis ensuite montre-moi ta balance ou ta mesure. Jusques \u00e0 quand ne mesureras-tu que de la cendre ? Ce que tu dois d\u00e9montrer, n'est-ce pas ce qui rend l'homme heureux, ce qui fait que les choses lui arrivent comme il les d\u00e9sire, ce qui est cause qu'il doit ne bl\u00e2mer personne, n'accuser personne, mais se conformer \u00e0 la mani\u00e8re dont le monde est gouvern\u00e9 ? Voil\u00e0 ce qu'il te faut me montrer. \u2014 Voici, dis-tu, ma d\u00e9monstration : je vais t'analyser des syllogismes. \u2014 Esclave, c'est l\u00e0 ta mesure ; mais ce n'est pas ce que tu mesures ! Voil\u00e0 comment tu es puni aujourd'hui d'avoir n\u00e9glig\u00e9 la philosophie : tu trembles, tu ne dors pas, tu consultes tout le monde ; et si les r\u00e9solutions que tu prends ne conviennent pas \u00e0 tout le monde, tu crois avoir eu tort de les prendre. Tu crois aujourd'hui redouter la faim ; mais non : ce n'est pas la faim que tu redoutes. Ce que tu crains, c'est de n'avoir plus de cuisinier, de n'avoir plus personne pour tes sauces, personne pour t'attacher tes chaussures, personne pour te passer tes habits, personne pour te frictionner, personne pour te faire cort\u00e8ge. Tu veux pouvoir aux bains te d\u00e9pouiller, t'\u00e9tendre \u00e0 la fa\u00e7on de ceux qu'on met en croix, puis te faire frotter et de ci et de l\u00e0 ; tu veux que le ma\u00eetre baigneur, qui pr\u00e9side \u00e0 l'op\u00e9ration, dise ensuite : \u00ab Passe ici ; montre-nous le flanc ; prends-lui la t\u00eate ; pr\u00e9sente ton \u00e9paule \u00bb ; puis, rentr\u00e9 chez toi apr\u00e8s le bain, tu veux crier : \u00ab Ne m'apporte-t-on pas \u00e0 manger ? \u00bb Et apr\u00e8s cela : \u00ab Enl\u00e8ve la table ; passe l'\u00e9ponge. \u00bb Ce que tu crains, c'est de ne pouvoir plus mener la vie d'un malade. Quant \u00e0 la vie de ceux qui se portent bien, apprends \u00e0 la conna\u00eetre : c'est celle que m\u00e8nent les esclaves, les ouvriers, les vrais philosophes ; c'est celle qu'a men\u00e9e Socrate, quoique avec femme et enfants ; c'est celle de Diog\u00e8ne, celle de Cl\u00e9anthe, qui tenait une \u00e9cole et \u00e9tait porteur d'eau. Si tu veux mener cette vie, tu la pourras mener partout, et tu vivras dans une pleine assurance. Fond\u00e9e sur quoi ? Sur la seule chose \u00e0 laquelle on puisse se fier, sur la seule qui soit s\u00fbre, qui soit sans entraves, que nul ne puisse t'enlever, sur ta propre volont\u00e9. Pourquoi par ta faute es-tu si inutile et si impropre \u00e0 tout, que personne ne veut te prendre chez lui, ne veut se charger de toi ? Un vase intact et propre au service aura beau \u00eatre jet\u00e9 dehors, quiconque le trouvera l'emportera, et croira que c'est tout profit ; toi, au contraire, chacun croira que c'est tout perte. Ainsi tu ne peux m\u00eame pas rendre les services d'un chien et d'un coq, et tu veux encore vivre, tel que tu es !\n\nLe Sage craindra-t-il que les aliments viennent \u00e0 lui manquer ? Ils ne manquent pas \u00e0 l'aveugle ; ils ne manquent pas au boiteux ; et ils manqueraient au Sage ! Un bon soldat trouve toujours qui le paye ; un bon ouvrier, un bon cordonnier aussi ; et celui qui est l'homme parfait ne le trouverait pas ! Dieu sera-t-il si insoucieux de ses propres affaires, de ses ministres, de ses t\u00e9moins, de ceux qui lui servent \u00e0 prouver par des faits aux hommes ordinaires, qu'il existe, qu'il gouverne sagement ce monde, qu'il ne n\u00e9glige pas l'humanit\u00e9, et qu'il n'y a jamais de mal pour le Sage, ni de son vivant, ni apr\u00e8s sa mort ? \u2014 Mais lorsqu'il ne me fournit pas de quoi manger ? \u2014 Que fait-il autre chose que de me donner le signal de la retraite, comme un bon g\u00e9n\u00e9ral ? Je lui ob\u00e9is alors ; je le suis, en chantant les louanges de mon g\u00e9n\u00e9ral, en approuvant bien haut tout ce qu'il fait. Je suis venu, en effet, quand il l'a voulu ; je m'en irai de m\u00eame, quand il le voudra ; et, de mon vivant, qu'avais-je pr\u00e9cis\u00e9ment \u00e0 faire, que de chanter les louanges de Dieu, seul avec moi-m\u00eame, en face d'un autre, ou de plusieurs ? Il me donne peu, il ne me donne pas en abondance, il ne veut pas que je vive dans la mollesse ; mais il n'a pas donn\u00e9 davantage \u00e0 Hercule, son propre fils. C'\u00e9tait un autre qui r\u00e9gnait sur Argos et sur Myc\u00e8nes ; la part d'Hercule \u00e9tait l'ob\u00e9issance, les travaux, les \u00e9preuves. Mais Eurysth\u00e9e \u00e9tait ce qu'il \u00e9tait, et ne r\u00e9gnait pas plus r\u00e9ellement sur Argos et sur Myc\u00e8nes qu'il ne r\u00e9gnait sur lui-m\u00eame ; tandis qu'Hercule, par toute la terre et par toute la mer, \u00e9tait v\u00e9ritablement roi, v\u00e9ritablement chef, r\u00e9parant les iniquit\u00e9s et les injustices, amenant avec lui la justice et la pi\u00e9t\u00e9 ; et tout cela il le faisait nu et seul. Quand Ulysse fut jet\u00e9 \u00e0 la c\u00f4te par un naufrage, se laissa-t-il abattre par son d\u00e9nuement ? Perdit-il courage ? Non : voyez comme il va demander \u00e0 des vierges ces v\u00eatements indispensables, que nous trouvons si honteux de demander \u00e0 un autre.\n\nIl allait comme un lion nourri dans les montagnes et qui se confie en sa force.\n\nQu'est-ce qui faisait donc sa confiance ? Ce n'\u00e9tait ni la r\u00e9putation, ni la richesse, ni le pouvoir ; c'\u00e9tait sa force int\u00e9rieure, c'est-\u00e0-dire, ses convictions sur ce qui d\u00e9pend de nous et sur ce qui n'en d\u00e9pend pas. Ce sont elles seules, en effet, qui nous font libres et ind\u00e9pendants, qui font relever la t\u00eate \u00e0 celui qu'on humilie, qui nous font regarder en face et d'un \u0153il fixe les riches et les puissants. Voil\u00e0 la part du philosophe. Mais toi, tu sortiras comme un l\u00e2che, tremblant de peur pour tes manteaux et pour ta vaisselle d'argent ! Malheureux, est-ce ainsi que tu as perdu ton temps jusqu'\u00e0 pr\u00e9sent ?\n\n\u2014 Mais si je suis malade ? \u2014 Tu seras ce que tu dois \u00eatre dans la maladie. \u2014 Mais qui me soignera ? \u2014 Dieu, et tes amis. \u2014 Je serai durement couch\u00e9. \u2014 Comme doit l'\u00eatre un homme. \u2014 Je n'aurai pas de maison commode. \u2014 Eh bien ! tu seras malade dans une maison incommode. \u2014 Qui me donnera les moyens de vivre ? \u2014 Ceux qui les donnent aux autres. Tu seras comme Man\u00e8s dans ta maladie. \u2014 Mais quelle sera la fin de cette maladie ? \u2014 La mort, et quoi de plus ? Ne sais-tu donc pas que la source de toutes les mis\u00e8res pour l'homme, la source de toutes ses faiblesses et de toutes ses l\u00e2chet\u00e9s, ce n'est pas la mort, mais bien plut\u00f4t la crainte de la mort ? Exerce-toi donc contre cette crainte ; crois-moi, que ce soit l\u00e0 que tendent tous tes raisonnements, tout ce que tu \u00e9coutes, tout ce que tu lis, et tu reconna\u00eetras que c'est par l\u00e0 seulement que les hommes s'affranchissent.\n\nLivre quatri\u00e8me\n\nII. SUR NOS LIAISONS\n\nVoici un point auquel il te faut faire attention avant tout : ne te lie avec aucun de tes habitu\u00e9s ou de tes amis d'autrefois, jusqu'\u00e0 descendre o\u00f9 il en est descendu ; sinon, tu te perdras. Si l'id\u00e9e te vient qu'il te trouvera d\u00e9plaisant, et qu'il ne sera plus pour toi ce qu'il \u00e9tait auparavant, rappelle-toi que l'on n'a rien pour rien, et qu'on ne peut pas, en n'agissant plus de m\u00eame, rester l'homme qu'on \u00e9tait jadis. D\u00e9cide donc lequel tu pr\u00e9f\u00e8res : ou de garder intacte l'affection de ceux qui t'aimaient auparavant, en demeurant ce qu'auparavant tu \u00e9tais ; ou de ne plus obtenir d'eux la m\u00eame affection, en devenant meilleur. Si c'est ce dernier parti qui vaut le mieux, il faut le prendre, et sur-le-champ, sans t'en laisser d\u00e9tourner par d'autres consid\u00e9rations. Il n'est pas possible d'avancer, quand on va tant\u00f4t d'un c\u00f4t\u00e9, tant\u00f4t d'un autre. Si tu as jug\u00e9 que ce parti valait mieux que tous les autres, si tu veux t'attacher \u00e0 lui seul, et ne travailler que pour lui, laisse-moi l\u00e0 tout le reste. Sinon, ces tergiversations auront pour toi ce double r\u00e9sultat, que tu ne feras pas les progr\u00e8s que tu devrais faire, et qu'on ne t'accordera plus ce qu'on t'accordait auparavant. Auparavant, quand tu d\u00e9sirais franchement des objets sans valeur r\u00e9elle, tu \u00e9tais agr\u00e9able \u00e0 tes amis ; mais tu ne peux pas r\u00e9ussir aux deux choses \u00e0 la fois : il faut n\u00e9cessairement que ce que tu gagneras d'un c\u00f4t\u00e9, tu le perdes de l'autre. Tu ne peux pas, si tu cesses de boire avec qui tu buvais, para\u00eetre \u00e0 ces gens aussi agr\u00e9able qu'alors. D\u00e9cide donc ce que tu pr\u00e9f\u00e8res : ou de t'enivrer et de leur \u00eatre agr\u00e9able, ou de leur d\u00e9plaire en \u00e9tant sobre. Tu ne peux pas, si tu cesses de chanter avec qui tu chantais, rester aussi cher \u00e0 ces gens. Choisis donc encore ici le lot que tu voudras. S'il vaut mieux \u00eatre temp\u00e9rant et r\u00e9gl\u00e9, que de faire dire de soi : \u00ab Quel homme agr\u00e9able ! \u00bb, laisse-moi l\u00e0 tout le reste ; renonces-y ; d\u00e9tourne-t'en ; n'y touche plus. Si ce parti-l\u00e0 ne te pla\u00eet pas, donne-toi tout entier au parti contraire : sois un de nos hommes-femmes ; sois un de nos coureurs d'aventures ; fais tout ce qui s'ensuit, et tu arriveras \u00e0 ce que tu veux. N'oublie pas aussi de tr\u00e9pigner des pieds en acclamant le baladin. Mais on ne peut pas r\u00e9unir en soi ces deux personnages si diff\u00e9rents : on ne peut pas jouer \u00e0 la fois le r\u00f4le de Thersite et celui d'Agamemnon. Si tu veux \u00eatre Thersite, il te faut \u00eatre bossu et chauve ; si tu veux \u00eatre Agamemnon, il te faut \u00eatre beau, et de haute taille, et aimer ceux qui te sont subordonn\u00e9s.\n\nV. CONTRE LES GENS QUERELLEURS ET M\u00c9CHANTS\n\nLe Sage ne se querelle jamais avec personne, et, autant qu'il le peut, emp\u00eache les autres de se quereller. Sur ce point, comme sur tous les autres, la vie de Socrate est l\u00e0 pour nous servir d'exemple. Non seulement il a partout \u00e9vit\u00e9 de se quereller, mais il a emp\u00each\u00e9 les autres de le faire. Vois chez X\u00e9nophon, dans le Banquet, que de querelles il a apais\u00e9es ; vois d'autre part sa patience avec Thrasymaque, avec Polus, avec Callicrate ; vois cette m\u00eame patience avec sa femme, avec son fils, quand celui-ci essayait de le r\u00e9futer par ses sophismes. C'est qu'il savait de science trop certaine que nul n'est le ma\u00eetre de l'\u00e2me d'autrui ; et qu'en cons\u00e9quence il n'avait de volont\u00e9 que pour lui-m\u00eame. Et qu'est-ce que cela ? C'est ne pas avoir la pr\u00e9tention de faire agir les autres conform\u00e9ment \u00e0 la nature, car cela ne d\u00e9pend pas de nous ; mais s'attacher, tandis que les autres agissent pour leur compte comme bon leur semble, \u00e0 vivre et \u00e0 agir soi-m\u00eame conform\u00e9ment \u00e0 la nature, seulement en faisant tout ce qui d\u00e9pend de soi pour qu'eux aussi vivent conform\u00e9ment \u00e0 la nature. Car tel est le but que se propose toujours le Sage. Veut-il \u00eatre g\u00e9n\u00e9ral ? Non, mais si son lot est de l'\u00eatre, il veut dans cette position maintenir pure en lui sa partie ma\u00eetresse. Veut-il se marier ? Non, mais si son lot est de le faire, il veut dans cette position se maintenir en conformit\u00e9 avec la nature. Quant \u00e0 vouloir que son fils ou sa femme ne fissent jamais rien de mal, ce serait vouloir que ce qui ne d\u00e9pend pas de lui en d\u00e9pend\u00eet. Or, s'instruire n'est autre chose qu'apprendre \u00e0 distinguer ce qui d\u00e9pend de vous et ce qui n'en d\u00e9pend pas.\n\nQuelle occasion de dispute y a-t-il donc encore pour celui qui est dans ces sentiments ? Rien de tout ce qui arrive l'\u00e9tonne-t-il ? Rien lui para\u00eet-il extraordinaire ? Est-ce qu'il ne s'attend pas toujours, de la part des m\u00e9chants, \u00e0 des choses plus f\u00e2cheuses et plus tristes que ce qui lui arrive ? Est-ce qu'il ne regarde pas comme autant de gagn\u00e9 tout ce qui manque au malheur complet ? \u2014 Un tel t'a injuri\u00e9, dit-il, sache-lui gr\u00e9 de ne pas t'avoir frapp\u00e9. \u2014 Mais il m'a frapp\u00e9 ! \u2014 Sache-lui gr\u00e9 de ne pas t'avoir bless\u00e9. \u2014 Mais il m'a bless\u00e9 ! \u2014 Sache-lui gr\u00e9 de ne pas t'avoir tu\u00e9. En effet, quand, ou de qui, a-t-il appris qu'il est un animal sociable, fait pour aimer les autres, et que l'injustice est un grand mal pour qui la commet ! Et, puisqu'il ne l'a pas appris, et qu'il ne le croit pas, comment ne suivrait-il pas ce qui lui semble son int\u00e9r\u00eat ? \u2014 Mon voisin m'a jet\u00e9 des pierres ! \u2014 Eh bien ! as-tu pour ta part commis quelque faute ? \u2014 Tout ce qui est dans ma maison a \u00e9t\u00e9 bris\u00e9 ! \u2014 Serais-tu donc toi-m\u00eame un meuble ? Non : tu es un jugement et une volont\u00e9. Qu'est-ce qui t'a donc \u00e9t\u00e9 donn\u00e9 contre ce dont tu te plains ? En tant que tu tiens du loup, il t'a \u00e9t\u00e9 donn\u00e9 de mordre \u00e0 ton tour, et de jeter un plus grand nombre de pierres. Si tu cherches ce qui t'a \u00e9t\u00e9 donn\u00e9 en tant que tu es homme, regarde dans ta bourse, et vois quelles ressources tu avais en venant ici. Serait-ce la f\u00e9rocit\u00e9 ? Serait-ce l'esprit de vengeance ? Quand un cheval est-il malheureux ? Quand il a perdu ses facult\u00e9s naturelles ; non quand il ne peut point chanter comme le coq, mais quand il ne peut plus courir. Et le chien ? Non quand il ne peut point voler, mais quand il ne peut plus suivre la piste. Eh bien ! n'est-il pas pareillement vrai que l'homme malheureux n'est pas celui qui ne peut \u00e9trangler des lions, ou embrasser des statues (nul n'est venu au monde en tenant de la nature des moyens pour cela), mais celui qui perd sa bienveillance et sa loyaut\u00e9 ? Voil\u00e0 celui sur qui devraient g\u00e9mir ceux qui le rencontrent, \u00e0 la vue des maux dans lesquels il est tomb\u00e9. Par Jupiter ! il faut le plaindre, non pas d'\u00eatre n\u00e9 ou d'\u00eatre mort, mais d'avoir perdu de son vivant ce qui lui appartenait en propre : non point son patrimoine, son champ, sa maison, son h\u00f4tellerie, ses esclaves (rien de tout cela n'appartient \u00e0 l'individu ; ce sont toutes choses en dehors de lui, au pouvoir et \u00e0 la merci d'autrui, que donnent tant\u00f4t \u00e0 l'un, tant\u00f4t \u00e0 l'autre, ceux qui en sont les ma\u00eetres), mais ce qui est vraiment de l'homme, la marque qu'il portait dans son \u00e2me, lorsqu'il est venu au monde, marque semblable \u00e0 celle que nous cherchons sur les monnaies, pour les juger bonnes quand nous l'y trouvons, pour les rejeter quand nous ne l'y trouvons pas. \u2014 Quelle marque (disons-nous) a cette pi\u00e8ce de quatre as ? \u2014 La marque de Trajan. \u2014 Apporte. \u2014 Elle a la marque de N\u00e9ron. \u2014 Jette-la ; elle est de mauvais aloi ; elle est alt\u00e9r\u00e9e. \u00bb Il en est de m\u00eame ici : \u2014 Quelle marque portent ses fa\u00e7ons de penser et de vouloir ? \u2014 Celle d'un \u00eatre doux, sociable, patient, affectueux. \u2014 Apporte. Je le re\u00e7ois ; j'en fais mon concitoyen ; je le re\u00e7ois pour voisin, et pour compagnon de travers\u00e9e. Prends garde seulement qu'il ne porte pas la marque de N\u00e9ron. Ne serait-il pas col\u00e8re, rancunier, m\u00e9content de tout ? Ne serait-il pas sujet, quand l'id\u00e9e lui en vient, \u00e0 casser la t\u00eate de ceux qu'il rencontre ? Si cela est, pourquoi l'appelais-tu un homme ? Ce n'est pas \u00e0 la forme seule qu'on distingue chaque esp\u00e8ce d'\u00eatres. \u00c0 ce compte, en effet, il faudrait dire qu'une pomme en cire est une vraie pomme, tandis qu'il y faut encore et l'odeur et le go\u00fbt, la configuration ext\u00e9rieure n'y suffisant pas. De m\u00eame, pour faire un homme il ne suffit pas des narines et des yeux ; il y faut encore des fa\u00e7ons de penser et de vouloir qui soient d'un homme. Un tel n'\u00e9coute pas la raison ; il ne se rend pas, quand on l'a convaincu d'erreur : ce n'est qu'un \u00e2ne. Toute retenue est morte chez cet autre : il n'est bon \u00e0 rien ; il n'y a rien qu'il ne soit plut\u00f4t qu'un homme. Celui-ci cherche \u00e0 rencontrer quelqu'un afin de ruer ou de mordre : ce n'est pas m\u00eame un mouton ou un \u00e2ne ; c'est une b\u00eate sauvage.\n\n\u2014 Quoi donc ! veux-tu que je me laisse m\u00e9priser ? \u2014 Par qui ? Par ceux qui s'y connaissent ? Eh ! comment ceux qui s'y connaissent m\u00e9priseraient-ils un homme pour sa douceur et sa retenue ? Par ceux qui ne s'y connaissent pas ? Que t'importe ! En dehors de toi, quel homme expert dans un art s'inqui\u00e8te des ignorants ? \u2014 Mais ils s'en acharneront davantage apr\u00e8s moi ! \u2014 Comment dis-tu apr\u00e8s moi ? Peut-on donc alt\u00e9rer ton jugement et ta volont\u00e9, ou t'emp\u00eacher de faire de toutes les id\u00e9es qui t'arrivent un emploi conforme \u00e0 la nature ? \u2014 Non. \u2014 De quoi donc te troubles-tu ? Et pourquoi tiens-tu \u00e0 te montrer redoutable ? Pourquoi plut\u00f4t ne pas t'avancer en public et proclamer que tu vis en paix avec tous les hommes, quoi qu'ils puissent faire ? Pourquoi ne pas rire surtout de ceux qui croient te nuire ? \u00ab Ces esclaves (dirais-tu) ne savent ni qui je suis, ni en quoi consistent pour moi les biens et les maux. Ils ignorent qu'ils ne sauraient atteindre ce qui m'appartient. \u00bb\n\nC'est ainsi que les habitants d'une ville bien fortifi\u00e9e se rient de ceux qui l'assi\u00e8gent. \u00ab Qu'est-ce qu'ont ces gens, disent-ils, \u00e0 se donner tant de peine pour rien ? Nos murailles sont solides ; nous avons des vivres pour longtemps ; nous sommes bien munis de tout. \u00bb Avec ces moyens, en effet, une ville est forte et imprenable ; mais l'\u00e2me humaine ne l'est que par ses principes. Car, pour la rendre telle, quel mur serait assez solide, quel corps assez de fer, quelle fortune assez s\u00fbre, quel rang assez au-dessus de toutes les attaques ? Toutes ces choses sont partout p\u00e9rissables et promptes \u00e0 succomber. Celui qui s'y attache doit n\u00e9cessairement se troubler, esp\u00e9rer \u00e0 tort, s'effrayer, g\u00e9mir, \u00e9chouer dans ses d\u00e9sirs, tomber dans ce qu'il veut \u00e9viter. Et nous ne prenons pas le parti de fortifier la seule chose solide qui nous ait \u00e9t\u00e9 donn\u00e9e ! Et nous ne nous arrachons pas aux choses p\u00e9rissables et d\u00e9pendantes, pour donner tous nos soins \u00e0 celles qui, de leur nature, sont imp\u00e9rissables et ind\u00e9pendantes ! Nous ne songeons point que personne ne peut faire du mal ou du bien \u00e0 un autre, et que les opinions de chacun \u00e0 l'\u00e9gard de tout cela sont la seule chose qui nuise et qui bouleverse ; la seule cause des querelles, des dissensions, des guerres ! Qu'est-ce qui a fait \u00c9t\u00e9ocle et Polynice ? Rien autre chose que leurs opinions sur la royaut\u00e9 et sur l'exil. Celui-ci leur paraissait le dernier des maux, et celle-l\u00e0 le plus grand des biens ; or, la nature de tous les \u00eatres est de chercher le bien et de fuir le mal, et de regarder comme un adversaire et comme un ennemi quiconque veut leur enlever l'un et les jeter dans l'autre, f\u00fbt-il leur fr\u00e8re, leur fils ou leur p\u00e8re. Rien, en effet, ne nous tient de plus pr\u00e8s que le bien ; et de l\u00e0 suit que, si les choses ext\u00e9rieures sont des biens ou des maux, le p\u00e8re n'est plus l'ami de ses enfants, le fr\u00e8re n'est plus l'ami de son fr\u00e8re ; partout il n'y a plus que des ennemis, des tra\u00eetres et des calomniateurs. Si, au contraire, le bon \u00e9tat de la facult\u00e9 de juger et de vouloir est le seul bien, son mauvais \u00e9tat le seul mal, que deviennent les querelles et les invectives ? \u00c0 propos de quoi existeraient-elles ? Pour des choses qui nous sont indiff\u00e9rentes ? Et contre qui ? Contre des ignorants et des malheureux qui se trompent sur les choses les plus importantes ?\n\nC'est parce que Socrate savait tout cela, qu'il demeurait dans sa maison, en supportant la plus m\u00e9chante des femmes et un fils ingrat. \u00c0 quoi aboutissait, en effet, la m\u00e9chancet\u00e9 de sa femme ? \u00e0 lui verser sur la t\u00eate toute l'eau qu'elle voulait, et \u00e0 tr\u00e9pigner sur son g\u00e2teau. \u00ab Qu'est-ce que cela me fait, disait Socrate, d\u00e8s que je le regarde comme indiff\u00e9rent ? Or, ceci d\u00e9pend de moi : il n'y a ni tyran ni ma\u00eetre qui puisse m'en emp\u00eacher, si je le veux ; la multitude ici est impuissante contre l'individu, le plus fort contre le plus faible. L'ind\u00e9pendance sur ce point est un don de Dieu \u00e0 chacun de nous. \u00bb\n\nVoil\u00e0 les principes qui mettent l'amiti\u00e9 dans une famille, la concorde dans une ville, la paix entre les nations. Par eux, on est reconnaissant pour Dieu, et toujours sans crainte, parce qu'il n'y a jamais en question que des choses qui ne nous appartiennent pas et qui sont sans valeur.\n\nQuant \u00e0 nous, nous sommes bons pour \u00e9crire ou lire tout cela, et pour l'approuver quand nous l'avons lu ; mais que nous sommes loin de nous en p\u00e9n\u00e9trer ! Aussi ce qu'on disait des Lac\u00e9d\u00e9moniens, qu'ils sont des lions chez eux, des renards \u00e0 \u00c9ph\u00e8se, peut s'appliquer \u00e0 nous aussi : \u00ab Lions dans l'\u00e9cole, renards dehors. \u00bb\n\nXI. DE LA PROPRET\u00c9\n\nIl est des gens qui doutent que la sociabilit\u00e9 soit dans la nature de l'homme ; mais je ne vois pas ces gens eux-m\u00eames douter que la propret\u00e9 soit r\u00e9ellement dans notre nature, et qu'\u00e0 d\u00e9faut d'autre trait, il y ait l\u00e0 du moins quelque chose qui nous distingue des animaux. Lorsque nous voyons un animal se nettoyer, nous avons l'habitude de dire avec surprise : \u00ab C'est comme un homme \u00bb et, par contre, si l'on reproche \u00e0 un animal sa malpropret\u00e9, nous avons l'habitude de dire aussit\u00f4t, comme pour le d\u00e9fendre : \u00ab Ce n'est pas un homme. \u00bb Nous croyons donc qu'il y a l\u00e0 quelque chose de sp\u00e9cial \u00e0 l'homme, et ce quelque chose c'est des dieux m\u00eames que nous le tirons tout d'abord. Les dieux, par leur nature, sont purs et sans taches ; autant donc l'homme se rapproche d'eux par la raison, autant il devra s'efforcer d'\u00eatre pur et sans souillure. Il est impossible \u00e0 son \u00eatre de se trouver jamais compl\u00e8tement pur, avec les mat\u00e9riaux dont il est compos\u00e9 ; mais la raison, qui lui a \u00e9t\u00e9 donn\u00e9e, essaye du moins de le rendre pur dans la mesure du possible. La premi\u00e8re puret\u00e9, la plus noble, est celle de l'\u00e2me ; et r\u00e9ciproquement pour l'impuret\u00e9. On ne d\u00e9couvre pas les impuret\u00e9s de l'\u00e2me aussi ais\u00e9ment que celles du corps ; mais que peuvent \u00eatre ces impuret\u00e9s de l'\u00e2me, si ce n'est ce qui l'encrasse et la g\u00eane dans ses fonctions ? Or, les fonctions de l'\u00e2me sont de vouloir, de repousser, de d\u00e9sirer, de fuir, de se pr\u00e9parer, d'entreprendre, de donner son adh\u00e9sion. Qu'est-ce donc qui nuit chez elle \u00e0 ces fonctions, en la salissant et la rendant impure ? Rien autre chose que ses m\u00e9chants jugements. L'impuret\u00e9 de l'\u00e2me, ce sont donc ses opinions d\u00e9fectueuses ; et le moyen de la purifier, c'est de lui faire des opinions telles qu'elle en doit avoir. L'\u00e2me pure est celle qui a les opinions qu'elle doit avoir ; car c'est la seule dont les fonctions ne soient troubl\u00e9es par aucune salet\u00e9.\n\nIl y a quelque chose de pareil \u00e0 faire pour le corps \u00e0 son tour, autant qu'il s'y pr\u00eate. Il \u00e9tait impossible que les narines ne coulassent pas, l'homme \u00e9tant compos\u00e9 comme il l'est. C'est pour cela que la nature lui a fait dos, mains et les narines elles-m\u00eames, esp\u00e8ces de canaux pour mettre dehors les humeurs. Si donc quelqu'un ravale ces humeurs, je dis qu'il n'agit pas comme doit le faire un homme. Il \u00e9tait impossible que les pieds ne fussent jamais boueux, jamais sales d'aucune fa\u00e7on, avec les choses sur lesquelles nous marchons. C'est pour cela que la nature nous a donn\u00e9 de l'eau ; c'est pour cela qu'elle nous a donn\u00e9 des mains. Il \u00e9tait impossible qu'apr\u00e8s que nous avons mang\u00e9, quelque salet\u00e9 ne nous rest\u00e2t pas aux dents. C'est pour cela qu'elle nous dit : \u00ab Lavez vos dents. \u00bb Et pourquoi ? Pour \u00eatre des hommes, et non des b\u00eates sauvages ou des cochons. Il \u00e9tait impossible avec la sueur et les habits que nous portons, qu'il ne rest\u00e2t pas sur le corps quelque salet\u00e9 qui e\u00fbt besoin d'\u00eatre nettoy\u00e9e. C'est pour cela que nous avons l'eau, l'huile, les mains, le linge, les brosses, la soude, avec tout le reste de l'attirail pour nettoyer le corps. \u00ab Non \u00bb, dis-tu. Mais quoi ! l'ouvrier qui travaille les m\u00e9taux nettoiera le fer et aura des instruments faits pour cela ; toi-m\u00eame, lorsque tu seras pour manger, tu laveras ton plat de bois, si tu n'es pas compl\u00e8tement sale et malpropre ; et tu ne laverais ni ne nettoierais ton corps ! \u00ab Pourquoi le ferais-je ? \u00bb dis-tu. Je te r\u00e9pondrai : \u00ab D'abord pour te conduire en homme ; puis pour ne pas incommoder ceux qui se trouvent avec toi. \u00bb Car c'est l\u00e0 ce que tu fais maintenant, sans t'en apercevoir. Tu trouves convenable de t'empester toi-m\u00eame ; soit ! Je veux bien que ce soit convenable. Mais l'est-il \u00e9galement d'empester ceux qui s'asseyent pr\u00e8s de toi, ceux qui couchent avec toi, ceux qui te baisent ? Ou va-t'en dans un d\u00e9sert, ce qui est ta place ; ou vis seul, \u00e0 n'empester que toi ! Il est bien juste que tu aies seul la jouissance de ta malpropret\u00e9. Mais, quand tu es dans une ville, vivre avec cette n\u00e9gligence et cette stupidit\u00e9, de qui crois-tu que ce soit le fait ? Si la nature t'avait confi\u00e9 un cheval, le laisserais-tu ainsi sans soins ? Regarde aujourd'hui ton corps comme un cheval qu'on a remis entre tes mains ; lave-le, essuie-le ; fais que personne ne s'en d\u00e9tourne, que personne ne s'en recule. Qu'est-ce qui ne se recule pas d'un homme sale, d'un homme qui sent, d'un homme qui pue, encore plus que d'un individu couvert d'ordures ? La puanteur dans ce dernier cas nous vient du dehors ; mais celle qui na\u00eet de notre incurie vient de nous : elle ressemble \u00e0 celle d'une charogne.\n\n\u2014 Mais Socrate se lavait rarement ! \u2014 Oui, mais son corps reluisait ; mais ce corps \u00e9tait si agr\u00e9able et si attrayant, que les plus jeunes et les plus nobles s'en \u00e9prenaient, et auraient mieux aim\u00e9 coucher avec lui qu'avec les plus beaux gar\u00e7ons. Il aurait eu le droit de ne pas se baigner, de ne pas se laver, s'il avait voulu ; et, si peu qu'il le fit, le r\u00e9sultat y \u00e9tait. Si tu ne veux pas qu'il se baign\u00e2t \u00e0 l'eau chaude, il se baignait du moins dans l'eau froide. \u2014 Mais, il y a contre lui le mot d'Aristophane : \u00ab Je parle de ces gens p\u00e2les et sans chaussures. \u00bb\n\n\u2014 Mais Aristophane a dit aussi que Socrate marchait dans l'air, et volait les habits dans les gymnases ! Et tous ceux qui ont \u00e9crit sur Socrate en rapportent tout le contraire, qu'il n'\u00e9tait pas seulement s\u00e9duisant \u00e0 entendre, mais encore \u00e0 voir. On a \u00e9crit la m\u00eame chose sur Diog\u00e8ne aussi. C'est qu'en effet il ne faut pas \u00e9loigner le vulgaire de la philosophie par l'aspect de notre corps, mais nous montrer \u00e0 ses yeux dispos et heureux dans notre corps comme dans le reste. \u00ab Voyez, \u00f4 mortels, que je n'ai rien et que je n'ai besoin de rien ! Voyez comment sans maison, sans patrie, exil\u00e9, s'il le faut, et sans feu ni lieu, je vis plus heureux et plus calme que tous vos Eupatrides et tous vos riches. Voyez aussi mon corps, qui ne souffre en rien de ma vie s\u00e9v\u00e8re. \u00bb Si quelqu'un me parlait ainsi avec l'air et la mine d'un condamn\u00e9, quel est le Dieu qui pourrait me persuader de m'attacher \u00e0 un philosophe qui rendrait les gens tels ? Que le ciel m'en pr\u00e9serve ! Je m'y refuserais, alors m\u00eame que je devrais y devenir un sage.\n\nPour moi, par tous les dieux ! j'aime mieux que le jeune homme qui vient \u00e0 moi pour la premi\u00e8re fois, s'y pr\u00e9sente bien fris\u00e9, que sale et les cheveux en d\u00e9sordre. On voit du moins en lui quelque id\u00e9e du Beau, quelque amour de ce qui sied. Il le cherche o\u00f9 il croit qu'il est. On n'a plus qu'\u00e0 lui montrer o\u00f9 il est, et \u00e0 lui dire : \u00ab Jeune homme, tu cherches le Beau, et tu fais bien. Sache donc qu'il est pour toi o\u00f9 est ta raison. Cherche-le o\u00f9 est ta facult\u00e9 de vouloir et de repousser, de d\u00e9sirer et de fuir. Car c'est l\u00e0 chez toi ce qui a de la valeur ; pour ton corps, il n'est que boue de sa nature. \u00c0 quoi bon te donner pour lui des peines inutiles ? Le temps, \u00e0 d\u00e9faut d'autre chose, t'apprendra qu'il n'est rien. Mais si celui qui vient \u00e0 moi est couvert d'ordures et de salet\u00e9s, avec une barbe qui lui descend jusqu'aux genoux, que puis-je lui dire ? Par quelles analogies l'amener o\u00f9 je veux ? Apr\u00e8s quoi a-t-il couru qui ressembl\u00e2t au Beau, pour que je n'aie qu'\u00e0 le changer de direction, et \u00e0 lui dire : \u00ab Le Beau n'est pas l\u00e0, mais ici ? \u00bb Veux-tu que je lui dise : \u00ab Le Beau n'est pas dans la salet\u00e9, mais dans la raison ? \u00bb Est-ce qu'il se soucie du Beau ? Est-ce qu'il en a en lui quelque id\u00e9e ? Va-t'en donc disputer avec un pourceau, pour qu'il ne se roule pas dans la fange ! C'est gr\u00e2ce \u00e0 cela que les discours de X\u00e9nocrate ont touch\u00e9 Pol\u00e9mon : le jeune homme aimait le Beau. Quand il entra dans l'\u00e9cole, il avait en lui le principe de l'amour du Beau ; seulement, il cherchait le Beau o\u00f9 il n'\u00e9tait pas.\n\nIl n'y a pas jusqu'aux animaux qui vivent avec l'homme, que la nature n'ait faits propres. Est-ce le cheval qui se roule dans la fange ? Est-ce un chien de noble race ? Non, mais le pourceau, mais les sales oies, mais les vers, mais les araign\u00e9es, tout ce qu'il y a de fait pour vivre le plus loin de l'homme. Et toi, qui es un homme, voudras-tu n'\u00eatre m\u00eame pas un des animaux qui vivent avec l'homme ? Aimeras-tu mieux \u00eatre un ver ou une araign\u00e9e ? Ne te laveras-tu donc jamais, quel que soit le mode que tu pr\u00e9f\u00e8res ? Ne te baigneras-tu jamais ? Ne voudras-tu pas nous arriver propre, pour que l'on soit heureux d'\u00eatre avec toi ? Entreras-tu avec nous en pareil \u00e9tat dans ces temples, o\u00f9 il n'est permis de cracher ni de se moucher, toi qui n'es que morve et que crachat ?\n\n\u2014 Quoi donc ! doit-on vouloir se faire beau ? \u2014 \u00c0 Dieu ne plaise ! si ce n'est dans ce qui est nous par nature, dans notre raison, dans nos jugements, dans nos actes ; quant au corps, il ne faut s'en occuper que pour qu'il soit propre et ne choque personne. Parce qu'on t'aura dit qu'il ne faut pas porter de v\u00eatements \u00e9carlates, vas-tu couvrir ton manteau d'ordures ou le mettre en loques ? \u2014 Et d'o\u00f9 pourrais-je avoir un beau manteau ? \u2014 Homme, tu as de l'eau ; laves-y le tien. \u00d4 l'aimable jeune homme ! \u00d4 le vieillard fait pour aimer et pour \u00eatre aim\u00e9, \u00e0 qui on am\u00e8nera son fils pour qu'il l'instruise, que les jeunes filles et les jeunes gar\u00e7ons viendront trouver au besoin, et qui leur fera la le\u00e7on sur un tas de fumier ! Toute aberration a sa source dans quelque c\u00f4t\u00e9 de la nature humaine ; mais celle-ci est bien pr\u00e8s de n'avoir rien d'humain.\n\nXII. DE L'ATTENTION\n\nSi tu te rel\u00e2ches un instant de ton attention sur toi-m\u00eame, ne t'imagine pas que tu la retrouveras, lorsque tu le voudras. Dis-toi, au contraire, que, par suite de ta faute d'aujourd'hui, tes affaires d\u00e9sormais seront forc\u00e9ment en plus mauvais \u00e9tat. Car d'abord, et c'est ce qu'il y a de plus triste, l'habitude nous vient de ne pas veiller sur nous-m\u00eames, puis l'habitude de diff\u00e9rer d'y veiller, en remettant et reportant sans cesse \u00e0 un autre jour d'\u00eatre heureux, d'\u00eatre vertueux, de vivre et de nous conduire conform\u00e9ment \u00e0 la nature. S'il est utile de le remettre, il sera bien plus utile encore d'y renoncer compl\u00e8tement ; et, s'il n'est pas utile d'y renoncer, pourquoi ne pas continuer \u00e0 veiller constamment sur soi ? \u2014 Aujourd'hui je veux jouer ! \u2014 Eh bien ! ne dois-tu pas le faire en veillant sur toi ? \u2014 Je veux chanter. \u2014 Qu'est-ce qui t'emp\u00eache de le faire en veillant sur toi ? Est-il dans notre vie une chose exceptionnelle, \u00e0 laquelle l'attention ne puisse s'\u00e9tendre ? En est-il une que nous g\u00e2tions par l'attention, que nous am\u00e9liorions en n'\u00e9tant pas attentif ? Est-il quoi que ce soit, dans la vie, qui gagne au d\u00e9faut d'attention ? Le charpentier construit-il plus parfaitement en ne faisant pas attention ? Le pilote, en ne faisant pas attention, conduit-il plus s\u00fbrement ? Est-il quelqu'un des travaux les moins importants qui s'ex\u00e9cute mieux sans l'attention ? Ne sens-tu pas qu'une fois que tu as l\u00e2ch\u00e9 la bride \u00e0 tes pens\u00e9es, il n'est pas en ton pouvoir de les reprendre en mains, pour \u00eatre honn\u00eate, d\u00e9cent et r\u00e9serv\u00e9 ? Loin de l\u00e0 : tu fais d\u00e8s lors tout ce qui se pr\u00e9sente \u00e0 ton esprit, tu c\u00e8des \u00e0 toutes tes tentations.\n\n\u00c0 quoi donc me faut-il faire attention ? D'abord \u00e0 ces principes g\u00e9n\u00e9raux, qu'il te faut avoir toujours pr\u00e9sents \u00e0 la pens\u00e9e, et sans lesquels tu ne dois ni dormir, ni te lever, ni boire, ni manger, ni te r\u00e9unir aux autres hommes : \u00ab Personne n'est le ma\u00eetre du jugement ni de la volont\u00e9 d'autrui ; et c'est dans eux seuls qu'est le bien et le mal. \u00bb Il n'y a donc pas de ma\u00eetre qui puisse me faire du bien ou me causer du mal ; sur ce point je ne d\u00e9pends que de moi seul. Puis donc qu'il y a s\u00e9curit\u00e9 pour moi sur ce point, qu'ai-je \u00e0 me tourmenter pour les choses du dehors ? Pourquoi craindre un tyran, la maladie, la pauvret\u00e9, un \u00e9cueil quelconque ? Je n'ai pas plu \u00e0 un tel ! Est-ce donc lui qui est ma fa\u00e7on d'agir ? Est-ce lui qui est ma fa\u00e7on de juger ? Non. Que m'importe d\u00e8s lors ! Mais il para\u00eet \u00eatre un personnage ! C'est son affaire, et celle des gens qui le prennent pour tel. Pour moi j'ai \u00e0 qui plaire, \u00e0 qui me soumettre, \u00e0 qui ob\u00e9ir : c'est Dieu, et ceux qui viennent apr\u00e8s lui. C'est moi-m\u00eame que Dieu a pr\u00e9pos\u00e9 \u00e0 ma garde ; c'est \u00e0 moi seul qu'il a soumis ma facult\u00e9 de juger et de vouloir ; et il m'a donn\u00e9 des r\u00e8gles pour en bien user. Lorsque je les applique aux syllogismes, je ne me pr\u00e9occupe pas de ceux qui parlent autrement ; lorsque je les applique aux raisonnements \u00e9quivoques, je ne m'inqui\u00e8te de personne ; pourquoi donc dans les choses plus importantes les critiques me font-elles de la peine ? Qu'est-ce qui fait que je me trouble ainsi ? Une seule chose : c'est que je ne me suis pas exerc\u00e9 sur ce point-l\u00e0. Quiconque sait, en effet, d\u00e9daigne l'ignorance et les ignorants ; et je ne parle pas seulement des savants, mais aussi des gens de m\u00e9tiers. Am\u00e8ne-moi le savetier que tu voudras, et dans ce qui est de son art il se moquera de tout le monde. Am\u00e8ne-moi de m\u00eame le charpentier que tu voudras.\n\nIl faut, avant tout, avoir ces id\u00e9es pr\u00e9sentes \u00e0 la pens\u00e9e, et ne rien faire qui soit en contradiction avec elles ; il faut bander son \u00e2me vers ce but, de ne poursuivre aucune des choses qui sont hors de nous, aucune de celles qui ne sont pas \u00e0 nous. Acceptons-les comme en dispose celui qui a pouvoir sur elles. Les choses qui rel\u00e8vent de notre libre arbitre, il faut les vouloir sans restriction, mais les autres, comme on nous les donne. Il faut de plus nous rappeler qui nous sommes, et quel est notre nom, et nous efforcer de faire ce qui convient dans chaque situation. Demandons-nous quand il est \u00e0 propos de chanter, \u00e0 propos de jouer, et devant quelles personnes ; qu'est-ce qui est hors de saison ; qu'est-ce qui nous ferait m\u00e9priser des assistants ou prouverait de notre part du m\u00e9pris pour eux ; quand faut-il plaisanter ; qui faut-il railler ; en quoi et pour qui faut-il avoir de la condescendance ; puis dans cette condescendance comment faut-il faire pour sauver notre dignit\u00e9 ? Quand tu te seras \u00e9cart\u00e9 des convenances sur un de ces points, le ch\u00e2timent te viendra tout de suite, non pas du dehors, mais de ton acte m\u00eame.\n\nQuoi donc ! peut-on \u00eatre infaillible ? Non pas ; mais il est une chose que l'on peut, c'est de s'efforcer constamment de ne pas faire de faute. Et il faut nous trouver heureux, si, en ne nous rel\u00e2chant jamais de cette attention sur nous-m\u00eames, nous \u00e9chappons \u00e0 un certain nombre de fautes. Mais dire maintenant : \u00ab Je ferai attention demain \u00bb, sache que c'est dire : \u00ab Aujourd'hui je serai sans retenue, sans convenance, sans dignit\u00e9 ; il sera au pouvoir des autres de me faire de la peine ; je vais \u00eatre aujourd'hui col\u00e8re et envieux. \u00bb Vois que de maux tu attires l\u00e0 sur toi ! Si l'attention doit t'\u00eatre bonne demain, combien plus le sera-t-elle aujourd'hui ! Si demain elle doit t'\u00eatre utile, elle le sera bien plus aujourd'hui. Veille sur toi aujourd'hui pour en \u00eatre capable demain, et ne pas le remettre encore au surlendemain.\n\nXIII. POUR CEUX QUI PARLENT TROP AIS\u00c9MENT D'EUX-M\u00caMES\n\nLorsque quelqu'un semble nous parler de ses affaires \u00e0 c\u0153ur ouvert, nous sommes entra\u00een\u00e9s, nous aussi, \u00e0 lui r\u00e9v\u00e9ler nos secrets ; et nous croyons que cela est tout simple : d'abord parce qu'il nous para\u00eet contraire \u00e0 l'\u00e9quit\u00e9 d'\u00e9couter les affaires de notre prochain, sans lui faire part \u00e0 son tour des n\u00f4tres ; puis, parce que nous croyons que nous ne ferions pas aux autres l'effet d'un homme franc, si nous nous taisions sur nous-m\u00eames. Que de fois certes on nous dit : \u00ab Moi, je t'ai dit toutes mes affaires ; et toi, tu ne veux me rien dire des tiennes ! D'o\u00f9 cela vient-il ? \u00bb Ajoutez-y qu'on croit pouvoir se confier en toute s\u00fbret\u00e9 \u00e0 qui vous a d\u00e9j\u00e0 confi\u00e9 ses affaires ? Car la pens\u00e9e nous vient que cet homme ne contera jamais les n\u00f4tres, de peur que nous aussi nous ne contions les siennes. C'est ainsi qu'\u00e0 Rome les gens trop prompts \u00e0 parler se font attraper par les soldats. Un soldat vient s'asseoir aupr\u00e8s de toi sous l'habit d'un bourgeois ; il se met \u00e0 parler mal de C\u00e9sar, et toi, comme s'il t'avait donn\u00e9 un gage de sa bonne foi, en \u00e9tant le premier au d\u00e9nigrement, tu dis \u00e0 ton tour tout ce que tu penses ; on te garrotte alors, et on t'emm\u00e8ne. C'est l\u00e0 l'image de ce qui nous arrive \u00e0 tous. Parce qu'un homme s'est confi\u00e9 \u00e0 moi en toute s\u00fbret\u00e9, puis-je de m\u00eame, moi, me confier au premier venu ? Si je suis ce que je suis, je me tais, moi, sur ce qu'il m'a dit. Mais lui, il va conter \u00e0 tout le monde ce que je lui ai dit. Cela fait, si je lui ressemble, je veux me venger, quand j'apprends la chose, et je conte ses affaires ; je l'ab\u00eeme, et il m'ab\u00eeme. Si je me dis, au contraire, que personne ne peut nuire \u00e0 un autre, et qu'il n'y a que nos actes propres qui nous nuisent ou qui nous soient utiles, je parviens bien \u00e0 ne pas faire comme lui, mais ce qui m'est arriv\u00e9 par suite de mon bavardage, ne m'en est pas moins arriv\u00e9.\n\n\u2014 Soit ! Mais il est contraire \u00e0 l'\u00e9quit\u00e9 d'\u00e9couter les secrets de son prochain, sans lui faire part \u00e0 son tour de quoi que ce soit ! \u2014 \u00d4 homme, est-ce que je t'ai provoqu\u00e9 \u00e0 parler ? Lorsque tu m'as livr\u00e9 tes secrets, y a-t-il eu convention que tu entendrais les miens \u00e0 ton tour ? Si tu es un bavard, et si tu prends pour des amis tous ceux que tu rencontres, veux-tu que je te ressemble ? Quoi donc ! si tu as pu sans danger te confier \u00e0 moi, mais si l'on ne peut sans danger se confier \u00e0 toi, veux-tu que je tombe dans le pi\u00e8ge ? C'est comme si j'avais un tonneau bien solide, toi un tonneau perc\u00e9, que tu vinsses m'apporter ton vin pour le mettre dans mon tonneau, et que tu t'indignasses ensuite de ce que je ne voudrais pas te confier mon vin. Ma raison serait que tu as un tonneau perc\u00e9. Comment y aurait-il \u00e9galit\u00e9 ? Tu te livres \u00e0 un homme s\u00fbr, \u00e0 un homme honn\u00eate, qui croit que ses actes seuls peuvent lui \u00eatre utiles ou nuisibles, et que toutes les choses du dehors ne sont rien ; et tu veux que je me livre \u00e0 toi, qui tiens pour rien ton libre arbitre, qui veux arriver \u00e0 la fortune ou \u00e0 une magistrature, ou bien faire ton chemin \u00e0 la cour, quand tu devrais pour cela \u00e9gorger tes enfants, \u00e0 la fa\u00e7on de M\u00e9d\u00e9e ? Quelle \u00e9galit\u00e9 y a-t-il l\u00e0 ? Montre-moi que tu es un homme s\u00fbr, honn\u00eate, in\u00e9branlable ; montre-moi que tes id\u00e9es sont bienveillantes ; montre-moi que ton vase n'est pas perc\u00e9 ; et tu verras que je n'attendrai pas que tu me confies tes secrets, mais que j'irai moi-m\u00eame vers toi pour te prier d'\u00e9couter les miens. Qui, en effet, ne voudrait pas se servir d'un vase en bon \u00e9tat ? Qu'est-ce qui fait fi d'un conseiller bienveillant et s\u00fbr ? Qu'est-ce qui n'accueillerait pas volontiers celui qui vient pour ainsi dire prendre sa part du fardeau de vos affaires, et vous le rendre plus l\u00e9ger par cela seul qu'il en prend sa part ?\n\n\u2014 Oui ; mais, quand j'ai confiance en toi, n'auras-tu pas confiance en moi ? \u2014 D'abord, tu n'es pas un homme qui ait confiance en moi ; mais un bavard, qui ne peut rien garder. Car, s'il en \u00e9tait ce que tu dis, tu ne confierais tes secrets qu'\u00e0 moi seul. Or, aujourd'hui, d\u00e8s que tu vois quelqu'un inoccup\u00e9, tu vas t'asseoir \u00e0 ses c\u00f4t\u00e9s et tu lui dis : \u00ab Fr\u00e8re, je n'ai personne qui m'aime plus que toi ni qui me soit plus chef ; je te prie donc d'\u00e9couter mes secrets. \u00bb Et cela, tu le fais \u00e0 des gens que tu ne connais pas le moins du monde.\n\nSi tu as cependant confiance en moi, il est \u00e9vident que c'est parce que je suis s\u00fbr et honn\u00eate, et non point parce que je t'ai cont\u00e9 mes affaires.\n\nLaisse-moi donc \u00eatre dans les m\u00eames id\u00e9es. Montre-moi que, par cela seul que l'on conte ses affaires, on est s\u00fbr et honn\u00eate. Car, en ce cas, je m'en irais partout dire \u00e0 tout le monde mes secrets, si je devais \u00e0 ce prix \u00eatre s\u00fbr et honn\u00eate. Mais les choses ne vont pas ainsi ; et ce qu'il faut pour \u00eatre tel, ce sont des principes qui ne sont pas les premiers venus. Si donc tu vois quelqu'un s'attacher aux choses qui ne d\u00e9pendent pas de son libre arbitre, et leur soumettre ce libre arbitre m\u00eame, sache que cet homme a des milliers d'individus qui peuvent le contraindre ou l'emp\u00eacher d'agir. Il n'y a pas besoin d'employer la poix ou la roue pour lui faire dire ce qu'il sait ; un signe d'une femme le fera parler au besoin, ou bien les caresses d'un ami de C\u00e9sar, le d\u00e9sir d'une charge, d'un h\u00e9ritage, et mille autres choses de cette esp\u00e8ce.\n\nIl faut donc se rappeler, comme r\u00e8gle g\u00e9n\u00e9rale, que les secrets demandent un homme s\u00fbr, avec des principes qui le soient aussi. Mais o\u00f9 trouver cela facilement aujourd'hui ? Que l'on me montre un homme capable de dire : \u00ab Je ne m'inqui\u00e8te que des choses qui sont \u00e0 moi, que nul ne peut emp\u00eacher, et qui sont libres de leur nature ; c'est l\u00e0 qu'est pour moi le bien r\u00e9el ! Que les autres arrivent comme elles se trouvent ; j'y suis indiff\u00e9rent. \u00bb\n\u00c9pict\u00e8te\n\n\u00c9pict\u00e8te na\u00eet \u00e0 Hi\u00e9rapolis, en Phrygie (actuellement en Turquie), en 50 ; d\u00e8s son enfance, il est emmen\u00e9 \u00e0 Rome comme esclave, d'o\u00f9 lui vient son nom qui en grec signifie \u00ab homme achet\u00e9 \u00bb, \u00ab serviteur \u00bb. Selon la l\u00e9gende, il se fait remarquer en se laissant arracher la jambe par son ma\u00eetre \u00c9paphrodite, premi\u00e8re preuve de fermet\u00e9 et de ma\u00eetrise de soi. Apr\u00e8s avoir \u00e9t\u00e9 affranchi \u00e0 la mort d'\u00c9paphrodite, il s'adonne \u00e0 l'\u00e9tude du sto\u00efcisme, mais doit quitter Rome \u00e0 la suite d'un d\u00e9cret de l'empereur Domitien contre les philosophes en 90.\n\nIl s'installe alors \u00e0 Nicopolis, en \u00c9pire (les Balkans), o\u00f9 il commence une vie plus calme, en compagnie de sa femme. Il se fait conna\u00eetre en enseignant la philosophie sto\u00efcienne, fond\u00e9e par les philosophes grecs Chrysippe et Z\u00e9non ; parmi ses \u00e9l\u00e8ves, on compte Julius Rusticus, qui deviendra le ma\u00eetre de l'empereur et philosophe sto\u00efcien Marc Aur\u00e8le. Il meurt \u00e0 Nicopolis en 125 ou 130.\n\nComme Socrate, \u00c9pict\u00e8te n'a laiss\u00e9 aucun \u00e9crit, mais un de ses \u00e9l\u00e8ves, Arrien (il sera plus tard consul et historien), se charge de transcrire sa doctrine, avec concision dans le Manuel (l'Enchiridion) qui se pr\u00e9sente comme un ensemble de r\u00e8gles pratiques, et d'une fa\u00e7on beaucoup plus d\u00e9taill\u00e9e dans les huit livres des Entretiens, dont quatre seulement nous sont parvenus. Ces deux ouvrages, \u00e9crits en grec, ne seront pas traduits en latin avant la fin du Moyen \u00c2ge.\n\nLa vie d'\u00c9pict\u00e8te reste tr\u00e8s mal connue et son \u0153uvre, qui op\u00e8re la synth\u00e8se de diff\u00e9rentes tendances, sera quasiment oubli\u00e9e au Moyen \u00c2ge ; cependant, il redevient un mod\u00e8le de sagesse avec Montaigne et Pascal. \u00c0 la diff\u00e9rence des autres grands repr\u00e9sentants du sto\u00efcisme \u00e0 Rome, l'orateur Cic\u00e9ron, le pr\u00e9cepteur de la famille imp\u00e9riale S\u00e9n\u00e8que ou l'empereur Marc Aur\u00e8le, \u00c9pict\u00e8te a pass\u00e9 sa vie loin des fastes et des honneurs, dans la pauvret\u00e9 et l'humilit\u00e9. De m\u00eame que ses deux mod\u00e8les, Socrate et le cynique Diog\u00e8ne, il repr\u00e9sente ainsi le type du philosophe dont l'existence fut en ad\u00e9quation avec les principes, qui ne se soucia pas de devenir c\u00e9l\u00e8bre et chercha surtout \u00e0 proposer une sagesse pratique et exemplaire.\n\nTable\n\nDans la m\u00eame s\u00e9rie\n\nManuel d'\u00c9pict\u00e8te\n\nEntretiens (extraits)\n\nLivre premier\n\nII. Comment on peut conserver sa dignit\u00e9 en toute chose\n\nVIII. Les talents des ignorants ne sont pas sans p\u00e9rils\n\nXXI. Contre ceux qui veulent se faire admirer\n\nLivre deuxi\u00e8me\n\nIV. Sur un homme qui avait \u00e9t\u00e9 surpris en adult\u00e8re\n\nXV. Sur les gens qui persistent obstin\u00e9ment dans ce qu'ils ont d\u00e9cid\u00e9\n\nXVIII. Comment il faut lutter contre les id\u00e9es dangereuses\n\nXXIV. \u00c0 quelqu'un qu'il n'estimait pas\n\nLivre troisi\u00e8me\n\nIV. Contre ceux qui, au th\u00e9\u00e2tre, donnent des marques inconvenantes de faveur\n\nV. Contre ceux qui partent parce qu'ils sont malades\n\nX. Comment doit-on supporter les maladies ?\n\nXII. De l'exercice\n\nXIII. Qu'est-ce que c'est que l'abandon ? Et qu'est-ce qui est abandonn\u00e9 ?\n\nXVI. Qu'il faut y regarder \u00e0 deux fois avant de se laisser entra\u00eener \u00e0 une liaison\n\nXXIII. Contre ceux qui lisent ou discutent par d\u00e9sir de se montrer\n\nXXVI. \u00c0 ceux qui craignent la pauvret\u00e9\n\nLivre quatri\u00e8me\n\nII. Sur nos liaisons\n\nV. Contre les gens querelleurs et m\u00e9chants\n\nXI. De la propret\u00e9\n\nXII. De l'attention\n\nXIII. Pour ceux qui parlent trop ais\u00e9ment d'eux-m\u00eames\n\nFiche biographique\n\n","meta":{"redpajama_set_name":"RedPajamaBook"}}
+{"text":" \nWHY?\n\nExplaining   \nthe Holocaust\n\nPETER HAYES\n\nW. W. NORTON & COMPANY\n\n_Independent Publishers Since 1923_\n\n_New York_ | _London_\nIN GRATEFUL MEMORY OF INSPIRING TEACHERS:\n\n_Mary Faherty_\n\n_James McGillivray_\n\n_Athern Park Daggett_\n\n_John C. Rensenbrink_\n\n_Timothy W. Mason_\n\n_Henry Ashby Turner Jr_.\nCONTENTS\n\nINTRODUCTION: Why Another Book on the Holocaust?\n\n1. TARGETS: Why the Jews?\n\n_Antisemitism_\n\n_Emancipation and Backlash_\n\n2. ATTACKERS: Why the Germans?\n\n_Nation and_ Volk\n\n_Hitler's Opportunity_\n\n3. ESCALATION: Why Murder?\n\n_From Aryanization to Atrocity_\n\n_Gentile and Jewish Responses_\n\n4. ANNIHILATION: Why This Swift and Sweeping?\n\n_From Bullets to Gas_\n\n_Perpetrators: the \"generation without limits\"_\n\n_Enslavement_\n\n5. VICTIMS: Why Didn't More Jews Fight Back More Often?\n\n_Compliance and Resistance_\n\n_The World of the Camps_\n\n6. HOMELANDS: Why Did Survival Rates Diverge?\n\n_Varieties of Behavior_\n\n_The Case of Poland_\n\n7. ONLOOKERS: Why Such Limited Help from Outside?\n\n_Prewar Evasions_\n\n_Wartime Priorities_\n\n8. AFTERMATH: What Legacies, What Lessons?\n\n_Return, Resettlement, Retribution, and Restitution_\n\n_Memory, Myths, and Meanings_\n\nACKNOWLEDGMENTS\n\nNOTES\n\nSELECTED BIBLIOGRAPHY\n\nINDEX\nLIST OF FIGURES\n\n1. THE OVERLAPPING LAYERS OF ANTISEMITISM\n\n2. ANTISEMITIC VOTING IN IMPERIAL GERMANY\n\n3. ANTISEMITIC VOTING FOR THE REICHSTAG IN POST\u2013WORLD WAR I GERMANY\n\n4. THE GEOGRAPHICAL COMPRESSION OF THE HOLOCAUST\n\n5. THE FATE OF A GHETTO: LODZ, 1940\u201344\n\n6. TWO PHOTOS FROM _T HE STROOP REPORT_\n\n7. GOVERNANCE AND HOLOCAUST MORTALITY RATES\n\n8. ROMANIA, 1941\u201344\nINTRODUCTION\n\n[Why Another Book   \non the Holocaust?](contents.xhtml#intro_1)\n\nSEVENTY YEARS AFTER the Holocaust ended, it continues to resist comprehension. Despite (or maybe because of) the outpouring of some sixteen thousand books cataloged at the Library of Congress under the heading, despite the proliferation of museums and memorials, despite the annual appearance of new cinematic treatments, and despite the spread of educational programs and courses devoted to the subject, a coherent explanation of why such ghastly carnage erupted from the heart of civilized Europe in the twentieth century seems still to elude people. Indeed, perhaps the adjectives most frequently invoked in connection with the Holocaust are \"unfathomable,\" \"incomprehensible,\" and \"inexplicable.\" These words attest to a distancing reflex, an almost instinctive recoiling in self-defense. To say that one can explain the occurrence of the Holocaust seems tantamount to normalizing it, but professing that one cannot grasp it is an assertion of the speaker's innocence\u2014of his or her incapacity not only to conceive of such horror but to enact anything like it. Small wonder that incomprehension is the default position in the face of the enormity of the Holocaust, even though that stance blocks the possibility of learning from the subject.\n\nSelf-protection is not the only reason for the enduring difficulty of coming to intellectual grips with the Holocaust, however. Another is the complexity of the task. To understand the Holocaust requires solving multiple puzzles that surround it. In the course of teaching the subject to American undergraduates for almost three decades and lecturing widely to both academic and general audiences, I have come to recognize eight central issues that people grappling with the subject find most perplexing. Some of these issues involve acts of commission, some concern acts of omission, and still others entail both. All require interlocking clarification before a mind can comprehend and account for the cataclysm. Each chapter of this book examines one of those eight central issues, raised in the form of a question, and the book as a whole reflects my conviction that the Holocaust is no less historically explicable than any other human experience, though the job is not easy.\n\nIn answering these questions, I bring to bear expertise that is unusual among students of the Holocaust. I am by training an economic historian. That does not mean that I foreground material motivations for murder (in fact, I contend that they were secondary to ideological motives). My background makes me, however, alert to numbers and their significance, and I deploy them frequently in order to demonstrate their powerful interpretive effects. A second distinguishing feature of my account is its dialectical origins. This is not a book driven by a thesis that the author wants to prove but rather a work that emerged out of the give-and-take of many years of teaching and public speaking, during which I learned which aspects of the subject people most want clarified and why, directed my reading and thinking toward identifying the most reliable responses that scholarship can offer, and then honed ways to make that knowledge as accessible and memorable as I could.\n\nAlongside its explanatory purpose, this book also has another goal: to set the record straight. As the late historian Tony Judt observed, \"Impossible to remember as it really was, [the Holocaust] is inherently vulnerable to being remembered as it wasn't.\" Numerous myths have grown up around the subject, many designed to console us that things could have gone much differently if only some person or entity had acted more bravely or wisely, others intended to cast new blame on favorite or surprising villains or even on historians of the subject. This book dispels many such legends\u2014from the notion that antisemitism brought Adolf Hitler to power in Germany to the belief that a large number of major perpetrators of the Holocaust escaped punishment afterward\u2014and the final chapter reviews and debunks the most prevalent ones, including the loud and recurrent claim that the Holocaust never happened.\n\nThe arc of the book's argument is as follows. The Holocaust was the product of a particular time and place: Europe in the aftermath of the Industrial Revolution and the upheavals of World War I and the Bolshevik Revolution. These were the contexts in which ancient hostilities toward Jews and Judaism, deeply rooted in religious rivalry but updated with the trappings of modern science, turned into a fixation on removing Jews from civil society as a magical solution to all social problems. Germany was where the fault lines of disruption lifted this belief to power during the 1930s, but the murder of the Jews of Europe was neither pre-programmed by German history nor an exclusively German project. The massacre took shape under specific political and military conditions and intensified in part because it suited the objectives of many other Europeans, at least during the short, ferocious period when most of the killing occurred. In the face of the slaughter, the victims were largely powerless and the onlookers preoccupied with their own, to them more pressing concerns. The parts of the trap that clicked into place around European Jews during the Nazi era fit so tightly that only a minority could escape, most only just barely and in the nick of time. Afterward, most countries of the old continent delayed acknowledging what they had participated in yet also constructed numerous barriers to its repetition, barriers that now, seventy years later, are under stress.\n\nThe pace of specialist research on the Holocaust has outrun most people's ability to keep up and to integrate new findings into a general interpretive picture. Even as misleading notions about the subject have gained ground, antiquated ones linger. Given this, people interested in the subject need a comprehensive stocktaking directed squarely at answering the most central and enduring questions about why and how the massacre of European Jewry unfolded. That is what this book offers.\nWHY?\nCHAPTER 1\n\n[TARGETS:  \nWhy the Jews?](contents.xhtml#ch_1)\n\nOUTBREAKS OF HOSTILITY against minorities are almost always rooted both in ideas\u2014what the majority thinks about the minority\u2014and circumstances: the ways in which or the terms on which the two groups are interacting at a particular time. In order to explain why the Jews became objects of murderous intentions in the twentieth century, one has to look at both sorts of roots.\n\nANTISEMITISM\n\nNowadays the term usually used to describe hostility to Jews is antisemitism. A professor of mine in graduate school used to say that the problem with the word is that it is a single term for lots of different attitudes\u2014covering everything from telling crude jokes about Jews to desiring to kill them. He had a point, but a working definition is nonetheless possible. Mine goes like this: Antisemitism is a categorical impugning of Jews as collectively embodying distasteful and\/or destructive traits. In other words, antisemitism is the belief that Jews have common repellent and\/or ruinous qualities that set them apart from non-Jews. Descent is determinative; individuality is illusory.\n\nThat attitude has a long history; indeed, a famous book by Robert Wistrich and a widely seen documentary film on the subject are called _The Longest Hatred_. But that title is misleading for two reasons. First, if Jews have long been hated in Western culture, they have not been equally hated at all times and in all places; and second, the hatred has exhibited a good deal of shape-shifting. In fact, the name that we now use to describe prejudice against or hatred of Jews illustrates both points. The word \"antisemitism\" appeared only in 1879, and its popularization is usually ascribed to Wilhelm Marr, a German agitator who intended it to describe something new and different from previous forms of hostility toward Jews. Like other \"-ism\" words that appeared in abundance in the nineteenth century, the word was chosen to suggest that this new hostility was about politics and science. Note what the word claimed to be against: Not Jews but something called Semitism. What was that? Unlike the other targets of nineteenth century \"anti-\" movements (for example, antisocialism, anticommunism, anti-Catholicism, antivivisectionism, even antidisestablishmentarianism), this term did not combat a belief system that had named itself, but instead invented the phenomenon being opposed. Self-styled \"antisemites\" borrowed a category from linguistics, and they did so misleadingly. They claimed to combat Semites\u2014speakers of the Semitic family of languages, which differed in syntax and grammatical structure from the so-called Indo-European family of languages that predominated in Europe. But actually not all Semites were targeted, since Arabs generally were not included, though Arabic is a Semitic language. Neither were the modern speakers of Aramaic, the language Jesus spoke, though it is also a Semitic tongue. In the late 1930s and early 1940s, the Nazi regime implicitly conceded that the new term was a lie, as Germany took pains to reassure Arab governments that it regarded their inhabitants as neither threatening nor inferior.\n\nThe target of the new \"-ism\" was Jews, and by focusing on their ancestral language and using an abstract, pseudoscientific euphemism to group them, the antisemites purported to (a) differentiate Jews authoritatively from everyone else, (b) root their difference in their very nature and thought processes, and thus (c) assert that opposition to Jews was not a mere prejudice, but a response to a demonstrable reality that had to be dealt with politically.\n\nUntil recently, English spelling has unwittingly accepted the antisemites' case, since the customary insertion of a hyphen and a capital letter in \"anti-Semitism\" implies that there is something called \"Semitism\" somewhere. The original language of the term, German, doesn't make this mistake; the spelling is _Antisemitismus_ , all one word. Nowadays, people and institutions alive to this subtle fact, such as the United States Holocaust Memorial Museum, insist on the one-word spelling of antisemitism. Neither Microsoft Word's spellcheck function nor the _Oxford English Dictionary_ has caught on yet.\n\nThe principal way in which antisemitism has evolved and varied over time has to do with the relative strength of its xenophobic and chimerical forms, as identified by Gavin Langmuir, a distinguished medievalist, but slightly redefined here. The xenophobic form sees Jews as _different_ from others in some _observable_ respects, and its adherents exhibit varying degrees of _discomfort_ with this difference. The chimerical form sees Jews as _dangerous_ to others in some _imagined_ ways, and its exponents advocate _doing something_ in response. The origins of the words highlight the distinction: _Xenos_ is Greek for \"stranger, guest;\" _chimera_ is Greek for a mythical fire-breathing monster with a lion's head, a goat's body, and a serpent's tail.\n\nAncient Roman attitudes toward Jews best illustrate the consequences of the distinction. The Roman writer Tacitus criticized the Jews for a supposedly \"stubborn attachment to one another . . . which contrasts with their implacable hatred for the rest of mankind,\" and the Romans did not like or understand such Jewish customs as monotheism, which entailed refusing to worship the emperors as gods; the Sabbath, which amounted to taking only one and the same day off from work every week; endogamy, which mandated marrying only other Jews; and circumcision of male infants as a symbol and reminder of a special arrangement with God. But the Romans did not see the Jews as especially or intrinsically dangerous, except when they resisted the empire's authority. Even after the destruction of the temple in Jerusalem in 70 CE by the army of the future Emperor Titus and the suppression of the three successive revolts against Roman rule that led to the almost complete dispersal of the Jews from ancient Judaea after 136 CE, individual Jews could and did still become Roman citizens, and they populated many different walks of life.\n\nAlthough some ancient Egyptian and Greek texts express animosity toward Jews, the rise of intense hostility to and fear of them largely coincides with the rise of Christianity. The relationship between adherents of the two religions always has reflected a paradox: The two faiths were both very similar and very different, which created intense competition. Jews saw the new religion as essentially a heresy, an erroneous variation on their theology. Christians saw themselves as embracing a new, improved version of that theology, one that superseded the old, which should be cast off as a relic of an earlier era.\n\nChristians both took over and then deviated from the central tenets of Judaism. First, they proclaimed monotheism but declared Jesus the son of God and thus divine and advanced the doctrine of the Trinity, one God in three forms. Second, Christians accepted the Hebrew Bible as revealing the word of God and incorporated it into their Bible as the Old Testament, but then added the Gospels (the \"Good News\") and other books as new revelations of God's will. Third, Christianity adapted the Jewish ideas of election and the Covenant between God and His people to new purposes. Jews believed that they and God had concluded a series of special agreements or pacts, the most famous of which are the ones with Abraham and Moses in which God promised to make the Jews his Chosen People and \"a light unto the nations\" in return for obedience to his laws. These consisted initially of the Ten Commandments, but became elaborated into the 613 central laws or _mitzvot_ \u2014actually 248 commandments and 365 prohibitions\u2014set forth in the Torah, the first five books of the Bible, which Christians call the Pentateuch. These laws covered everything from what one may eat or wear to how one should wash and worship. Christianity declared that Jesus heralded a new Covenant that replaced Moses's, that the old laws were now obsolete, and that election to the status of Chosen People was now open to anyone who accepted Christ and the teachings of the Bible and the new scriptures.\n\nOne way of understanding what followed is to recall that Jews were the people who said no. Offered a new form of relationship with God, they said they preferred the one they had, and this rejection set off several hundred years of rivalry and mutual recrimination, as the two groups competed for followers until the fourth century of the common era, when Christianity became the official religion of the Roman Empire and thus seemed to win the battle.\n\nThat brings us to figure 1, which tries in schematic fashion to capture three interwoven matters: (1) the evolving and overlapping forms of animosity to Jews that developed in Europe during successive eras once Christianity had become dominant, (2) the changing definitions of the problem Jews supposedly represented, and (3) the shifting prescriptions for fixing the situation.\n\nThe time frames specified on the chart indicate that distinct frameworks for criticizing Jews developed in those periods, but that does not mean that the new ones erased the old ones entirely. Some people remained antisemitic in the 1940s for reasons devised during the first period; in fact, some people are still antisemites for these supposed reasons. One of the most interesting recent books on the Holocaust, Alon Confino's _A World Without Jews_ (2014), in fact argues that a secularized version of the Christian claim to historical supersession was at the heart of the Nazi drive to eradicate the Jews. Instead of advancing a new religion of supersession, the Nazis saw themselves as promoting an entirely new conception of morality. Confino's claim is not entirely original. Sigmund Freud and Maurice Samuel argued similarly about the roots of antisemitism on the eve of the Holocaust, L\u00e9on Poliakov and Norman Cohn about those of Nazi racism shortly afterward. But these thinkers understood that the Nazis were not so much trying to supersede Judeo-Christian morality as to nullify or repeal it. Nazi morality was of the \"back to the future\" sort; it demanded acknowledgment that the only governing principle of life is the primordial law of the jungle and that the only measure of goodness is physical survival.\n\nFIGURE 1: THE OVERLAPPING LAYERS OF ANTISEMITISM\n\nThat the justifications of antisemitism changed over time also does not mean, despite the prestige of science, that the prejudice became more intellectually sophisticated\u2014that the later phases were more informed and intelligent. They only posed as such.\n\nThe first horizontal block in figure 1 concerns the long era of European history in which the dominant framework of thought was religious and the central question that determined or legitimized ideas and policies was \"What does God want or demand?\" The governing dilemma of Christianity during this long period of discrimination against Jews is that the Church had to do a theological balancing act between two contradictory obligations toward them, as stipulated in the \"doctrine of Jewish witness\" devised by St. Augustine, the Bishop of Hippo in North Africa, in the early fifth century: persecution and preservation. On the one hand, Augustine taught that the Church had to demonstrate \"the negation of the Jews\" and \"the election of the Christians\" by, first, emphasizing the Jews' responsibility for Christ's death as alleged in the later Gospels and, second, making the Jews' existence on earth ever more isolated and miserable as a physical representation of the consequences of rejecting Christianity. Thus, according to this part of Christian theology, the Jews had to suffer because they were religiously benighted\u2014spiritually in darkness.\n\nOn the other hand, Jesus was a Jew, and the Jews once had been God's Chosen. Augustine taught that they could not be massacred, unlike every other religious group that denied or deviated from the claim to truth of Catholic or Orthodox Christianity. Indeed, they had to be allowed to live, albeit in misery, until the wondrous day when they saw the light and converted, for that development would herald the Last Judgment and the coming of the Kingdom of Heaven. This is the explanation for a remarkable irony of this story, the survival of the Jews. They were the only religious minority whose faith remained legal in Christian Europe, whose adherents were not automatically and always slaughtered, as the Cathars, Lollards, and other dissenters were, until the Reformation split Western Christendom, and the catastrophically bloody and ultimately stalemated Wars of Religion of the sixteenth and seventeenth centuries taught Catholics and Protestants the necessity of coexistence.\n\nThe results of Augustine's dicta included, for hundreds of years, Christian condemnation of the Jews, supplemented by constant establishment of barriers to contact with Christians so that their faith could not be subverted. The relegation of Jews to pariah status, the Church hoped, would induce them to convert. In the final centuries of the Roman Empire, Jews lost the rights, first, to acquire, and later even to hold, Christian slaves, which broke the back of Jews' wealth. One after another, new laws barred Jews from proselytizing, from reversing baptisms, from cohabiting with or marrying Christians, from holding public office, and from building synagogues. Enforcement of separation between Christians and Jews was uneven in Christian Europe, but it steadily increased, eventually creating a pattern of occupational and residential ghettoization that confined Jews to certain usually despised or dangerous activities, such as moneylending or leather tanning, and certain permissible locations, also usually less than desirable ones.\n\nAs all this unfolded, the Church found that it could not quite get away with simultaneously fostering hostility to Jews and forbidding violence toward them. Ordinary people periodically lost sight of the theological reasons why adherents of this religion that denied Christ's divinity should be treated differently from all other heretics and infidels and therefore periodically lashed out at Jews, especially in times of adversity. Forced conversions and expulsions flared up as early as the seventh century, then faded away until a rash of outbreaks following the millennial year 1000 and a widespread surge of attacks surrounding the First and Second Crusades (1095\u20131149). These were generally mob actions opposed by local priests and nobles, but they became common responses to crisis events, and in twelfth-century England they acquired a legitimizing legend, namely the blood libel or ritual murder accusation that ascribed disappearances or deaths of Christian children to an alleged Jewish need for their blood to make matzoh bread for Passover or other ritual purposes. Precisely because the charge was a blatant projection onto Jews of a corrupted form of the Catholic belief in transubstantiation\u2014the creed that the communion wafer and wine become the real flesh and blood of Christ during the Mass\u2014the charge stuck, and it became the pretext for numerous massacres, first in England and later in much of Europe.\n\nBy the late Middle Ages, a correlation between social crisis and the slaughter and expulsion of Jews had become firmly established. Whenever adverse developments occurred that people could not otherwise account for, they identified Jews as the agents of Satan who had caused the problems. Massacres of Jews followed the Italian famine of 1315\u201317 and the outbreak of the Black Death in the Rhineland in 1347, for example. Such popular panics, combined with monarchical desires to confiscate Jewish property, resulted in expulsions of Jews from England and southern Italy in 1290, from France in 1306 and again in 1394, from Spain and Portugal in 1492 and 1497, and from many German cities during the fifteenth century.\n\nAs segregation and degradation increased, so did the penetration of popular culture by denigrating images of Jews. The Passion Plays performed at Easter across Christian Europe highlighted the supposed role of Jews, rather than that of Pontius Pilate, in ordering Christ's crucifixion. Chaucer's _Canterbury Tales_ , written around 1386, include a story of ritual murder by Jews in \"The Prioress's Tale.\" The story of Shylock seeking his pound of flesh that is at the core of Shakespeare's _The Merchant of Venice_ , written in the final years of the sixteenth century, had appeared in Italy more than two hundred years earlier. After 1400, church decorations included an increasing number of depictions of Jews being nursed by sows, and the first printed version of what later became the stereotypical caricature of a Jew with a beaked nose and hunched back appeared in a book of 1493.\n\nBy the time of the Reformation in the sixteenth century, hatred of Jews was widespread, and it had crystallized around two central generalizations: (1) that Jews were parasitic profiteers, intent on extracting wealth from Christians, and (2) that Jews were incorrigible instruments of Satan, intent on serving his purposes and afflicting the pious. Martin Luther gave the most extreme voice to these prejudices when he discovered that Jews were no more willing to convert to his version of Christianity than the one he claimed to have reformed. He urged Christians to burn Jews' synagogues, schools, and homes and subject Jews who would not convert to forced labor. In fact, as David Nirenberg has pointed out, \"Like so many prophets before him,\" Luther literally \"died in combat with the Jews.\" In the winter of 1546, he traveled to Eisleben, the city of his birth, in order to dissuade the town from giving refuge to Jews who had fled other cities. He promptly came down with a chill, nonetheless delivered several angry sermons that turned out to be the last ones of his life, and passed away. Even Luther's contemporary, the learned sixteenth-century humanist Erasmus, a man generally regarded as one of the most open-minded thinkers of his day, wrote, \"If hatred of Jews makes the Christian, then we are all plenty Christian.\"\n\nAnd yet, we all were not, so to speak. In the mid-1500s, the Netherlands welcomed the Jews expelled from Spain, just as the kings of Poland earlier had encouraged the Jews driven from the Rhineland to migrate eastward. In the 1600s, England reversed its policy and opened its borders to Jews again. Despite the exiles from many of the territories that today compose Italy and Germany, Jews never entirely disappeared from all of them. And for all of Luther's fury, other Protestants, especially Calvinists, were respectful toward the people they saw as their religious forebears.\n\nIn other words, if hostility toward Jews was sometimes xenophobic and sometimes chimerical, it was also sometimes dormant. By the eighteenth century, hostility to Jews on various religiously rooted grounds, now fortified by centuries of segregation and condemnation, was widespread and habitual in Europe but not universal. And it was at least theoretically not murderous. The perceived problem was what the Jews believed or chose not to believe; the solution was for them to change their minds, to convert. The means to get them to do so was cruelty toward them, but generally not murder. They were to suffer, but they were also to survive.\n\nThat brings us to the second horizontal block in figure 1, the era in which the domination of thought by religion began to come to an end in the European world. The transition is beautifully and best expressed in a couplet from Alexander Pope's poem \"An Essay on Man\" (1734): \"Know then thyself, presume not God to scan; \/ The proper study of mankind is man.\" This is a fitting epigraph for the Age of Enlightenment, also known as the Age of Discovery, and the precursor to the Age of Revolution. In these new eras, the driving question was \"How can people improve the world?\" Of course, labels and generalizations of this sort should be treated warily, but, broadly speaking, the eighteenth century ushered in an age whose watchwords were freedom and liberation or, as the French Revolution's slogan went, \"liberty, equality, fraternity.\" Liberty not only from political tyranny, however, but also from intellectual restrictions, such as those set by religious authority and tradition. Alexander Pope's admonition amounted to a call to stop concentrating intellectual energy on matters like theology and to focus attention instead on the human and natural world. Of course, distinguished individuals had been doing that to some degree since the beginning of the Renaissance, but Pope's clarion call heralded a shift in emphasis, a change in the intellectual center of gravity in the Western world.\n\nThe emblematic figure in this sense was the French philosopher Fran\u00e7ois-Marie Arouet, better known by his pen name of Voltaire, who mocked those who believed they inhabited \"the best of all possible worlds\" and goaded his readers to use their heads to improve society. A fierce critic of all traditional religions, he attacked both the Catholic Church and traditional Judaism with equal vehemence for confining people's thinking and insisting on the continued practice of ancient rituals. In championing the human capacity for improvement, Voltaire embodied the optimism of the age. He also endorsed a new form of hostility to Jews, one that hoped in a figurative sense to \"kill them with kindness\"\u2014to end their difference from the rest of society by freeing them from inherited restrictions, such as ghettos and confinement to certain occupations.\n\nIn theory, this form of hostility to Judaism closely resembled its predecessor in everything but its religious foundation and method. The problem was no longer what Jews believed, though many eighteenth-century thinkers criticized Judaism as overly fixated on obeying old laws and rituals. The problem was the supposedly backward culture of intense Talmud study and rigid observance of traditional practices that prevented Jews from being free and full contributors to society. And the remedial method was no longer cruelty and suffering but kindness and opportunity\u2014the carrot, not the stick. Jews were to be enticed out of their distinctness and into a secular form of conversion: not necessarily a change of religion but a change of everything unique about the religion's adherents, until they became indistinguishable from everyone else. Making them useful was the initial goal of Emancipation\u2014the abolition of residential and occupational restrictions on Jews\u2014by the Austrian Emperor Joseph II in the 1780s, and by the French Revolution and Napoleon Bonaparte in subsequent decades, but making them similar was the ultimate purpose.\n\nThis strategy had notable successes, at least in Western Europe. But even there Judaism and differences between the customs and marriage patterns of Jews and non-Jews did not disappear. Many emancipators were disappointed with the results, even as many people who disliked Jews were, too, though for entirely different reasons.\n\nThat brings us to the third horizontal bar in figure 1, the bar concerning the period following the invention of the new word _antisemitism_. The invention marked an ominous qualitative change, in that the new form of hostility focused not on what Jews believed or how they behaved but on what they intrinsically and unchangeably supposedly are. Antisemites generally agreed, as the classification of Jews by their original language implied, that the nature of Jews, their inherited and common qualities, made them not only incapable of becoming like other people, but also fundamentally subversive of other peoples and their societies. Jews could not be changed, but only contained and then eliminated. We might call this the biologization of antisemitism, and it coincided with a shift in the central questions of intellectual and public life from \"What does God want?\" and its successor \"How can people improve the world?\" to \"What material or physical laws govern us?\"\n\nProponents of this depiction of Jews drew on both old and new forms of science. The old one was basically animal husbandry, the science of breeding. Such people argued that peoples or nationalities were essentially like breeds of horses or dogs, each with special qualities that were passed on from generation to generation and that could be enhanced by selective mating. Thus Germans, like their German shepherds, were good fighters; the French, like their poodles, were showy; and the British, like their bulldogs, were tenacious. The nineteenth century was the great age of generalization of this sort, as each competing European nationality strove to define what made it distinct and great and what made its rivals inferior. As the historian Albert Lindemann has pointed out, \"beliefs in racial or ethnic determinism were the norm in most countries\" in the nineteenth century, even among Jews.\n\nThis old science was reinforced by vulgarized understandings of a new one, Darwinism, the science that argued that animal and plant species survive by random, perhaps accidental, but definite adaptations to their environments. As populations of flora or fauna spread out, they become increasingly different from each other by virtue of this adaptation. Many nationalists argued that their fellow Frenchmen or Germans or Jews and so on were like species, specifically adapted to their historically different surrounding conditions and profoundly different from each other as a result. As Julius Langbehn, a widely read German antisemite, put the matter: \"A Jew can no more become a German than a plum can turn into an apple.\"\n\nThe other newer sciences were often belief systems that we no longer consider scientific at all, but until they were invalidated, they also sustained a line of thought that exaggerated the differences among groups of human beings. These belief systems played to a widespread desire in Europe during the heyday of colonialism to show that descriptive or horizontal differences among peoples in such things as skin color and eye shape in fact denoted qualitative or vertical differences in ability\u2014that is, superiority and inferiority. Arthur de Gobineau's three-volume _Essay on the Inequality of the Human Races_ , which appeared from 1853 to 1855, became the authoritative text of this sort. It divided humanity into three great racial blocs: the white peoples, who were supposedly spiritual and creative; the yellow peoples, who were allegedly materialist and imitative; and the black ones, who were reputedly sensual and primitive. Even worse than this sort of global categorization, if that is possible, were Gobineau's warnings against race mixing. He linked the existence and endurance of a civilization with the purity of its dominant race and thus, although he was not an antisemite, provided arguments that such people later could use.\n\nWhat Gobineau's and other nineteenth-century pseudosciences had in common was the claim that external qualities indicated internal ones. Among the other prototypical schools of thought were: physiognomy, the invention of Johann Lavater (1741\u20131801), who claimed that the shape of faces, notably the straightness of the line from brow to chin, denoted superior traits; and phrenology, the creation of Franz Joseph Gall (1758\u20131828), who claimed that the shape of heads did the same thing because that shape determined the configuration of the brain, and the size of its various parts determined humans' capacities. Gall's follower Anders Retzius (1796\u20131860) devised a system of measuring skulls and a formula for expressing the relationship between his findings that he called the cephalic index. Unsurprisingly, given his European origins, Retzius concluded that the longer and narrower the head, the more superior the person. Finally, a more legitimate field of study called philology focused not on people's appearance but on their speech. As practiced in the nineteenth century, philology traced the origins and historical relationship of languages. By the beginning of that era, scholars had established that most European languages\u2014the exceptions are Basque, Hungarian (Magyar), and Finnish\u2014descended from ancient Sanskrit, which had been carried from southern Asia to Europe by a people called Aryans. The point of origin and the destination are what account for titling this family of languages Indo-European.\n\nThe person who turned the descriptive classification of tongues into a hierarchical one was the German philologist Friedrich Schlegel (1772\u20131829), who became the godfather of the Aryan theory of transmission in a book published in 1808. He and his followers described the grammar of Sanskrit-based languages as more precise and subtle than that of other language families, especially the Semitic one that included Arabic and Hebrew, and thus as proof of higher imagination, reasoning, and intellectual growth potential on the part of those who spoke Indo-European tongues. The basis of modern antisemitism became the claim that Jews had been shaped over time\u2014not only by their language but also by their original desert environment\u2014into a species of people fundamentally and unchangeably different from all Europeans, who had been molded differently by the wooded and fertile setting that most of Europe provided. Moreover, because Jews were immutably alien, they had to be contained and expelled, not converted or absorbed, because\u2014this is where the animal husbandry and Darwinism got mixed into a witches' brew\u2014peoples could thrive, compete, and adapt only by preserving their purity, by inbreeding. Ethnic mixing inevitably corrupted the special qualities associated with each breed or nation and led to decline because the traits of the inferior partner always predominated in the offspring.\n\nOf course, this is nonsense as genetics; even as aesthetics, it is accurate only for the sort that prevail at the Westminster Kennel Club, where a winning dog must conform perfectly to an idealized image of its breed. Nowadays we know, partly as a result of such thinking, that inbreeding actually can be harmful. Pursued obsessively, it leads in humans, as in dogs, not to greater perfection but to a host of congenital ailments and to heightened vulnerability to illness.\n\nBut the appeal of breeding as a form of public policy increased in the final decades of the nineteenth century because of widespread anxiety over what industrialization and urbanization were doing to European populations. A buzzword of the time was \"degeneration,\" and its signs were supposedly everything from the mounting incidence of tuberculosis, alcoholism, and venereal diseases that went with crowded and poor urban conditions to the supposed brutishness and ineducability of the rapidly multiplying working classes. In this climate, support for ideas of improving the human stock by selective breeding increased rapidly; indeed, such ideas were considered the cutting edge of sophistication. Their chief proponent in the English-speaking world was Francis Galton (1822\u20131911), who coined the term \"eugenics\" for his program of human betterment. In Germany, the equivalent figure was Alfred Ploetz (1860\u20131940), who preferred the term \"racial hygiene\" to describe his system of defending the development of the \"West Aryan\" or \"Germanic race\" from the supposedly counterproductive consequences of what he termed the \"growing protection of the weak.\" Chief among the protective measures he advocated was the killing of deformed or handicapped children, so that they would not burden healthy people or reproduce physical or mental defects.\n\nAlthough these doctrines spoke a language of racial \"improvement,\" the measures they proposed were profoundly fatalistic and reactionary. The message of Galton and Ploetz was that throwing money at poor people's problems was pointless; they existed because poor people were less able or, in pseudo-Darwinian language, \"fit\" for survival in life's struggles. Thus, if one wanted to improve humanity, these eugenicists or racial hygienists contended, the way forward was not to help the downtrodden by building better housing, improving working conditions, and raising the level of public health, for example, but instead to reduce reproduction by the poor and diseased and to increase it by their betters. Galton's successors labeled these two processes \"negative\" and \"positive\" eugenics.\n\nNeither these doctrines nor their founders were necessarily or explicitly antisemitic, but their conceptions of what needed to be improved in various populations and what needed to be bred out of them swiftly spilled over into the arguments of racists and became adapted to their purposes. This reinforced the pseudoscientific pose that bigotry toward Jews assumed with the coinage of the word \"antisemitism.\" Once Jews were defined as distinct from others, then their presence could be depicted as an invitation to destructive cross-breeding; once they were declared the embodiments of unwanted characteristics, their removal from the national body could be justified as a form of racial hygiene.\n\nThus, by the late nineteenth century, European antisemitism had a long and varied history. The persecution of Jews had been recurrent but far from universal or continuous. Attacks on them had evolved over time from ones ostensibly inspired by religious differences to ones that expressed physical fear. Of course, the overlapping phases of Jewish stigmatization always had one constant element: a depiction of Jews as contaminating or corrupting. Their proximity was seen as potentially undermining: first to Christians' faith, then to liberals' belief in human improvement, and finally to the strength and health of other populations.\n\nYet persecution appeared to be on the wane at the end of the nineteenth century, even though new justifications for it had come into being. The expansion of Jews' rights contained the seeds of boisterous backlash that reinforced old prejudices but failed to erase Jews' gains. At the same time that antisemitism seemed to surge and swell, it remained politically largely impotent.\n\nEMANCIPATION AND BACKLASH\n\nIn order to explain why Jews encountered a resurgence of agitation against them in the late nineteenth and early twentieth centuries, we must shift our attention away from the ideas that supposedly legitimated hostility and toward the circumstances that made certain groups of people receptive to it. The result is an ironic and somewhat contradictory story of widening opportunities and rights for Jews accompanied by ever more fervent and frustrated attempts to reverse this process.\n\nUntil what historians call the \"long nineteenth century\"\u2014the 125-year period between the outbreak of the French Revolution in 1789 and the onset of World War I in 1914\u2014most Jews lived in very confined worlds. Jews could be moneylenders, tavern keepers, itinerant peddlers, or cattle buyers who came in contact with non-Jewish customers; in parts of Eastern Europe Jews often managed estates for noblemen and thus dealt with tenants; and observant Jews may have had a reliable non-Jewish employee who came in to light their fires and do any other work that was forbidden on the Sabbath by the 613 laws. Otherwise Jews had very limited interaction with and visibility to non-Jews.\n\nBoth of these circumstances began to change in the 1780s. The first crack in the wall of religiously inspired restrictions on Jews came via the succession of Patents of Toleration issued by Austrian Emperor Joseph II for disparate parts of his realm between 1781 and 1789. Of these, the most famous was the Edict of Tolerance of January 2, 1782 governing Vienna and its environs, which set forth the general purpose of \"making the Jews useful to the state.\" To that end, the edict opened Christian schools and universities to Jews, along with numerous trades and commercial occupations previously denied to them; permitted them to employ Christian servants; and relieved them of two conspicuous burdens: a special tax and the obligation of men to wear beards. But the edict also severely restricted Jews' abilities to settle and worship in and around the Austrian capital and to enforce documents written in Hebrew or Yiddish. The point of that last prohibition was to make Jews learn to read and write German, and it succeeded to a remarkable degree. In the German-speaking lands of the early nineteenth century, Jews enjoyed a higher literacy rate than even their gentile neighbors, who were relatively well educated by European standards.\n\nMuch more far-reaching than Joseph II's edict was the enactment of the Declaration of the Rights of Man on August 26, 1789, during the heady first days of the French Revolution. That document declared, \"Men are born and remain free and equal in rights. Social distinctions may be founded only upon the general good,\" and went on to proclaim that all citizens are equal in the eyes of the law and therefore equally entitled to hold office and to do \"everything that injures no one else.\" But it took another two years, until September 27, 1791, for the National Assembly to pass a law making Jews full citizens of France. Although Napoleon backtracked to some degree on Jewish equality in France over the next few decades, his armies spread French ideas and practice across much of Europe, tearing down ghetto walls and removing occupational and political restrictions. He thus set in motion both the modern process of Jewish emancipation and the backlash against it that produced the modern form of antisemitism. As noted earlier, the roots of modern antisemitism are in religious differences: Christianity caused Jews both to suffer and to survive for centuries in Europe. But the form of hostility toward Jews that arose in the late nineteenth century and that called itself antisemitism is fundamentally a political movement, an expression of resistance to the emancipation of Jews that began in the late eighteenth century, gathered strength throughout Western and to a lesser degree Central Europe in the nineteenth century, and then reached even into the eastern parts of the continent with the Russian revolution in 1917.\n\nFormally speaking, emancipation was the process by which Jews were freed of all occupational, residential, and political restrictions and placed on a legal status of equality with all other citizens of a state. But to put it that way is too abstract; that definition ignores what emancipation meant in human, day-to-day terms, including what it felt like to the non-Jews who experienced it. It meant the emergence of Jews from pariah status; it meant almost literally their \"entrance\" into society and into regular contact with non-Jews; and, above all, it meant two possibilities that aroused opposition: first, people who had previously been kept from competing with the practitioners of certain trades and professions now could do so; and second, people who had previously been derided as benighted and backward, as dirty and superstitious, could ascend to positions of authority over non-Jews, over people accustomed to seeing themselves as \"better\" than Jews. Fear of this second possibility was particularly pronounced in a by no means unusual Bavarian petition of January 10, 1850, opposing equality for Jews. In that document, eighty-three citizens of the town of Hilders in the province of Lower Franconia, which eighty years later became a Nazi stronghold, pleaded for the repeal of emancipation and, in particular, \"that . . . no Jew be admitted to a judicial or revenue office, lest we have to humble ourselves before the Jews.\"\n\nThese emotional and practical effects of emancipation go a long way toward explaining the intense resistance it encountered and the halting and erratic nature of its course. After the fall of Napoleon in 1815, the Austrian Empire retained the reforms that Joseph II had introduced, but France was the only other state in Europe that did not turn the clock back; the only legal difference that remained there between Christians and Jews was that the state paid priests and ministers, but not rabbis. In 1830, that distinction disappeared, too. But everywhere else where the French had brought emancipation the new or restored rulers rolled it back, even if sometimes only briefly. Then, between 1830, when Belgium established civil equality upon achieving its independence, and 1871, when newly unified Germany did so, every state that had once been under French domination, along with a few countries in Western and northern Europe that had not, such as Great Britain, Sweden, and Switzerland, reversed the rollback and completed the emancipation process.\n\nEmancipation did not extend, however, to the lands of the Russian Empire, including the largest population of Jews in Europe in the Pale of Settlement, the parts of today's Poland, Lithuania, Belarus, and Ukraine to which most Jews were confined until the revolution that overthrew the tsars in 1917. Neither were the Jews emancipated in Romania until the end of World War I, and then only at the insistence of the victorious Allies. The late onset of emancipation in these regions and the strong resistance to it there are significant, for these are the areas where the Nazis later found most of their victims and received the most widespread local assistance in their murder.\n\nEmancipation was the political project of people called liberals, and it rose or fell everywhere according to their strength. Who were they? The word \"liberal\" derives from the Latin word _liber_ , which means \"free.\" They were the advocates of political and economic freedom, of (a) the rule of law, as created through constitutions and popular elections, not by royal fiat; (b) open and competitive markets, as opposed to guilds that restricted access to an economic activity and tolls and tariffs that restricted the movement of goods; and (c) the importance of ability over birth, as opposed to the aristocratic principle. Uniting the liberals' political and economic tenets was a general openness to change expressed by the French phrase _laissez faire_ , \"allow to do\" or, more figuratively, \"let happen,\" the phrase connoting a willingness to permit economic events to take their course and to generate a continuous process of what Joseph Schumpeter later dubbed \"creative destruction.\"\n\nThe liberals' heyday in Europe was exactly the period when emancipation triumphed, the years between 1830 and 1870, but the strength of liberalism, like the pace of emancipation, declined from west to east, from Britain and France to Russia. The farther west, the quicker the liberals' ascent to power, and the quicker emancipation came; the farther east, the less influence they exerted and the less change occurred in the legal position of Jews and their interaction with gentiles. In England, a man of Jewish descent, Benjamin Disraeli, could become prime minister in the 1860s. But in the Russian Empire such a thing was unthinkable, the religiously rooted condemnation of Jews remained the official doctrine of the state, and violent attacks on Jews remained an ever-present possibility. As we shall see, Germany was \"the land in the middle,\" both geographically and with regard to the pace and extent of emancipation.\n\nThe liberals' triumph was gradual and incomplete because it encountered resistance almost everywhere, though to varying degrees. To understand why, we need to look at what else was happening while emancipation was spreading. In the nineteenth century, six sweeping trends transformed European society.\n\nFirst, Europe experienced a population explosion from about 190 million people in 1800 to about 420 million in 1900. In some places, the increases were even greater: The total inhabitants of England, Scotland, and Wales tripled from 1821 to 1911; the populations of the Netherlands, Denmark, Norway, and Germany almost did so from 1816 to 1909\/10; and those of Belgium and Sweden grew by 250 percent. Amid this massive upheaval, the European Jewish population multiplied even faster, from 1.5 million in 1800 to 8.7 million in 1900 (an almost sixfold increase). And it multiplied fastest where it was poorest and most persecuted, in the Russian Empire, which created enormous pressure on Jews to get out somehow to somewhere.\n\nSecond, Europe underwent widespread industrialization, which transformed landscapes, created massive factories, provided employment for those surging numbers of people, multiplied goods, and in the process extinguished entire lines of work. Factories, not cobblers, came to produce most shoes. Textile mills turned out cloth far more rapidly and cheaply than individual weavers at home. Whole trades disappeared\u2014how many people today know what a \"cooper\" is or a \"wainwright\"?\u2014and the skilled workers who populated them, known as artisans, lost their livelihoods and social standing. But mass production was sensitive to fluctuations of supply and demand, and mill owners tended to push the consequences of these fluctuations onto workforces, with the result that industrialization created cycles of boom and bust, widespread resentment, efforts to push back in the form of unions and organized socialist movements, and enormous social tensions.\n\nThird, with industrialization came urbanization: The population of London grew from 900,000 to 4.7 million between 1800 and 1900, that of Paris from 600,000 to 3.6 million, and that of Berlin from 170,000 to 2.7 million. In 1800, only two European cities had more than half a million inhabitants, London and Paris; in 1900, twenty-three cities did, including seven with more than one million people. Everywhere Jews were conspicuous participants in this migration from the countryside to the cities, and their share in the urban populations, along with their visibility, generally rose dramatically, especially in Vienna, Berlin, Warsaw, and Budapest.\n\nFourth, extensive improvements in transportation, notably the railroad and steam shipping, accelerated trade and opened Europe to increased competition, especially in agriculture, from newly developing regions, such as the Great Plains of the United States and the pampas of Argentina. This put substantial downward pressure on the prices European farmers could get for their harvests. It also meant that the handicrafts of some regions could be wiped out by the industrial production of others. Increasing exposure to market forces bred widespread insecurity and free-floating desire to blame someone for it.\n\nFifth, increasing democratization occurred in the forms of successive extensions of voting rights, though as yet only to men, and progressive though incomplete reductions in the privileges and political powers of aristocrats. The results included the rise of mass politics and political parties and of the popular press, much of it of the tabloid sort. Political agitation became a more regular feature of life, as newspapers sought to whip up circulation through sensational accounts, especially of mysterious, behind-the-scenes wire pulling. The term \"muckraking\" is a creation of the era, and there was plenty of it going on in the last thirty years of the nineteenth century, when one financial and\/or political scandal after another occurred.\n\nSixth, though religious observance remained important, the nineteenth century saw considerable secularization in thought and education, and the trends were resisted fiercely by the papacy, many Protestants, and the Orthodox Church in the East. In fields as disparate as theology, where David Friedrich Strauss launched the critical historical study of Jesus, or biology, where Darwin advanced his theory of the long-term evolution of all life through adaptation, the Christian worldview and traditional piety came under attack and became increasingly regarded in sophisticated quarters as pass\u00e9. Perhaps the most advanced state of secularization was reached in France, which passed the Ferry Laws between 1879 and 1886, removing elementary education from the purview of the Catholic Church and setting up an explicitly anticlerical school system.\n\nIn short, the nineteenth century was an era of rapid, constant, and often bewildering change, and change always unnerves and\/or harms some people. The \"losers\" were clear: clergy who experienced declining deference to their persons and views; nobles who no longer monopolized office or found their lands a guarantee of great relative wealth; conservatives who disliked change in principle and parliamentary government in practice; farmers who faced international competition and thus downward pressure on their incomes; artisans driven out of business by factory production; property owners who feared the growing strength, as the century progressed, of workers' unions and workers' political movements, notably socialism; and even university graduates, who faced steep competition for professional positions. Of course, not every member of these groups experienced a decline of wealth or status during the nineteenth century, but a good many of them did.\n\nMembers of all these groups sought explanations for what was happening, and more importantly for what was going wrong for them. In such a context, conspiracy theories found an audience. They were easy to understand, and, then as now, no matter how convoluted, such theories were precise about who to blame for events, namely whoever is apparently benefiting from them. The perpetual motto of conspiracy mongers is the Latin phrase _cui bono_. Who benefits? Or in modern parlance, \"Follow the money.\"\n\nMany Jews were among the conspicuous and principal beneficiaries of the open and competitive universe that liberalism fostered. Many Jews also remained grindingly poor, especially the farther east one looked in Europe. But the number who became prosperous during the nineteenth century, the number who seized on the opportunities that came with emancipation, was real and striking. This was especially true in the spheres of banking and commerce and the professions of law and medicine. In a sense, the Jews of nineteenth-century Europe engaged in what sociologists and historians think of as classic first-generation, upwardly mobile \"immigrant\" behavior in the United States. Newly emancipated Jews sought out and strove for places in lucrative and secure walks of life, activities that would make their and their children's existences reliably better than their parents'. And, indeed, most of these Jews were immigrants or at least internal ones. Massive numbers of Jews from the far eastern provinces of the Austro-Hungarian monarchy (Galicia, Ruthenia, and Bukovina) migrated to Vienna and its environs, where their traditional garb and their Yiddish speech, which sounded to German ears like a corrupted and grammatically simplified form of their language, later aroused the ire of Adolf Hitler. In Paris, much of the Jewish population arrived in the nineteenth century from Alsace, the border province that Germany took away from France in 1871. In Berlin, a similar inflow came from Posen, a largely rural eastern province that Prussia had stripped from Poland in the late eighteenth century.\n\nInvisible among college students, lawyers, and doctors and rare among business leaders in 1800, Jews seemed disproportionately present in all these prized roles by the 1880s in many places, and even more so by the early 1900s. Here are some illustrative figures from Central Europe:\n\nIn the 1880s, Jews accounted for only 3\u20134 percent of the Austrian population, but 17 percent of all university students and one-third of those at the University of Vienna; in Hungary, Jews constituted 5 percent of the population, but 25 percent of the university students and 43 percent of those at the leading technological university; in Prussia, the biggest state in the German Empire, Jews made up less than 1 percent of the population in 1910\u201311, but 5.4 percent of the university students, and 17 percent of those at the University of Berlin.\n\nAt the turn of the century in Vienna, 62 percent of the lawyers, half the doctors and dentists, 45 percent of the university medical faculty, and one-fourth of the total faculty were Jews; so were some 55 percent of the professional journalists, 40 percent of the directors of publicly traded banks, and 70 percent of the board members of the Vienna stock exchange. In Hungary at the same time, Jews accounted for 34 percent of the lawyers and 48 percent of the physicians.\n\nIn 1912, 20 percent of the millionaires in Prussia were Jews; in Germany as a whole, Jews came to 0.95 percent of the population but made up 31 percent of the wealthiest families.\n\nOf course, this surge of success was not simply explicable as standard, upwardly mobile immigrant behavior; it also had specific cultural origins. Much of Jews' initial success in commercial activities represented an extension of the few economic roles previously permitted to them. Moneylenders became bankers; peddlers became shopkeepers and later owned and ran department stores; and cattle traders became brokers of commodities and stocks. And the ascent of Jews in the professions certainly drew on the premium their families and faith placed on learning. The discipline in childhood of religious study with heavy doses of memorization and debate over the meaning of texts is not bad training for going into medicine and law. That may have been what Albert Einstein had in mind when he supposedly quipped that the extent of Jewish academic success in nineteenth-century Europe suggested that the Jews had spent the last two thousand years preparing for university entrance exams.\n\nIn nineteenth-century Europe, most Jews did not become successful and\/or rich in the ways just listed, but the number and percentage of Jews rose among the people who did achieve these forms of success. This pattern was noticed, envied, and resented by the social groups that felt and often were disadvantaged or threatened by the change and competition that liberalism favored. Unlike some disappointed emancipators who thought Jews had not taken enough advantage of liberalism by becoming just like everyone else, members of the declining groups argued that Jews had taken too much advantage of the opportunities liberalism opened up. The tendency within these groups often was to confuse correlation with cause, to conclude that the rise of some Jews resulted from a conspiracy by all Jews. A group that benefited from modernization became pilloried as its destructive driving force. Of course, one can hear in these charges echoes of the medieval tradition of blaming Jews for plagues or other catastrophes. But the linkage also echoed the modern socialist movement, which posited a conspiracy on the part of the capitalists to maximize their wealth at the expense of the proletariat. In fact, leftists derided antisemitism as \"the socialism of fools,\" the belief system of people who mistook the identity of their real exploiters by focusing on Jews instead of capitalists. Whatever its medieval or modern inspirations, the connection between the incidence of antisemitism and the extent of perceived economic crisis is close; a clich\u00e9 of the subject is that the appeal of antisemitism rises and falls in inverse relationship with the stock market.\n\nCountering the antisemites' association of Jews with commercial corruption was made more difficult by the fact that many of the late nineteenth century's worst economic and political scandals did involve noticeable numbers of Jews. The most notorious instance in France, the Panama Scandal of 1888\u201392, centered on widespread bribery of French officials and parliamentarians in order to obtain loans to finance a French company seeking to build a canal through Panama. In the end, more than one hundred deputies, senators, ministers, and ex-ministers were exposed as corrupt, and thousands of small investors lost their savings. The bagmen who bought and paid these politicians were almost exclusively Jews, and the case was grist for antisemitic propaganda that attacked their supposed greed and selfishness.\n\nIn sum, the more liberalism triumphed, the more visible and successful Jews became, and the more groups that felt endangered or harmed by economic and political trends lent an ear to a convenient explanation of their troubles. That explanation blamed the Jews and promised relief by repealing emancipation and relegating them to their former contained status. The prevalence of such views seemed to grow with the rise of mass politics and the popular press, both of which encouraged agitators and ideologues. Antisemitism became vocal and loud in many parts of Europe after 1879, and the number of its spokespersons multiplied. Wherever they appeared, such figures as \u00c9douard Drumont in France, Georg von Schoenerer in Austria, and Hermann Ahlwardt in Germany had one thing in common. They came from and spoke to the social groups described here as susceptible to discontent with the direction of the modern world. Wilhelm Marr, the man most responsible for popularizing the word \"antisemitism,\" almost prototypically embodied the frustration and downward mobility that characterized those who found solace in attacking Jews. By the late 1870s, he had failed in succession as a businessman, a journalist, a politician, and a husband, in the last case to a succession of Jewish and half-Jewish wives.\n\nAnd yet the story of emancipation during the long nineteenth century ends with a paradox. Despite their volubility, antisemitic political parties and movements had very little to show for their agitation prior to World War I. Yes, Karl Lueger campaigned on an antisemitic platform, got elected Lord Mayor of Vienna repeatedly, and served from 1897 till his death in 1910. But he also did the Jews of the city no practical harm\u2014in fact, they experienced a sort of golden age during his time as mayor\u2014and his popularity was atypical. At the same time, Budapest elected a Jewish mayor, Adam Vazsonyi, and in 1895, the Hungarian parliament enacted a law that placed the Jewish and Christian faiths on the same legal footing. Indeed, after 1870, emancipation was not rolled back in a single European state. And in some countries, such as France, Italy, and Austria, Jews gained access to the historic bastions of the aristocracy in the diplomatic and officer corps and the university professorships. The reason for this is that, despite all the disruptive effects of modernization and change, the trajectory for most people in Western and Central Europe during the decades preceding World War I was steadily upward as standards of living improved. Occasional recessions were sharp but usually brief or merely sectoral; they hit particular economic sectors, usually farmers, harder than others, but scarcely affected everyone else. In this context, the laments of the pessimists and their claims that the Jews were at the root of all evil never stopped, but these cries also never gained a wide enough following to change laws.\n\nWhatever the popular strength of antisemitism anywhere, it proved really dangerous to Jews only when powerful officials or elites set out to exploit it or harness it to their purposes. The most famous examples are the Dreyfus affair of 1894\u20131906, in which conservative and self-serving army officers tried to pin spy charges on a Jewish colleague, and the ritual murder trial of Mendel Beilis in Kiev in 1913. But Dreyfus ultimately was exonerated, though the effort took years, and a jury of non-Jews, half of whom belonged to an antisemitic organization called the Union of the Russian People, actually acquitted Beilis. Even when power holders sought to exploit antisemitism for their own purposes, an aroused or embarrassed public could and did fight back successfully.\n\nStill, the message conveyed by both the Dreyfus and the Beilis affairs regarding the strength of antisemitism was ambiguous. The evidence is strong, as Barbara Tuchman pointed out in the 1960s and several other scholars have since, that Captain Alfred Dreyfus of the French army General Staff did not come under suspicion of being a spy for the German embassy in Paris solely or even primarily because he was a Jew. Equally important in leading to his indictment were two other facts: His handwriting strongly resembled that of the most incriminating document in the matter, the famous _bordereau_ found in a wastebasket of that embassy by a cleaning woman; and he was a rather remote and condescending person, much given to bragging about his wealth. The French officer corps was monarchist, Catholic, and antiliberal, but an average of 3 percent of the officers were Jews at any given time during the half-century leading up to World War I, which was thirty to sixty times their share in the total French population in that era, so the institution was not overtly antisemitic. In other words, Dreyfus's military peers and superiors turned on him initially and impetuously in 1894 because they needed a culprit, the handwriting evidence seemed plausible, and they disliked him personally. They persisted in professing his guilt because they feared that backtracking would embarrass the army to whose prestige they were devoted. The antisemitic gutter press turned Dreyfus's heritage into the central issue in the case, not the army, and the prosecutors at his trial did not even mention the subject. At the moment of Dreyfus's conviction in shamelessly manipulated proceedings, even prominent Jewish leaders, as well as Jean Jaur\u00e8s, the leading French socialist who later was one of Dreyfus's most vigorous defenders, believed in his guilt.\n\nAnother disconcerting fact is that the man who first identified another, more plausible spy within the General Staff and whose efforts ultimately led to Dreyfus's vindication was exactly the sort of person usually depicted as having persecuted him. The hero's name was Colonel Georges Picquart, and he was a conservative Catholic with distinctly negative attitudes toward Jews. So were Captain Louis Cuignet and Minister of War Godefroy Cavaignac, the men who later exposed the perjurer who had deflected attention from Picquart's alternative suspect. Finally, \u00c9mile Zola, the famous writer who led the crusade to free Dreyfus, articulated crude forms of racial determinism of the sort discussed earlier in this chapter, and these sometimes bordered on antisemitism. He fought for Dreyfus not to defend a Jew from persecution but to combat the Catholics, reactionaries, and militarists he held responsible for Dreyfus's prosecution. In the words of one sharp observer, Zola and the leading Dreyfusards were \"enemies of the antisemites, not of antisemitism.\" The Dreyfus affair stirred up and bequeathed a great deal of antisemitism, but it did not play out along strict party lines, and its resolution was not an unqualified victory over prejudice.\n\nMendel Beilis appears to have been set up by a local group of prosecutors interested in placating public opinion in Kiev and by several ministers in Moscow who were playing to the deep-seated antisemitism of Tsar Nicholas II. These people connected Beilis to the murder of a thirteen-year-old boy named Andrei Yushchinsky, whose body was discovered in a cave just outside Kiev, for two purely circumstantial reasons: first, the body had been stabbed in ways that supposedly facilitated the draining of blood, as in the sort of ritual murder connected to the blood libel, and second, Beilis owned a brick factory located near the cave and was a Jew. But, unlike in the Dreyfus case, the frame-up took in almost no one. From the beginning, local newspapers questioned the allegations, and a municipal detective swiftly produced evidence that linked a local gang to the murder. Apparently, that gang had gathered up a great deal of loot during the pogroms in Kiev in 1905\u201306 and hoped to instigate a new round by butchering a body in a manner intended to suggest a ritual murder and cast suspicion on a Jew. Once again, as in the Dreyfus affair, many of Beilis's local defenders were antisemites who simply hated those attacking Beilis more than they hated Jews and thought that the integrity of their own kind was more at stake than the rights of Jews.\n\nIn the decades leading up to World War I, the prevailing combination of constant antisemitic agitation, on the one hand, and general growth of Jews' rights and opportunities, on the other, goes a long way toward explaining twin developments among Jews that were the mirror image of what was happening among other Europeans. I am referring to the launching by Theodor Herzl in 1897 of the movement called Zionism, the drive for a Jewish homeland that soon centered on Jerusalem, which occurred in reaction to enduring antisemitism, and to the very limited success of this movement in winning support from Jews in the early decades of this century. Although obsessive and noisy, antisemitism not only generally failed to bend governments to its will, but also generally failed to panic Jews into thinking that their only sustainable future lay in founding their own country. Persistent antisemitism drove millions of Jews to leave Eastern Europe between 1880 and 1910, but rarely for Palestine. Instead, they came overwhelmingly to the United States.\n\nTo return to the question with which this chapter began: Why the Jews? Because an ancient tradition of blaming them for disasters, both present and prospective, a tradition deeply rooted in religious rivalry and superstition, persisted into the modern world and even assumed new forms during the eighteenth and nineteenth centuries. That tradition and its adaptations remained available to wax and wane as the impulse to blame did. In the decade immediately preceding World War I, the blaming impulse seemed to course primarily through other channels, especially those of class warfare, and antisemitic outbursts generally were held in check. At the middle of the continent, the territories that became the German Empire in 1871 and the Republic of Austria in 1918 remained for antisemites epicenters of agitation but also of frustration. We will see next why that was so and why the situation changed for the worse during that war and in its aftermath.\nCHAPTER 2\n\n[ATTACKERS:  \nWhy the Germans?](contents.xhtml#ch_2)\n\nANY EUROPEAN ASKED in the immediate aftermath of the Dreyfus and Beilis affairs to identify the country most likely to persecute Jews in the future surely would have named France or Russia. Yet Germans became the principal tormenters of Europe's Jews in the second quarter of the twentieth century. Explaining how this happened involves examining a highly contradictory history.\n\nNATION AND _VOLK_\n\nPerhaps one way of approaching the contradictions is to remember that Germany is the land in the middle of Europe. In the nineteenth century, this was true not only geographically, looking west to east, but also with regard to political structure and the relative strength of antisemitism. The states to Germany's west, notably Great Britain, France, Holland, and Belgium, were all more democratic countries than the German Empire that came together in January 1871. They were constitutional monarchies or republics in which parliaments elected by steadily expanding sectors of the population chose the cabinets and prime ministers that made the major decisions, not kings or queens. To the east, the Russian Empire, on the other hand, was the last great autocracy in Europe, a state in which the tsar claimed to rule alone by divine right, and where a parliament did not exist until 1906. Even thereafter, the tsar claimed the right to dismiss that body whenever he chose and to appoint his ministers without regard to its preferences.\n\nUnder the German constitution of 1871, that nation was a political and constitutional hybrid, a mix of these two systems. On the one hand, it had a parliament (the Reichstag) chosen by the broadest electorate then allowed in Europe, all male citizens over the age of twenty-five voting by nominally secret ballot. On the other hand, the parliament had very restricted powers: it could set the national budget annually, but the 75\u201380 percent of expenditures that went to the military could be debated and authorized only once every seven, later five, years, and the government could take out loans without parliament's permission. In other words, the power of the purse that is the foundation of legislative authority was severely circumscribed. Parliament did not select the prime minister, called the chancellor; the kaiser (emperor) did, and he had exclusive power to declare war in response to an attack and to command the army. In short, the German Empire that lasted from 1871 to 1918 was an authoritarian, militarized country with the trappings of democracy, one that blended elements of the form of governance that had prevailed in Europe before the French Revolution and still prevailed in Russia with the newer form of parliamentary rule that had developed in Great Britain during the eighteenth century and on the continent after 1789.\n\nSomething similar can be said about antisemitism in this newly unified state. If we describe the period of post-Napoleonic emancipation as extending from 1815 to 1918, then Germany's enactment of equality for Jews before the law, which occurred in 1869 for the northern two-thirds of the country and in 1871 for the entire realm, falls almost precisely at the midpoint. The breakthrough came after emancipation in virtually every country to Germany's west or north and before emancipation in most of the lands to its south and east, Austria-Hungary being the exception. Germany occupied a middle point not only temporally but also in the forms and extent of emancipation, which were more complete than to the country's east but less than to its west or south.\n\nAnother distinct feature of nineteenth-century Germany both determined the timing and influenced the extent of emancipation there. Germany was not only the land in the middle, it was also, in the eyes of its citizens, \" _die versp\u00e4tete Nation_ ,\" the delayed nation. Like Italy, which also completed national unification only in 1870, the word \"Germany\" was only a geographical term prior to that year. An entity called, in English, the \"Holy Roman Empire of the German Nation\" had existed until 1806, but a truer description of reality would have been \"of the German nations.\" It was a very loose association under a single monarch of many highly autonomous entities, 1,789 of them, in fact, in 1789. Most Germans thought of themselves as Bavarians, Prussians, Swabians, Hessians, Westphalians, and so on, and most of these names of duchies and kingdoms derived from the Latin names of the tribes that had inhabited each centuries earlier. Bavaria comes from _Bajuvarii_ , and Prussia from _Borusii_. Insofar as a sense of German nationalism developed during the nineteenth century, it did so in reaction to and rejection of the French conquest and occupation under Napoleon, and it crystallized around the only idea that could unite so much difference, the notion that all the tribes were related and parts of a common people, or _Volk_.\n\nThe founding father of this line of thought was Johann Gottfried Herder, who did his most significant work before the armies of the French Revolution got to Germany and died while they were there. He maintained that nationalities are \"wonderfully separated . . . by languages, inclinations, and characters,\" and that each has an essence, a special set of core characteristics possessed by nearly all people born into it. He was not hostile to Jews, and though he insisted on enduring national differences rooted in different languages, he refused to postulate hierarchies of languages and peoples. \"Every nation bears within itself the standard of its perfection,\" he said. But his sentimental glorification of the unchanging virtues of the German _Volk_ , along with his insistence that \"every human perfection is national,\" encouraged a self-exalting quality in German nationalism.\n\nEstablishing precisely what this _Volk_ had in common was the great task of German nationalist thinkers during the early nineteenth century. They labored to identify, some would say \"invent,\" a collective German nature, and they began by defining it around what Germans in the early 1800s were collectively against: the conquering French and the ideas they had brought with them and stood for. Since emancipation of the Jews was a French import, many German nationalists rejected it as the product of an alien spirit. One of the earliest exponents of this rejection was Johann Gottlieb Fichte, a philosopher who in 1808 delivered a series of lectures published under the title _Addresses to the German Nation_. Fichte's animosity toward Jews predated his nationalism; in the late 1790s, he had called Jews \"a state within a state\" and had spoken out against their emancipation. Now he flatly argued that \"making Jews free German citizens would hurt the German nation\" and identified antisemitism with German patriotism. As for the nature of Germanness, he located it in the heroic and martial virtues that Tacitus had ascribed to the German tribes seventeen centuries earlier.\n\nDuring the later years of the French occupation, the Brothers Grimm began collecting folktales as sources for the essence of Germanness. Though not explicitly anti-French or antisemitic, their enterprise was implicitly exclusionist. The goal was to establish the human qualities that were intrinsically, continuously, and definitively German, qualities that, drawing on Herder, could not be possessed or combined in the same way by any other nationality. Ironically, the most famous tales that the Grimms reproduced\u2014the ones known as Snow White, Red Riding Hood, and Sleeping Beauty\u2014were, in fact, French in origin. The brothers learned them from Hessians descended from Huguenots\u2014that is, from French Protestant immigrants. This telling fact highlights the artificiality of the Grimms' quest to maximize national and ethnic differences. Nonetheless, by the middle of the nineteenth century, this sort of thinking produced Richard Wagner's pamphlet \"Jewishness in Music.\" It asserted that genuine musical works of art were products of the profound German spirit, to which Jews had no access, which is why they supposedly could produce only shallow and artificial works. The very notion of \"German culture\" ( _Kultur_ ) had become a prized family birthright that no outsider could inherit or exercise.\n\nAll of this made the German sense of nationality somewhat different from that which developed in Britain and France. In Great Britain, the cohering principle was a Protestant monarchy, and it embraced and pulled together different ethnicities\u2014English, Scottish, Welsh, and Scotch Irish. In France, the glue after 1789 was allegiance to the nation\u2014whether it was republic, empire, or kingdom\u2014and citizenship was open to any free person, regardless of race, creed, or color. French reading primers may have begun with the words \"Our ancestors the Gauls,\" but loyalty, not lineage, determined citizenship, and anyone born on the soil of France was, in principle, equal in its eyes. In Germany, and in the multiple states that preceded its unification, citizenship was more exclusive; it derived from one's parents, not the accident of where one was born, and was generally difficult for immigrants or outsiders to acquire.\n\nThese conceptual developments help explain the contested status of emancipation in Germany after Napoleon's fall, and the halting and relatively slow pace of its progress between 1828 (when the Kingdom of W\u00fcrttemberg became the first German state to enact lasting emancipation) and 1864 (when the city of Frankfurt became the last to do so before the spread of civil equality to all of the north of Germany in 1869 and to the south two years later). The process required forty-three years from beginning to end because resistance was considerable. It sometimes took violent form, as in the Hep-Hep riots, which began in W\u00fcrzburg and Frankfurt in 1819, spread to thirty other cities, and lasted for two months. The instigators were small-scale craftsmen and merchants angry at the prospect of competition if Jews were made citizens. One of the rioters' spokesmen, the writer Hartwig von Hundt-Radowsky, declared that the Jews' \"freedom to choose their own trades . . . is also a license to plunge Christians into misery.\" Usually the resistance remained rhetorical; nonetheless, it was impassioned. Representative examples are some of the poems of Heinrich Hoffmann von Fallersleben, who also wrote the words to what has been Germany's national anthem ever since 1922, and the numerous petitions against Jewish equality that were submitted to the Frankfurt parliament when it met in 1848 to write an ultimately abortive constitution for a united Germany. Most of these pleas came from small towns and rural farming communities, and most emphasized traditional complaints about supposed Jewish profiteering. Wherever and whenever it occurred, however, resistance to emancipation had a unifying theme: They are fundamentally different from us\u2014less honest and less spiritual\u2014and can never become like us.\n\nBut emancipation came, and it came in tandem with national unification in 1867\u201371, because liberals were the chief parliamentary patrons of both causes. Achieving one meant, to liberals, insisting on the other. Otto von Bismarck, the conservative Prussian leader who masterminded the three wars against Denmark, Austria, and France that forged German unification, initially found working with the liberals convenient, so he accepted the establishment of full civil and political equality for Jews at the time. But Bismarck was no liberal himself, and he was no fan of political equality in general. He was a fierce defender of his aristocratic caste, the Prussian Junkers, and determined to protect its economic interests and to preserve its near monopoly on leading positions in the government and the military.\n\nIf emancipation rode to success on the back of national unification, the backlash against emancipation gained strength when the economic consequences of unification began to look adverse. In 1873, the German stock markets, which had been driven upwards by an inflow of investment capital in the form of enormous indemnity payments from the defeated French, abruptly plummeted. The event has gone down in German history as the founders' crash ( _Gr\u00fcnderkrach_ ), since it came so soon after the founding of the unified empire. The trigger was the collapse of some railroad shares promoted by a baptized entrepreneur of Jewish descent named Bethel Henry Strousberg. A year later, a journalist named Otto Glagau published a series of articles in the popular weekly magazine _Die Gartenlaube_ (The Garden Bower) alleging that the crisis had been brought on by stock manipulators, \"ninety percent\" of whom were Jews. The Catholic newspaper _Germania_ soon spread the charges, and in 1877 Glagau republished his articles as a book, adding an introduction that read, in vitriolic part:\n\nNo longer should we tolerate Jews pushing themselves everywhere to the foreground. . . . They push us Christians continuously aside, they press us to the wall, they take away the air we breathe. In fact, they exercise domination over us . . . and they exert an extremely unwholesome influence. . . . The whole history of the world knows no other example of a homeless, definitively physically and psychically degenerate people, simply through fraud and cunning . . . ruling over the orbit of the world.\n\nMeanwhile, Germany's leading conservative newspaper, the _Kreuz-_ _zeitung_ , had gotten into the act. In mid-1875, it published a series of five articles that purported to disclose how the policies of German government and business were conducted \"almost exclusively in favor of our co-citizens of the Mosaic faith and Jewish nationality,\" largely because these policies were secretly directed by a Jewish banker in Berlin, Gerson von Bleichr\u00f6der, who was Bismarck's personal advisor. And, finally, in 1876, the first general secretary of the German Conservative Party, the political vehicle of landowners and agricultural regions, a man named Carl Wilmanns, gave this school of antisemitism a popular catchphrase when he titled a book _The \"Golden\" International_. Accusing the Jews of constituting a rich, self-interested, unpatriotic, and transnational conspiracy to promote their own wealth, the work went through six editions within a few months.\n\nIn short, the 1870s illustrated the force of the remark that antisemitism rises and falls in inverse relationship to the stock market. In that decade, when the market crashed, bigotry rose. The economic fallout of the stock market crash, in the forms of increased unemployment and lost savings, was substantial. The downturn coincided with a crisis in German agriculture brought on by an influx of cheap wheat and corn from the United States that pushed prices down and made large landowners and marginal farmers clamor for tariff protection. All of this created an audience for simple explanations, and the antisemitic agitation of the 1870s provided them. Thus the emergence in February 1879 of Wilhelm Marr and the new word \"antisemitism\" came as the culmination of a decade of rising reaction against emancipation.\n\nTwo other significant events in the history of antisemitism also occurred in 1879. In September, Adolf Stoecker, the Protestant chaplain to the Emperor and his court, added an antisemitic plank to the platform of the Christian Social Workers' Party, which he had formed to strengthen religious feeling and combat socialism among the working classes of Berlin. His motive was more pragmatic than ideological. His party had failed to win a large following through religious appeals, so he now sought a more attractive vote-catching strategy\u2014namely, the claim that an alien minority of greedy and immoral materialists was threatening to take over and corrupt Germany. In December, Heinrich von Treitschke, a professor of history at the University of Berlin, published an essay that praised the antisemitic agitation of the 1870s as a \"natural reaction of the Germanic national consciousness against an alien element that has taken too much space in our life.\" Near the end of his text he lamented, \" _Die Juden sind unser Ungl\u00fcck!_ \" \"The Jews are our misfortune!\" Antisemites soon turned the phrase into an accusation. In their hands, the words came to convey something like \"The Jews are the cause of our misfortune,\" and that was the message heard when the Nazis turned the phrase into a slogan emblazoned on the mastheads of their newspapers and the banners at Party rallies during the 1920s and 30s.\n\nThe repeated invocation of Treitschke's words demonstrates the lasting legacy of the antisemitic wave of the 1870s, but its immediate impact was not so great. In 1880\u201381, 265,000 German men signed the Antisemites' Petition, the centerpiece of a campaign to repeal emancipation by prohibiting immigration by Jews, compiling a census of those in the country, and removing all Jews as teachers, judges, and civil servants. But the drive was a political failure. Chancellor Bismarck refused even to respond to the petition, and the number of signatures collected disappointed its initiators. That Treitschke declined to sign showed that the document went too far for even critics of Jewish influence. Stoecker's party was overwhelmed in Berlin in the election of 1881 by the pro-emancipation Progressive Party, whose popular vote nationally almost doubled that of the previous elections in 1878 and raised the party's delegation to the second largest in the Reichstag.\n\nThat was the story of antisemitism in Germany before World War I in microcosm: The movement was loud, quotable, recurrent, but it had little political traction or legislative success. From 1887, when Otto B\u00f6ckel won election to the Reichstag from the city of Marburg, to 1912, the last election prior to World War I, a bewildering series of leaders and political parties dedicated to reversing emancipation came and went without attracting very large followings or enacting a single restriction on Jews' civil rights. At the polls, these parties largely flopped, as shown in figure 2. In seven parliamentary elections from 1887 to 1912, antisemites won only 78 out of a total of 2,779 seats, or 2.8 percent of the whole. They never won more than 4 percent of the popular vote or more than 5.5 percent of the parliamentary seats in any single election. Not only was their electoral base small, it was remarkably narrow: 35 of those 78 seats, or 45 percent of them, were won in the same area that elected B\u00f6ckel: Electoral Hesse, a small province in the west\/center of the country, north of the city of Frankfurt, that Prussia had conquered and annexed in 1867. By the 1880s, the region was economically depressed, and B\u00f6ckel and his followers thought they knew who was responsible. His party ran on the slogan \" _Gegen Junker und Juden_ ,\" \"Against the Prussian nobles and the Jews.\" Notice the order. Moreover, of the 44 men who ever held those 78 seats, 1 was a peasant, 2 were aristocrats, and 41 belonged to what Germans call the _Mittelstand_ , which means they were mostly artisans and shop owners, people who worked for themselves and were struggling against competition from factories and department stores.\n\nFIGURE 2: ANTISEMITIC VOTING IN IMPERIAL GERMANY\n\nfor the Reichstag (the national Parliament)\n\nfor the Prussian Landtag (the largest state legislature)\n\nThese data suggest that as an electoral phenomenon antisemitism was largely a vehicle of economic protest and not sufficiently popular in its own right to sustain a political movement. So do two other interesting pieces of electoral sociology. First, the only other part of Germany where antisemites did unusually well was the Kingdom of Saxony, along the border with today's Czech Republic, which elected another quarter of those antisemitic Reichstag deputies. But of the six seats they had won in the election of 1893, they lost five even before 1903, when all of them went to the left-wing Social Democrats. Second, notice in figure 2 what happened to the Conservatives after they added an antisemitic plank to their platform at the Tivoli Convention of 1892. At the national level, their vote rose slightly in 1893, but it then declined steadily thereafter, falling by more than one-third by 1912. In voting for the Prussian parliament their support dropped by an even steeper 41 percent. In Imperial Germany, antisemitism was hardly a ticket to electoral success.\n\nWhy could German antisemites generate a series of bestselling books, such as Julius Langbehn's _Rembrandt als Erzieher_ (Rembrandt as Educator) in 1890 and Houston Stewart Chamberlain's _The Foundations of the Twentieth Century_ in 1899, but not a sustained national political movement or any legislative victories? One reason was that the leaders of the antisemitic parties were often incompetent and corrupt, which generated scandals that undercut their popularity. Another was that these leaders had trouble working together, so the history of antisemitism in Imperial Germany is a history of constant mergers and splits and little stability to even the names of the groupings. Wilhelm Marr, the so-called patriarch of German antisemitism, was so disputatious that he ended up quarreling with virtually every other leader of the movement in the 1880s and then repudiating antisemitism altogether. In parting, he mocked the ideology as \"a business\" that blamed Jews for social problems created by industrialization.\n\nBut the more fundamental problem for the antisemitic parties was that the discontent they mobilized was always sectoral; it was generally confined, in the period 1887\u20131912, to one or two particular parts of the country at a time or to one or two particular social groups. Broadly speaking, when Hesse was hurting, Bavaria or Brandenburg was not suffering as badly or in the same ways; when artisans and farmers were complaining, the fortunes of workers were improving. So long as discontent was not general or other groups offered responses to it that some people found more persuasive, as the Center Party did to devout Catholics, the socialists did to industrial workers, and the Conservative Party did to landowners and pious Lutherans, political antisemitism could not thrive. Intellectual antisemitism, however, was another matter; it had a broader, more constant audience and reflected a persistent unwillingness to see Jews in Germany as Germans.\n\nIn Imperial Germany, a peculiarity of the electoral process erected one additional barrier to political antisemitism. The German constitution that governed national elections mandated universal manhood suffrage, but the separate states of Germany had their own electoral systems that often privileged wealth. Two states, Prussia until 1918, which made up over 60 percent of the country, and Saxony from 1896 to 1909, weighted votes in parliamentary and local elections according to the taxes on property and income that men paid. Basically, those who paid the top third of taxes in each election district chose one-third of the electors for a seat, the men who paid the next third chose the second set of electors, and the remaining male taxpayers chose the third set. People too poor to pay direct taxes could not vote at all. This system awarded disproportionate influence to the prosperous. In Essen, Alfred Krupp, a vastly wealthy coal and steel magnate, cast the only vote for the first third of the electors from 1886 to 1894, so he in effect chose them. In Berlin 10 percent of the population chose the first third, and the usual breakdown in election districts was something like 3\u201310 percent\/10\u201315 percent\/75\u201387 percent. This meant that local and state elections in Prussia and Saxony were decided by the richest quarter or less of the electorate, which consisted of only 15\u201320 percent of the adult male population. Because Jews were disproportionately well represented in the top two tax groups in most cities, their votes carried extra weight in urban districts and municipal elections. For example, in Frankfurt in 1900, Jews made up 63 percent of the people who chose the first third of the electors. Distributions like this worked against antisemitic candidates and encouraged others to support Jews' rights or at least to pay lip service to them. After the German Empire fell in 1918, the new republican regime made German elections more uniformly democratic, and the electoral prospects of antisemitic candidates actually benefited.\n\nAs political antisemitism both ebbed and flowed during the lifespan of the German Empire, another contradictory set of trends developed\u2014namely, a transformation of the German Jewish population that made Jews both more like and more unlike the rest of the nation's citizens. On the one hand, Jewish distinctness seemed on the way to disappearing and Jews on the way to fitting into German society in three senses. First, the Jews of Germany constituted a steadily declining share of the population (from 1.25 percent of the national population in 1871 to 0.95 percent in 1910) and, after 1910, when 615,000 Jews lived in Germany, a steadily declining number of people, too. The cause was not conversions to Christianity, as only about 34,000 of these took place from 1800 to 1918. Rising rates of intermarriage also played but a small role, as they began to jump only at the end of the imperial period, when the ratio of mixed to all-Jewish marriages rose from 1:5 in 1901\u201305 to 2:5 in 1916\u201320. The main reason was the drop in the Jewish birthrate to just above replacement level. If almost 80,000 Jews had not immigrated to Germany under the empire, the Jewish population would have barely grown at all between 1871 and 1910. Despite an inflow of a roughly comparable number of Jewish immigrants in the years surrounding the end of World War I, the Jewish population in Germany continued to fall; in 1933, it was almost 20 percent smaller than in 1910.\n\nSecond, German Jews became increasingly acculturated, demonstrating great enthusiasm for German literature, art, and philosophy and eagerly participating in the German glorification of _Bildung_ , or cultivation. One consequence was the steep and rapid decline of Jewish schools and the use of Yiddish, and the nearly total integration of Jews into the German educational system. Third, Jewish religious practices also moved in a somewhat syncretic direction, as Germany became the homeland of Reform Judaism. That movement relaxed observance of many of the 613 laws, abandoned routine rituals and customs that seemed to smack of non-European origins, and introduced new forms of observance, including the seating of men and women together in the synagogue, the use of choirs and music during worship services in German, and sometimes the designation of Sunday rather than Saturday as the Sabbath. Though Jewish synagogue architecture remained quite distinct, favoring Moorish towers and domes, in other ways the observable differences between Christian and Jewish practice clearly diminished.\n\nOn the other hand, Jews continued to stand out from other Germans, sometimes increasingly, in four conspicuous ways. First, Jews left the eastern and rural parts of the country\u2014places like Posen, Prussia, Hesse, and southwestern Germany\u2014and migrated to cities even faster than did non-Jews. Between 1871 and 1910, the percentage of all German citizens living in cities with more than 100,000 residents rose from almost 5 percent to over 21 percent; for Jews in Germany, the corresponding figures were 20 percent to 58 percent. By 1910, almost 28 percent of Germany's Jews lived in Berlin, where they made up about 4 percent of the capital's population; in Frankfurt, their share exceeded 6 percent. Moreover, they tended to cluster in particular neighborhoods in each big city\u2014for example, Mitte, Charlottenburg, and Wilmersdorf in Berlin.\n\nSecond, the traditional concentration of Jews' occupations in trade and commerce grew steadily more pronounced, and within those spheres the patterns of Jewish employment were quite distinct. German Jews were three times more likely than all Germans to own their own businesses. Of the roughly one-quarter of Jews categorized as working in manufacturing, more than half were tailors. By the turn of the twentieth century, Jews owned 80 percent of the nation's department stores, 70 percent of its metal wholesalers, and 60\u201370 percent of the ready-to-wear clothing stores, and had preponderant positions in the advertising and printing industries. Regionally, Jews constituted 75 percent of the livestock dealers in Franconia, Westphalia, and Hesse, and half the grain dealers in Hesse and Baden. Finally, in 1910, when Jews made up less than 1 percent of the national population, they were 15 percent of the lawyers, 6 percent of the doctors and dentists, and 10 percent of the law school students and 14 percent of the medical students. As a result of the declining birthrate, all of these figures trended downward after World War I, as did the margin between the average income of Jews and non-Jews in Germany, but that did little to offset the general identification of Jews with non-manual labor and prosperity.\n\nThird, Jewish immigrants under the empire bulked larger because they concentrated in cities. Jewish immigrants from Poland, who were often far more traditional in dress and religious practice than German Jews, came to only 13 percent of the Jews in all of Germany in 1910 but to much larger shares of those in certain municipalities: 67 percent of the Jews in Leipzig, for example, 53 percent in Dresden, and 15 percent in greater Berlin. They stood out and created an illusion of a massive influx of alien people. After 1914, only 90,000\u2013100,000 more Jews gained entrance to Germany, but their visibility and even greater concentration in places like Berlin and Leipzig had the same effect and gave rise to a veritable psychosis of \"inundation\" by Jews that antisemites cultivated.\n\nFinally, German Jews stood somewhat politically apart from their fellow citizens, voting noticeably more frequently for the moderate left than most Germans. In the empire, this meant that they consolidated increasingly behind the Progressives; after World War I, it meant that they voted mostly for the Democratic Party; and as that party declined during the Depression, they gravitated toward the Social Democratic Party (SPD). Amos Elon writes of the Jewish bourgeoisie, \"They lived like bankers but voted like hard-pressed workers and leftist intellectuals.\"\n\nOnce again, Germany was the land in the middle, the country in which native-born Jews were less integrated in society than to the west but more so than to the east. Despite a great deal of acculturation, the separateness of Jews from other Germans remained apparent in certain respects. Similarly, despite the electoral and legislative failure of antisemitism, it enjoyed administrative and sociocultural successes. An example was the tight limits on immigration and naturalization that the Reich imposed. Most of the Jews who migrated to the United States from Eastern Europe in the 1890s and early 1900s embarked from the ports of Hamburg and Bremen. To get there, they traveled in trains that were sealed the moment they crossed from Russian Poland into Germany and that arrived at long piers, built out into the harbors alongside ocean liners. Steel doors were locked behind the last car before the passengers could descend and board the ships. The goal was to make sure that no one could alight in Germany along the way. Almost 80,000 Jews from Eastern Europe got into Germany between 1871 and the onset of World War I in 1914, but the Reich labored hard to limit the number and to restrict the immigrants' chances of becoming citizens.\n\nAnother manifestation of lingering antisemitism was the way Germany mixed formal legal equality with a great deal of social and professional discrimination. The Antisemites' Petition may have been a political bust, but 41 percent of the students at the University of Berlin signed it, and it led to the founding of the League of German Students (Verein deutscher Studenten), an increasingly popular organization that promoted the exclusion of Jews and the children of converts from Judaism from much of student life. By 1896, the national association of German university fraternities banned the initiation of Jews. In 1910, the Austro-Hungarian army had 2,000 Jewish officers; the French army, 720; and the Italian army, 500. The Prussian army, which made up the great majority of the Reich's forces, had none and refused to let Jews become officers in reserve units, as well. Jews were largely kept out of prestigious teaching positions: Prussia's secondary school faculties included only 12 Jews in 1910. In the same year, only 2 percent of the professors in all of Germany were Jews, almost all of them in medicine and the sciences. Antisemitism became institutionalized in elite and conservative society rather than in laws. As Shulamit Volkov has demonstrated, it became part of the \"cultural code\" of German conservatives and right-wingers, part and parcel of their self-described responsibility to uphold traditional values against the ideologies of liberalism, materialism, and internationalism.\n\nNonetheless, on the eve of World War I, the trend of events seemed to favor German Jews. The three-class voting system assured that attempts to exclude Jews from professions at the local level\u2014for example, as teachers in elementary schools\u2014were much less successful than snobbish barriers at the elite governmental level. The Prussian state had taken firm action against the last outbreaks of ritual murder accusations at Xanten in 1891 and Konitz in 1900, even dispatching troops to put down antisemitic riots in the latter case, and the accused Jews had been acquitted. Prominent Jewish industrialists such as Walther Rathenau, the head of the German General Electric corporation, and Alfred Ballin, the chief of the Hamburg-America Line, were becoming part of the kaiser's entourage (though Jewish wives still were not invited to court). The election of 1912 routed the antisemitic parties and sent more Jews to Parliament than in the preceding thirty years. Not only did the number of deputies of Jewish descent reach nineteen, but also some of them belonged to the National Liberal and Progressive parties, which had not even nominated Jews during the previous two decades. Many people, Jews and sympathetic non-Jews alike, confidently likened antisemitism to a _Kinderkrankheit_ , a childhood disease that German society was outgrowing.\n\nThe force that shattered these expectations was the cataclysm of World War I, and the turning point came in 1916, when the German High Command, desperate to divert blame for the murderous military stalemate, authorized the infamous \"Jew count,\" or _Judenz\u00e4hlung_. The generals hoped to prove the charge made by antisemites in Parliament that Jews were shirking their military duty and thus to provide an excuse for the army's failure to win the war. In fact, the census showed a slight overrepresentation of Jews in the military compared to their share of the national population: 100,000 served in the German army, 80,000 in combat; 35,000 were decorated and 12,000 killed. The disappointed military leaders thereupon concealed the results; declined to contradict partial, leaked figures that appeared in the antisemitic press; and allowed the army's political arm, the Fatherland Party, to revive accusations of Jewish draft dodging. In a sense, this episode was Germany's Dreyfus affair, another instance of an elite institution, again the army, trying to use antisemitism to conceal its own failures by spreading vitriol against Jews. However, unlike in the Dreyfus affair, a countermovement did not arise to expose and discredit the lie in public, so it had even more lasting effects. Not the least of them is a paragraph in _Mein Kampf_ in which Hitler claims that Germany would have won World War I with less loss of life if only 12,000 or 15,000 more Jews had faced and succumbed to poison gas at the front.\n\nThe toxic effects of this new libel against the Jews\u2014indeed, of the preceding forty years of ceaseless agitation and vilification\u2014became apparent even before World War I ended in Germany's defeat and humiliation. By February 1918, Kaiser Wilhelm II had convinced himself that an international Jewish conspiracy controlled all the forces arrayed against him. Meanwhile, Erich Ludendorff, one of Germany's two principal military commanders, had begun contemplating the expulsion of two million supposedly politically unreliable Jews from the part of Poland he planned to annex upon winning the war. After Germany's collapse in the fall of 1918, those desperate to blame the outcome on anything or anyone other than the nation's leaders or armed forces echoed the charges that provoked the Jew count and scapegoated the Jews, along with liberals and leftists, for undermining the war effort.\n\nThe audience for such claims grew wider than ever before because the sense of crisis was no longer sectoral but had become national. The combined effect of the Versailles Treaty terms and of the huge debt the country had run up to fight the war, the difficult process of demobilizing the army and converting to a peacetime economy, and the huge burden of supporting veterans and widows led swiftly to rising unemployment and runaway inflation. By 1923, the German currency was not worth the paper it was printed on, and the nation was in turmoil. The opportunity this presented for political antisemitism in Germany is reflected in figure 3, which shows the vote for openly antisemitic political parties rising from 10.3 percent in 1919 (a little less than where it stood in 1912) to 26 percent in early 1924. At the same time and continuing into the late 1920s, the incidence of violent acts against individual Jews increased, along with that of politically motivated violence in general. Yet figure 3 also records that the opportunity passed, and the vote for antisemites fell again, only to surge once more in 1930 after the onset of the Depression and then to spike in 1932, after the nation's largest banks had failed and unemployment peaked at 36 percent of the workforce.\n\nFIGURE 3: ANTISEMITIC VOTING FOR THE REICHSTAG IN POST\u2013WORLD WAR I GERMANY\n\nELECTION| NAZI % OF VOTES| NATIONALIST %| COMBINED %  \n---|---|---|---  \n1919| \u2014| 10.3| 10.3  \n1920| \u2014| 15.1| 15.1  \n1924| 6.5| 19.5| 26.0  \n1924| 3.0| 20.5| 23.5  \n1928| 2.6| 14.2| 16.8  \n1930| 18.3| 7.0| 25.3  \n1932| 37.4| 6.2| 43.6  \n1932| 33.1| 8.9| 42.0\n\nHITLER'S OPPORTUNITY\n\nThe statistics in figure 3 suggest that antisemitism acquired a new lease on life in Germany during the 1920s, a development that raises two challenging questions: How could a political fixation on rolling back Jewish emancipation go from a prevalent but unsuccessful movement before 1918 to a victorious one in 1933? And how could such hatred succeed at a time when the relative position and even the raw number of Jews in Germany were in decline?\n\nThe answers to these questions lie primarily in the changed nature of Germany's problems after 1918: They were no longer episodic and sectoral, they became continuous and national, and they therefore generated a pervasive sense of crisis that fostered support for extremist positions and simplifying explanations. The remainder of this chapter concentrates on that crisis and on how the Nazi Party and Adolf Hitler became its ultimate beneficiaries.\n\nBut the answers do not lie only in the depth and breadth of Germany's crisis. One other, vital impetus to antisemitism's resurgence both there and in many European countries after World War I emerged from that conflict: the linking of Jews to the specter of communist revolution. In 1917, when the Bolsheviks came to power in Russia, a number of Jews were prominent among their leaders. Leon Trotsky is the most famous, but he was not alone, and supporters of the tsar, including thousands who fled the revolution into Central and Western Europe, played up this fact. Jews such as Rosa Luxemburg, Kurt Eisner, and Bela Kun assumed leading roles in the revolutions in Germany and Hungary in 1918\u201319, and opponents trumpeted this as proof that these regime changes were alien impositions that confirmed the menace Jews embodied. As a result, a new variation crystallized on the old practice of demonizing Jews as agents of destructive change, and a new kind of fear\u2014fear of communism\u2014became available for antisemites to exploit.\n\nOf course, some conservatives long had linked Jews to the political left, but symptomatic of the new virulence and its appeal was the sudden popularity of a failed prewar fabrication, the infamous _Protocols of the Elders of Zion_. Largely unknown outside Russia before World War I, the _Protocols_ purported to be the transcripts of meetings among nefarious Jewish leaders intent on fomenting discord within all nations in order to increase Jews' power and wealth. In the aftermath of the Russian Revolution, tsarist loyalists brought the _Protocols_ west, and translations into most European languages found a large and credulous audience. The first German edition in 1920 sold 120,000 copies, for instance. In 1921, the _Times_ of London conducted a thorough debunking that exposed the _Protocols_ as an invention\u2014in fact, a pastiche of plagiarism from two works of fiction of the 1860s, Hermann Goedsche's German novel _Biarritz_ and Maurice Joly's French political satire _Dialogue betweenMachiavelli and Montesquieu in Hell_. But these disclosures made no difference to the _Protocols_ ' fervent devotees. Adolf Hitler spoke for them in _Mein Kampf_ , insisting that \"the moans and screams\" about the falseness of the _Protocols_ actually constituted \"the best proof that they are authentic after all.\"\n\nThe pervasive sense of crisis that afflicted Germany after World War I was both emotional and material. The emotional part was a product of the way the war ended, which Germans found profoundly humiliating and unfair. When they asked for an armistice, overthrew the imperial regime, and drove the kaiser into exile in 1918, Germans thought they would get a negotiated peace from the victorious Allies, and that it would be based on Woodrow Wilson's Fourteen Points, which promised \"no annexations, no indemnities.\" Instead, the Germans got the Versailles Treaty, which the Allies worked out among themselves and presented in 1919 on a \"take it or leave it\" basis. Not only was this what the Germans called a _Diktat_ , a dictated peace, but it stripped the country of 10 percent of its territory and most of its armed forces, stigmatized Germany with a clause that assigned it sole responsibility for the outbreak of the war, and imposed an at first unspecified but ultimately staggering monetary penalty in the form of a bill of reparations for the damages inflicted on France and Belgium. Germans of all political stripes felt, as their expression goes, _belogen und betrogen_ (lied to and deceived). But they already had demobilized their army as required by the armistice, so the German government had no choice but to sign a document that its people never viewed as legitimate. This gave rise to a kind of siege mentality among the Germans after 1918, an attitude of \"it's us against the cruel and unjust world.\"\n\nThe material part of Germany's postwar crisis was the result of the combined challenges of paying reparations, trying to undermine them at the same time, servicing the huge debt that the nation had run up to fight the war, converting from a war economy to a peacetime one, and supporting large numbers of disabled veterans and widows. The reparations came to either $12.5 billion, which was what the Allies actually expected the Germans to pay, or $35 billion, which was the amount the Allies nominally imposed to please their own electorates, and the payback period was estimated to last from seventeen to thirty-six years. The sums due yearly came to about 5 percent of the average real annual German national income between 1918 and 1931 ($11 billion), which may not sound particularly onerous, but the Reich's debts, mostly to Germany's own citizens who had bought government bonds, came to another $41.5 billion at the end of World War I. Germany's debt burden, in other words, amounted to 38 percent of the country's total national income during these thirteen years. The repayment obligations, when added to recurrent government expenditures, swamped revenues: In 1922, the Reich collected less than one-fifth of its budgeted outlays. The government could not borrow (who would lend to such a debtor?); it feared raising taxes (which might generate a revolution or help one of the country's recurrent putsches to succeed); and it could not earn funds from exports because of foreign tariffs that priced German goods out of other markets.\n\nThe government's only recourse was simply to print more money, and the result was runaway inflation. By 1923, the exchange rate had reached 4.2 trillion reichsmark to the dollar, meaning the German currency was worthless, and the nation was in turmoil. During that year, leftists rebelled in Hamburg; Hitler's Nazis staged the unsuccessful Beer Hall Putsch in Munich; the Lithuanians marched into East Prussia and annexed the city of Memel; and the French occupied Germany's industrial heartland, the Ruhr region, in order to force Germany to keep up with reparations payments and meanwhile to collect their equivalent directly. And, in Berlin, one reflection of the tensions was the Scheunenviertel (Barn District) riot in early November, a small-scale pogrom directed at Jewish immigrants from Eastern Europe who had set up shops in the nation's capital.\n\nThe Weimar Republic, the democratic regime that replaced the monarchical German Empire, survived this crisis, thanks to a brief period of military dictatorship and an influx of billions of dollars in loans from the United States attracted by fatefully high interest rates. But both before and after 1923, the nation was deeply polarized over who was to blame for its miseries. On the one side were the political left and the supporters of the republic who said that everything was the consequence of the old regime that had plunged the nation into war in 1914 and then led it badly and to defeat. On the other side were the political right and supporters of the old monarchy, many of them still entrenched in the judiciary, civil service, and the military, who said that the root of all evil was a supposed sinister conspiracy of Marxists and Jews that had undermined the war effort from within, overthrown the kaiser in 1918, and introduced an incompetent parliamentary government. For most of the life of the Weimar Republic, the two groups were fairly evenly balanced, but also internally divided. On the left, the communists and socialists fought each other, and on the right the old-line nationalists competed with other groups, including the fledgling National Socialist German Workers' Party (NSDAP), the Nazis. This situation did not make for stable or effective leadership. Twenty-two governments came and went in the short fourteen years of the Republic, and the constant wrangling and instability undermined the popularity of democracy.\n\nAdolf Hitler was the ultimate beneficiary of this stalemated blame game, though he failed in his first bid for power in 1923. What did he offer Germans, and why and how did he succeed? The core of Hitler's message was a flattering explanation of what ailed Germans and of why they deserved so much better. Flattering because the central claim was that Germans had not brought their troubles on themselves by following a blundering imperial government or fighting a war they could not win. No, the disasters had been done _to_ the Germans, not _by_ them. Who were the culprits? Above all, the duplicitous Allies, the delusional Marxists, and the debilitating Jews. Central to Hitler's narrative were the claims that Germany was a victim and thus entitled to lash back by all means necessary. In other words, \"they did evil to us, so we get to pay them back.\" Hitler believed profoundly and unshakably in this narrative because it performed the same function for his wounded psyche after 1918 that the message did for the people attracted to it. It explained his nation's unjust fate, exonerated him and his compatriots for bringing it on, exposed the villains, and exhorted Germans to fight back. The psychiatrist James Gilligan argues that all violence results from the attempt to replace shame with self-esteem. Whatever the general validity of that remark, it brilliantly captures the motivation behind the violence of Hitler's ideology toward Jews, communists, and foreigners. Shame at the defeat in 1918 generated a furious determination to punish the alleged authors of that defeat so as to expunge it and restore national pride.\n\nThe rhetorical centerpieces of this story were the phrases \"stab in the back\" and the \"November criminals.\" The first asserted that the German army had not lost the war but had been undermined at home by an insidious coalition of Jews and leftists; the second labeled the people who had overthrown the monarchy in November 1918 as traitors. Both claims diverted attention from the German military's and the German people's roles in the defeat and the revolution. After all, the General Staff had begged for the armistice in the fall of 1918 as the only way of preventing the retreating German army from completely breaking up, and many Germans were war-weary and welcomed the kaiser's overthrow. But the Nazis explained these facts away by treating them as creations of the forces that had conspired to undermine the war effort and overthrow the old regime. Both phrases became key components of Hitler's and Nazism's insistence that antisemitism was a defensive, not an offensive, stance. This is a central theme in the history of the Holocaust. The argument that persecution was an act of self-defense was so essential as a justification for what the Nazis wanted to do that it repeatedly appears in ever new forms: They threaten us, so we must strike to protect ourselves.\n\nHitler tricked his message out with a synthesis of pseudoreligion and pseudoscience that may be aptly dubbed a \"theozoology\": On the one hand, he posed as an evangelist of the _Volk_ , the person who would lead a national revival by making the German people sense its own power and, as the Nazi slogan \" _Deutschland Erwache_ \" said, \"Awaken Germany.\" Hitler presented himself as the one person, singled out by providence and arising from modest origins, who could deliver Germans from their afflictions and, indeed, from division, controversy, and internal conflict altogether. \"His speeches,\" an early biographer observed, \"begin always with deep pessimism and end in overjoyed redemption, a triumphant happy ending.\" At the same time, he claimed to be the eugenicist of the race, the person tough enough to purge the German people of defective and degenerate elements and maximize its purity and strength through selective breeding. Together, evangelism and eugenics promised to create a rejuvenated, unified, and healthy people that would shape its own destiny, and the offer had widespread appeal in a defeated, economically troubled, and politically polarized country that felt battered by the demands of the nations that had triumphed over it.\n\nHitler based his claim to be able to accomplish all this on the assertion that he alone grasped the fundamental laws and processes that govern history. What were these? Basically they amounted to a kind of bastardized Marxism that substituted race for class. Whereas Karl Marx taught that all history is the struggle among classes to control the means of production and distribute wealth in the victorious class's favor, a process he called dialectical materialism, Hitler taught that all history is the struggle among races to control space or territory from which to generate food and wealth that will support further expansion. In 1949, the first postwar president of West Germany, Theodor Heuss, aptly described this doctrine as \"biological materialism\" because it so perfectly parallels Marxian notions of class struggle. In a nutshell, Nazism is an ideology of feed and breed or race and space that posits a permanent struggle to the death among ethnic groups. Hitler insisted that perpetual struggle is \"the law of nature,\" but a more fitting term would be \"the law of the jungle.\"\n\nBecause struggle is perpetual, Hitler insisted that Germans lived in a permanent state of emergency. Although they deserved to succeed by virtue of the cultural superiority he claimed they possessed, they were not necessarily destined to triumph, as Marx had claimed that the proletariat is or as Christ promised Christians in the Sermon on the Mount by predicting that the meek will inherit the earth. The only assurances of success were fertility, military strength, and racial purity. The state's job is to promote these and to destroy anything that works against them. Morality is defined not by principles or commandments but by service to these goals. What promotes them is good and praiseworthy, what impedes them is evil and traitorous. In other words, Nazism combined arrogance about Germany with anxiety about its future, and the combination translated into virtually unlimited aggressiveness.\n\nGiven these premises, Nazi ideology was thoroughly and unabashedly self-centered. Hitler openly and repeatedly proclaimed: \"We know only one people for whom we fight, and that is our own. Perhaps we are inhumane! But if we save Germany, we have accomplished the greatest deed in the world. Perhaps we perpetrate injustice! But if we save Germany, we have abolished the greatest injustice of the world. Perhaps we are immoral! But if our people is saved, we have paved the way again for morality.\" This absolute ethical solipsism is a\u2014perhaps _the_ \u2014central article of faith of Nazism. That the philosopher Hannah Arendt, herself a refugee from Nazi Germany, believed she had discovered the distinguishing attribute of Adolf Eichmann, the quintessential Nazi \"desk murderer,\" in his supposed \"thoughtlessness,\" which she defined as his inability to see the world through the eyes of others, always has struck me as puzzling. His supposed inability was, in fact, a refusal, and it was not a characteristic feature of the task-fulfilling automaton that she saw Eichmann as, but rather the cultivated trait of a fervent adherent to Nazism. To subscribe to Hitler's ideology was to affirm that only the views and only the fates of Germans mattered; swearing never to put oneself in the place of non-Germans was part and parcel of being a National Socialist.\n\nIn this thought system, the greatest enemy of the Germans is _der Jude_ (\"the Jew\") and _das Judentum_ (Jewry), generally referred to with these singular nouns in order to deny any variation among Jews and to assert their homogeneity. That people is supposedly like no other in that it has no country of its own, but instead lives as a parasite within other societies. And, like a parasite, \"the Jew\" allegedly drains the strength of the host. Jews, said Hitler, unalterably seek to undermine Germans' fertility, military strength, and purity in order to make them too weak to cast Jews off and out. Thus, Jews were behind prostitution and venereal disease, delusional notions like international law and human rights, and softhearted ideas about the equality and brotherhood of peoples. Like Nietzsche, Hitler thought Jews had introduced the debilitating language of morality, ethics, compassion, and empathy into the world. Their idea of conscience was, he insisted, choosing his simile deliberately, \"a blemish like circumcision\"\u2014a supposedly unnatural alteration of how human beings are created.\n\nLogically, then, \"the Jew\" must be contained and ultimately \"removed\" from the German sphere if Germany is to succeed in the struggle for \"living space\" ( _Lebensraum_ ) and survival. Hitler therefore promised, in _Mein Kampf_ , to roll back emancipation and drive Jews into their own world or abroad by expelling them first from German political life, then from the nation's cultural life, and finally from its economic life. Most of the Nazi Party's public statements and private planning documents prior to 1933 followed this three-stage format. The Party platform, the Twenty-five Point Program of 1920, for instance, contained Point 4, calling for the denial of citizenship to Jews and their descendants; Point 5, demanding their classification as \"resident aliens\"; Point 6, excluding them from public office; Point 8, blocking further immigration by Jews and expelling all who had entered the country since the beginning of World War I; and Point 23, barring them from owning newspapers. These were all political and cultural restrictions. The programs laid down by the Legal and Domestic Policy sections in the Party headquarters in Munich in 1931 included these intentions, as well as removing Jews from the civil service and banning intermarriage with non-Jews. In June 1932, Hermann G\u00f6ring of the NSDAP made a speech envisioning these actions plus an exclusion of Jews from all prominent positions in the press, theaters, film, universities, and schools, all of which are cultural institutions. But he also said that in a future Nazi state every Jewish business person who stayed as an alien \"will remain able to operate his business undisturbed and under the protection of the law.\" So far as the Party let on prior to 1933, the goal was separation of Jews from non-Jews, reduction of Jews' capacity to influence non-Jews, expulsion of immigrant and naturalized Jews, and making the life of the rest so difficult that they gradually would leave.\n\nAlthough Nazi leaders did not talk openly of murder, let alone en masse, they made plenty of threats of violence and organized occasional local assaults on Jews, such as the bloody riot of 1932 on Berlin's elegant boulevard, the Kurf\u00fcrstendamm. And the storm troopers (SA) sang a marching tune with the words \"when Jewish blood spurts from the knife.\" Moreover, Nazi antisemitism always was implicitly murderous because of the metaphors it used: Jews were likened to vermin, parasites, germs, and cancer and called carriers of \"racial tuberculosis.\" These are things to kill or cut away, and Hitler dubbed himself more than once the Robert Koch of politics, referring to the famous bacteriologist who discovered the bacilli that cause anthrax and tuberculosis and thus greatly reduced their incidence. Above all, Hitler was always more dedicated to the goal than to any particular means; it was fixed, they were changeable. At the core of the Nazi vision was an unwavering dream of a Jew-free environment, since that was a precondition of German strength and happiness. This is extremely important because, as will become apparent, the combination of the appeal of that dream and its frustration by events drove the Nazis to consider ever more radical means of pursuing Hitler's goal.\n\nIn sum: Nazi ideology was a witches' brew of self-pity, entitlement, and aggression. It was also a form of magical thinking that promised to end all of Germans' postwar sufferings, the products of defeat and deceit, by banishing their supposed ultimate cause, the Jews and their agents.\n\nYet the centrality of the so-called Jewish problem was much more important and obvious to Hitler than to the average German voter. We have no reason to think that the antisemitic nucleus of his ideology propelled Hitler's rise to power. It played an important role in attracting many of the core believers to the Nazi Party, but not the mass of the Nazi electorate. Hitler was a product of crisis and opportunity, and Germans seem to have been drawn to him out of desperation and a sense that only the Nazis were energetic and organized enough to deal with the nation's woes. In 1928, before the Great Depression struck, the NSDAP received only 2.6 percent of the votes in the national parliamentary election, which was less than half the Party's share in the first of two rounds of voting four years earlier. Clearly, antisemitism alone had, as before, little political traction. As always, it could gain mass support only in tandem with a crisis that antisemites could exploit.\n\nAfter 1930, by which time Germany's economic difficulties had intensified and the Nazis' share of the national vote had jumped to over 18 percent, Hitler and the Nazis actually steadily downplayed antisemitism as a campaign issue, knowing that it already had attracted as many followers as it could. Instead, the Nazis concentrated on attacking what they called \"the System,\" by which they meant parliamentary democracy and free market capitalism, both of which they wanted to replace with more authoritarian political and economic arrangements. The platform they ran on was summarized succinctly by Gregor Strasser, the day-to-day director of Party operations in the early 1930s, when he defined National Socialism as \"the opposite of what exists today.\" And their method in state and national parliaments, as well as in municipal councils, was to disrupt democratic government, make it dysfunctional, and thus \"prove\" its ineffectiveness in meeting Germans' needs. In a fundamental sense, this highly partisan political force ran against politics, with all its messy compromises, disagreements, and imperfections, and promised to replace it with order and strength. National Socialism promised Germans both radical change and reassuring return to old certainties, and the mix appealed to many people in the atmosphere of anxiety that the Depression spread. In short, dissatisfaction with the nation's political and economic condition, along with fear of communism, the votes for which also were rising, clearly had more to do with Hitler's ascent than hatred of Jews.\n\nYet, as before 1918, antisemitism continued to have social traction. Various forms of discrimination escalated in the 1920s, including physical attacks on German Jews. In part, these developments were continuations of the earlier backlash against emancipation, since the Weimar Republic had removed the last forms of professional discrimination against Jews. Many of them became professors, judges, and civil servants during the 1920s; a few even became military officers and diplomats. Ironically, even as German Jews' birthrates continued to fall and their rates of intermarriage rose, Jews seemed to loom ever larger in public perception. The 100,000 or so Jews from Eastern Europe who managed to get into Germany during the years of weak border enforcement between 1916 and 1920 became the subject of paranoid fears of \"overforeignization\" ( _\u00dcberfremdung_ ), particularly because of their concentration in Berlin, and the prominence of Jews in the arts became an excuse to blame them for the alleged \"corruption\" of German culture during the Roaring Twenties. The nation's moralists had a field day with the fact that the leading proponent of sex education and research and of gay rights, Magnus Hirschfeld, was a Jew, as was the owner of Germany's preeminent manufacturer of condoms, Julius Fromm, an immigrant from Poland who had changed his first name from Israel. At a time when Jews were actually a declining presence in German life, whether measured by their total number, their share of the population, their representation in the professions and among university students, and their incidence among the very wealthy and in corporate boardrooms, Jews remained the subject of a persistent fixation on the part of many other Germans who were dissatisfied with the nation's condition.\n\nThis fixation eased the Nazi Party's electoral ascent in 1930\u201332 but did not propel it. The real driving force of Hitler's rise was the widespread and increasingly desperate desire in Germany for deliverance from the Depression and its unsettling effects. The nation's catastrophic economic situation increased receptivity to the Nazi movement and reduced antisemitism as a disqualifier for office. The context of Hitler's rise between 1928 and 1932 was unemployment that exceeded one-third of the workforce, a drop in industrial production by 42 percent, the collapse of the value of stock market shares by 60 percent, a decline in farm prices by 38 percent, a fall in total national income by 41 percent, and a reduction in real wages for people who still had jobs by 15 percent. The parliamentary system seemed incapable of devising policies that would reverse the crisis, and in fact the national legislature was stalemated after 1930 and unable to form a coalition that commanded a majority of the votes in Parliament. The president therefore exercised his power under Article 48 of the Constitution to appoint the prime minister and cabinet and rule by decree. These governments chosen by President Paul von Hindenburg adopted first a policy of deflation, which is to say cutting government expenditures\u2014what we nowadays call austerity\u2014and that only worsened the crisis. The cabinets that followed Heinrich Br\u00fcning's then switched in 1932 to a version of supply-side economics, by reducing the tax burden on firms, and that had only slightly positive effects.\n\nBut why were the Nazis the principal beneficiaries of the crisis? Why did they alone seem to capitalize on it? Actually, they were not alone; the communists also gained greatly in strength during the death rattle of the Weimar Republic, though not nearly as much as the Nazis did. But this fact actually worked in the Nazis' favor; it seemed to confirm what they constantly reiterated: Germans' choice came down to us or them, brown or red, and no middle ground remained. When the nation's options were reduced to these, the Nazis were bound to benefit. This is why they actively sought to generate street fights with leftist groups; every such battle strengthened the Nazi claim that the nation was on the verge of civil war, and that citizens therefore had to choose up sides between Hitler and the Commies ( _die Kozis_ ).\n\nIn addition, the competing political parties all seemed tired and unwilling to reach beyond their natural bases; for the Social Democrats these were unionized workers; for the Center Party, Catholics; for the People's Party, business leaders; for the Democrats, educated professionals; for the Nationalists, primarily aristocrats and farmers; and for the communists, the unskilled and largely nonunionized parts of the labor force. None of these parties had any imaginative or creative response to the Depression beyond waiting it out or, in the case of the communists, nationalizing everything. Even the Social Democrats in the summer of 1932 voted down the so-called WTB-Plan, named for the first initials of the last names of its authors, a massive government spending program that represented the only potentially successful way to jump-start the economy. The Nazis were fortunate in their opponents.\n\nThe way the Nazis campaigned\u2014relentlessly and energetically\u2014exploited the contrast between those groups and Hitler's party. Nazism described itself as a movement, a _Bewegung_ , and it was indeed a kind of political perpetual motion machine that never shut down. Nazis did not campaign just during elections but constantly. In the little north-central German town of Northeim, whose 10,000 citizens did not have a lot of entertainment options, the Nazi Party held an average of three meetings per month between 1930 and 1933. And the gatherings had the format and impact of religious revival meetings, with plenty of military music, well-trained speakers brought in from outside the town, and pageantry. Often the speakers were former war heroes or, in Protestant areas, Lutheran pastors who railed against \"the Godless left.\" Always there was emphasis on the youthful nature of the Party, its disproportionate appeal to the young\u2014over 40 percent of Nazi Party members prior to 1933 were thirty years old or younger\u2014in order to demonstrate that Nazism represented Germany's future. Moreover, the Party did not just campaign via meetings, rallies, and street fights. Its brown-shirted members were constantly visible taking up collections for the destitute or opening soup kitchens for the unemployed, thus giving the impression that they had the _will_ , a very important word in the history of Nazism, to fix things. All of this made a huge political impact in places like Northeim, which became a bedrock of Nazi support. Long before Adolf Hitler visited the town for the first time in mid-1932, almost two-thirds of its citizens were voting for the Nazi Party.\n\nRelated to this was a special feature of Nazi campaigning, the Party's propaganda, which was carefully tailored to disparate audiences. In working-class districts, the Party played up its populist streak, attacked the selfishness of aristocrats and big business, and posed as the defender of the little guy. In traditional areas like Northeim, the Party berated the unions, spoke up for family values, and emphasized patriotism. Nazism was, in other words, not quite all things to all people but agile in adjusting to its immediate surroundings.\n\nThe contrast between the lethargy and stasis of the old parties and the dynamism and youthfulness of the Nazis opened the way for them to offer Germans something distinct and appealing: unity. Alone among the parties, the Nazis could claim to draw followers from every social class and every part of the nation (other than Jews). Even though German Protestants were more inclined to join than Catholics, rural and small-town residents more than city dwellers, middle-class people more than workers, and men more than women, significant numbers of people in all these groups were members of the Party. It alone could claim to be gathering Germans of all walks of life into a \"People's Community\" ( _Volksgemeinschaft_ ). Unity is a very seductive word when people are tired of or frustrated with politics, and the Nazis seemed convincing in their pledge to wipe out divisions, if necessary by force.\n\nThe promise of Nazism was to restore all that was best in Germany's traditions yet also to revolutionize the country at the same time. Perhaps the best way to grasp how this worked is to look at what the Party held out to women: On the one hand, it promised to \"emancipate women from woman's emancipation\"\u2014that is, to restore their primary field of activity as the home and childbearing; on the other hand, it enlisted women in all sorts of paramilitary, athletic, and productive activity from which they had been largely excluded previously and told them they could be just as important as men in building the People's Community, only in different roles.\n\nThese circumstances explain why the Nazis became the largest political party in Germany by 1932, but they were not enough to propel Hitler to a majority in Parliament. At the end of 1932, German politics was deadlocked. Between the parliamentary elections in July of that year and those in November, Hitler had lost 2 million votes, 4 percent of the total cast. His electoral march seemed to have crested, and the Party faced a severe financial crisis because the membership dues and fees on which it depended had fallen off sharply. On New Year's Day 1933, the humor magazine _Simplicissimus_ ran a poem with the final line, \"This 'F\u00fchrer's' time is up,\" and the more sober _Frankfurter Zeitung_ congratulated Germans on having survived the Nazi onslaught. Elections had carried Hitler to the threshold of power but not across it. For that, he needed the help of an elite conservative group around Franz von Papen, a former chancellor. The conspirators wanted to engineer and serve in a cabinet backed by Hitler's large block of votes in Parliament and expected to be able to control Hitler because the Nazi leader had little formal education and had never held major office. Article 48 left the choice of chancellor to President von Hindenburg, and a clique of aristocrats and landowners went to work on him in January 1933. Led by Papen, they persuaded the aged president to offer the prime minister's position to Hitler.\n\nThe Jews of Germany were almost powerless to affect the course of events. Far from being the fantastically controlling wire-pullers of Hitler's feverish imagination, they were too few and isolated and their resources too limited to make any difference. Their fate depended on a German population that contained a minority deeply hostile to them and a vast majority that was indifferent or unsympathetic to them.\n\nIndifference and lack of sympathy were the principal effects of the combination of many decades of vocal German antisemitism and a decade and a half of intense German crisis. Both processes reduced the number of vigorous antiantisemites, the people who were willing to defend Jews or who thought that Nazi threats to Jews made Nazis unacceptable as leaders. If the Nazis' antisemitism was not a major contributor to their victory, neither was it a significant barrier to it. Even sympathetic non-Jews were inclined to understate the menace the Nazis represented by quoting the old German maxim, \"Nothing is eaten as hot as it is cooked.\"\n\nStill, probably 55 percent of the Germans had never voted for Hitler or the Nazis by the time he came to power. A majority had remained loyal to their traditional political allegiances: the Center Party for the Catholics, the socialists and communists on the left for most workers. As a result, William Sheridan Allen has ventured the observation that more Germans \"were drawn to antisemitism because they were drawn to Nazism, not the other way around.\" He probably is correct, and the observation is a reminder that the key to understanding what happened in Germany after 1933 is not so much events and attitudes that predated that turning point but ones that developed after it. The short answer to the question \"why the Germans?\" is \"because Hitler came to power,\" but it is too short an answer.\nCHAPTER 3\n\n[ESCALATION:  \nWhy Murder?](contents.xhtml#ch_3)\n\nHITLER AND THE NAZI PARTY came to power having declared their intention to strip Germany's Jews of citizenship and the right to hold office, to exclude them from the civil service, journalism, education, and the arts, and to ban intermarriage with non-Jews. The new masters of the nation expected these measures would reduce not only Jews' influence over the rest of the population but also their very numbers in Germany, and the regime planned to accelerate the latter process by barring Jewish immigration and expelling all Jews who had entered the country since the outbreak of World War I. In short, the Nazis set out to degrade, segregate, and diminish Germany's Jews but not yet to kill them, let alone all the Jews of Europe. Although Nazi rhetoric toward Jews regularly employed implicitly murderous metaphors, likening Jews to pests or diseases to eradicate, official policy initially concentrated on harassment, intimidation, isolation, and dispossession but generally stopped short of organized and widespread physical violence. The individual Jews subjected to brutality during the formative months of the Nazi dictatorship were usually officeholders or politicians, executives of firms that attracted the Nazi Party's attention for various reasons, or people who dared to object to Nazi actions, and those did not yet include large-scale destruction of property and roundups of Jews, let alone mass murder. Why not? And why did the situation escalate thereafter?\n\nIn answering these questions, much depends on whether the intervals January 1933\u2013November 1938 and January 1933\u2013June\/October 1941 seem like short or long times. Does the first interval, the time between Hitler's appointment as chancellor and the onset of systematic assaults upon and arrests of Jews during the Crystal Night pogrom, amount to \"merely\" or \"more than\" five and a half years? Does the second interval, the time between Hitler's appointment and the beginnings of mass murder of the Jews, come to \"merely\" or \"more than\" eight and a half years? If the answer is \"merely,\" the implication is that the Nazi leaders moved fast and probably knew what they were up to rather quickly. If the answer is \"more than,\" that suggests that the regime actually proceeded gradually and may have changed its objectives along the way. Either way, an important question arises about each of the turning points of 1938 and 1941, a question that a good historian has to ask about every significant event she or he studies: Why now?\n\nMy answer to that question is that the Nazi regime engaged in a three-stage discovery or learning process between 1933 and 1941. In the first phase, which lasted for just over five years from the time Hitler came to power until the annexation of Austria in March 1938, the so-called Third Reich learned what it could do, namely persecute the German Jews without encountering serious resistance from Germany's other inhabitants or from other countries. In the second phase, which lasted for a bit more than three years from the takeover in Austria until the invasion of the Soviet Union in June 1941, Nazi Germany learned what it nonetheless could not achieve\u2014namely, the complete \"removal\" or expulsion of Jews from its territory. In the third phase, which lasted only five months from the attack on the Soviets to the fall of 1941, Hitler and his most important advisor and executor in this matter, Heinrich Himmler, recognized that they possessed not only the motive but also the means and the opportunity to murder the Jews in not only the newly occupied territories of Serbia and the Soviet Union under cover of war, but also in all of Europe.\n\nFROM ARYANIZATION TO ATROCITY\n\nThe first phase of the Nazi assault on the German Jews proceeded under the euphemistic watchword of \"Aryanization\" ( _Arisierung_ ), which referred to the process of transferring Jews' jobs and property in Germany into the hands of non-Jews. Since Nazi ideology depicted Jews as parasites who had acquired what they had by draining it from the gentile majority of the population, the Party faithful regarded this process as simple payback for decades of deception and theft and thirsted to begin the repossession immediately after Hitler took office. But the Nazi leaders were more cautious.\n\nHitler and his principal advisors could not yet be sure in 1933 of how much persecution domestic or foreign opinion would accept, and they had other issues on their minds. After all, over half of the German population had never voted for Hitler, Nazis had only three of twelve seats in the cabinet President von Hindenburg appointed, and the authority to rule by decree was initially the president's, not Hitler's. Hitler knew that even many German antisemites were not as \"scientific,\" by which he meant categorical, in their hatred as he was. He frequently complained that the problem with most Germans is that each had a \"good Jew,\" a friend or acquaintance who did not conform to antisemitic stereotypes and who therefore should be treated as an exception to the general condemnation. The Nazi F\u00fchrer knew he would need time to win over most of the population to his conviction that persecuting all Jews was a necessary act of self-defense and indispensable to national survival. Moreover, the new regime needed stability and an appearance of moderation while generating a recovery from the Depression that would secure Hitler's hold on power. Finally, the Reich had to lull Britain and France into tolerating the military buildup that was a prerequisite for the conquest of \"living space\" for Germany in Eastern Europe. Hitler the fanatic was obsessed with Jews, but Hitler the politician and expansionist dared not let the obsession show too much or too early.\n\nCaught between the ideological fervor of its followers and the practical requirements of economic and foreign policy, the Nazi regime devised a two-tier approach to the so-called Jewish question. At the national, official, and public level, a stop-and-go policy allowed the regime to feel its way forward from 1933 to 1937 and to test the limits of public acceptance, both domestic and foreign. Overt displays of organized antisemitism were confined to the boycott of Jewish stores and businesses on April 1, 1933, which the regime depicted as merely a reprisal to a supposed wave of \"atrocity propaganda\" that Jews had instigated abroad. Otherwise, the Nazis generally contented themselves at the national level with a few well-spaced decrees that enacted the sorts of measures the Party long had advocated. Conspicuous outbreaks of overt violence against Jews, such as two more nasty rampages on Berlin's Kurf\u00fcrstendamm, in March 1933 and July 1935, were exceptional.\n\nIn 1933, the regime focused its efforts on driving Jews from political and cultural life. That goal led to four laws that: (1) purged Jews from the German civil service, including the law courts and hospitals, since these were state institutions in Germany, unless a Jew had held his position since before World War I, served in the army during that conflict, or had a father or son who died while doing so (these were the so-called Hindenburg exceptions, adopted in order to placate the field marshal-turned-president); (2) allowed the government to denaturalize people who had become citizens since that war began; (3) excluded Jews from cultural institutions, such as theaters, orchestras, and newspapers; and (4) imposed a _numerus clausus_ restricting Jews' share of students in German secondary schools and universities to 1.5 percent. In the economy, on the other hand, the Nazis treaded somewhat carefully, harassing individual Jewish executives and demanding their removal in many cases, but not actively trying to drive out Jewish owners except in sectors that were particularly important to the Party rank-and-file, notably department stores and breweries. The one major legislative initiative in this sphere in 1933 was a prohibition on Jews owning farmland, a particularly sensitive issue for a Nazi Party that proclaimed the twin pillars of Germandom to be _Blut und Boden_ , Blood and Soil.\n\nThe year 1934 brought a legislative lull, as the Third Reich decreed only one major antisemitic measure, a law that increased the government's ability to deport people it denaturalized. Then, in 1935, the regime closed the ranks of the German military to Jews, forbade them to display German flags on national holidays, and completed the agenda laid down before 1933 by stripping Jews of German citizenship and reducing them to resident \"subjects\" of Germany, banning new intermarriage and all extramarital sexual relations between Jews and non-Jews, terminating the Hindenburg exceptions, now that the aged president had died, and dismissing the last Jews from the civil service. Nineteen thirty-six saw another lull, as the regime downplayed its antisemitism in the run-up to the Summer Olympics in Berlin, lest other nations decline to participate, and little happened at the national level in 1937, either, aside from a prohibition on granting doctoral degrees to Jews.\n\nThis staccato pattern of increasing persecution at the national level from 1933 to 1937 belied, however, a continuous \"squeezing\" of Jews by Nazi activists at the local or street level, usually out of ear- or eyeshot of foreign reporters. Even in big cities, but especially in small towns, pressure was brought to bear on Jews' jobs and businesses in a host of ways. While the brown-shirted storm troopers of the SA threatened or inflicted harm on Jews' property or children, Nazi officeholders canceled contracts or refused to entertain bids from firms owned or led by Jews, welfare agencies prohibited the use of payments or vouchers at Jewish-owned shops, local leaders forbade their employees to buy at such establishments or to patronize Jewish professionals and publicly posted lists and\/or pictures of people who did so, Jews' businesses became identifiable by the absence of \"German firm\" ( _Deutsches Gesch\u00e4ft_ ) window signs that now proliferated among competitors, municipal councils banned Jews from having stands at public market halls or using public swimming pools, local and regional savings banks and credit unions stopped making loans to Jews or their businesses, branches of the Nazi labor union (the NSBO) insisted on dismissals of managers, tax authorities seized ledger books and charged Jews with tax evasion or illegal transfers of money abroad, and in many places, Nazi stalwarts intimidated non-Jewish shopkeepers, especially sellers of foodstuffs, into refusing to accept Jewish customers, thus forcing them either to move or to shop far from home where they would not be recognized. All the while, the Nazi-controlled press kept up a barrage of allegations regarding supposed Jewish criminality and deceitfulness.\n\nDiscriminatory actions of these sorts gave the Party's radical antisemites satisfaction and habituated Germans to Jews' suffering. As the forms of exclusion and persecution multiplied, the Nazi regime also learned that almost no non-Jew would stick up for Germany's Jews; instead, most people and institutions hastened to adapt to the way the wind was blowing. Across the country in 1933, clubs, singing groups, bowling leagues, and similar organizations began restricting membership to so-called Aryans and thus inflicting on Jews what Marion Kaplan has called \"social death.\" Jews found themselves increasingly abandoned and alone.\n\nThis popular acceptance, even adoption and internalization, of Nazi antisemitism was not the only success of the two-tier policy between 1933 and 1937. Another was the regime's dispelling or deflecting of international opposition. Despite some vocal criticism overseas, notably at large rallies in New York City, and attempts to boycott the sale of German goods abroad, the persecution of the Jews did little to dampen the urge in Britain and France to avoid war by appeasing Hitler or to undermine the resurgence of the German economy that increased his popularity at home.\n\nYet from the Nazis' point of view, their success was incomplete and the Jewish problem only half solved by late 1937. On the one hand, they had achieved the isolation of Jews from the rest of the population and gone a long way toward impoverishing them. Since 1933, up to 40 percent of the indeterminate number of businesses that Jews owned in Germany and between 40 percent and 50 percent of their wealth had become the property of someone else or the German state. In addition, most of the Jews still in Germany had been relegated to a destitute economic ghetto, as they scraped together meager livings working for themselves or each other.\n\nOn the other hand, the Jewish population in Germany had fallen by only about 35 percent, and the slow pace was an increasing irritant to Hitler. The F\u00fchrer held the Jews responsible for Germany's defeat in World War I; he did not intend to let them undermine the nation if World War II occurred, and as the 1930s passed, he saw that conflict coming ever closer. Already in mid-1936, he had written a memorandum that laid the basis for an economic Four Year Plan. The document called for an economy impervious to blockade and an army capable of war within four years and included a passage demanding \"A law making the whole of Jewry liable for all damage inflicted upon the German economy by individual specimens of this community of criminals.\" That Hitler inserted a provision about Jews in a long discussion of military and economic preparations shows how seriously he took the stab-in-the-back legend from World War I and how determined he was to hold the Jewish community collectively liable for perceived acts of sabotage.\n\nOn November 5, 1937, the F\u00fchrer presided over a meeting of his foreign and war ministers and his principal military commanders and gave a speech, summarized in a memorandum by his adjutant Colonel Friedrich Hossbach, that Hitler described to them as \"in the event of his death, his last will and testament.\" The gist was that Germany had to fight for living space by 1943\u201345 at the latest, when the Reich's window of opportunity would close. By then, the greater resources of the British and French empires would have enabled them to catch up with the momentary advantage in armaments that Germany had achieved by breakneck spending since 1933. Meanwhile, however, opportunities to annex Austria and wipe out Czechoslovakia might arise with surprising speed, and the Nazi regime would have to seize them, even at the risk of conflict coming earlier. Hitler said nothing about Jews at this meeting, but its aftermath had a great deal to do with Jews.\n\nClearly, Hitler's remarks alarmed the people assembled at the conference, as well as a few people outside it. Economics Minister Hjalmar Schacht, who was not there, already had cautioned Hitler that the pace of German rearmament had to slow down lest inflation get out of hand. Now, War Minister Werner von Blomberg, Commander in Chief of the Army Werner von Fritsch, and Foreign Minister Constantin von Neurath warned against precipitous action because they feared the army was unready and the British and French too strong. In the ensuing months, Hitler fired all of these men, Schacht promptly and premeditatedly in November, the others opportunistically the following February when a series of perceived sexual scandals created room for political intrigue.\n\nMoreover, the following months saw the enactment by Acting Economics Minister Hermann G\u00f6ring of a series of measures designed to speed up the process of driving Jews out of the German economy and then out of the country altogether. The fact that the regime went over to a program of forced, accelerated Aryanization at this juncture was not coincidental. The move reflected Hitler's conviction that the Jews were disloyal and sure to be saboteurs and fifth columnists when a conflict came. Nazi planners knew that at the current rate of attrition through emigration and death, the German Jewish population would disappear in fifteen to twenty years, but that was well beyond Hitler's time horizon for war. More pressure had to be put on Jews to leave, lest they once more have the supposed opportunity to stab the nation in the back.\n\nA crushing avalanche of new decrees designed to pauperize the Jews of Germany and convince them that they had no future in the country began with the definition of Jewish firms as ones with even a single senior Jewish executive or more than 25 percent of their stock in the hands of Jews. Such enterprises became immediately ineligible to receive government contracts, foreign currency to pay for necessary imports, and rationed raw materials, without which those enterprises could not operate. In March 1938, Jewish communities lost their legal status and the right to own property, which opened the way to the confiscation of their synagogue and school sites. In April, all Jewish-owned enterprises were required to register and all Jews were ordered to fill out an itemized census of their property and its value, down to the last teaspoon. To make Jews instantly recognizable, they had to add uniform middle names\u2014Israel for men, Sarah for women\u2014to all their identity papers in August, and in October to have a large red letter _J_ stamped onto the front page of their passports. In July, Jews were forbidden to work as traveling salespeople, which cost 30,000 their jobs; in September, Jewish doctors were forbidden to treat non-Jews; and in November, Jewish lawyers were demoted to legal counselors whose sole permitted task was to help other Jews wind up their businesses and dispose of their property. In December, a new law permitted local governments to ban Jews from the public streets on certain days of the week.\n\nAs if all this were not enough, now the Nazis decided also to terrorize and deplete the Jewish population. In annexed Austria, unfettered intimidation characterized the German occupation from its earliest days, as Nazis broke into Jews' homes, looting and smashing with impunity. The violence spilled over into Germany during the summer of 1938, producing the destruction of the main synagogue in Munich in June and its counterpart in Nuremberg in August. In both the old and the new parts of the Reich, about 5,000 Jews were carted off to concentration camps on various pretexts, sometimes on none at all. Meanwhile, forced expulsions of foreign Jews occurred, beginning with those who held Soviet citizenship in February and culminating with the deportation of some 18,000 Polish Jews in late October, mostly to the village of Zbaszyn on Germany's eastern border. The Poles had triggered this action by announcing their intention to bar any Polish citizen residing abroad from ever reentering the country unless he or she quickly applied for and obtained an authorization to return by November 1 for passport revalidation. Because the Polish government was trying to shed these citizens, its representatives in Germany dragged their feet in granting the necessary authorizations, obviously trying to run out the clock on the return visits. Because the Nazis wanted Polish Jews in Germany to have somewhere to go, either immediately or eventually, which cancelation of their passports would make more difficult, the Reich wanted to expedite the revalidations. Thus the Germans rounded up thousands of Polish Jews in Germany and delivered them to the border, the Poles simply refused to let the Jews in, and many of them languished miserably in no-man's-land well into 1939. Among the deportees were the parents of Herschel Grynszpan, a young Jew living illegally with relatives in Paris, and he took his revenge by walking into the German embassy in Paris on November 7, 1938 and shooting the third secretary, a young diplomat named Ernst vom Rath.\n\nHitler and the Nazi regime seized on vom Rath's death two days later as the pretext for a vicious collective assault on the German Jewish population, once more billed as an act of self-defense against Jewish hostility. This was the so-called _Kristallnacht_ (Crystal or Broken Glass Night) pogrom, a wave of destruction and plundering that swept over most remaining Jewish-owned homes and businesses and nearly all of the nation's synagogues. The storm troopers disguised as civilians who spearheaded this operation found a good many fellow citizens, especially teenagers, willing to join in the violence. By the time the mayhem stopped, the perpetrators had killed at least 91 Jews but perhaps many more, driven at least 300 people to commit suicide, and rounded up some 36,000 Jewish men across the country. About 26,000 of them were exposed the following day to public humiliation as they marched to trains and buses destined for the concentration camps at Buchenwald, Dachau, and Sachsenhausen. At least 600 and perhaps up to 1,000 of these men died from brutal treatment in subsequent months at these places, from which a person could obtain release only by signing over virtually everything he owned and promising to emigrate. In addition, in the aftermath the German government seized a fraction of the payments due to the Jews for insured damage and allowed the German insurance companies to renege on paying the rest. Then the Nazi state imposed a collective fine of one billion reichsmark on the Jews, payable in part by the confiscation of all their possessions containing precious metals, except for wedding rings and one table setting per person. And in April 1939, after having stripped nearly all Jews of gainful employment and all unemployed Jews from the welfare rolls, the Nazi state imposed compulsory labor on all Jewish males below the age of sixty-five, tens of thousands of whom now had to clean streets, shovel snow, and work in factories at discriminatory wages.\n\nEven before this cascade of cruelty, few Jewish Germans needed much convincing that they had to leave. By early 1938, more applications for visas to get into other nations were on file at their consulates and embassies in Germany than Jews were left in Germany. But getting out was difficult, especially because the German policy of stripping Jews of all they owned made them unattractive immigrants in the eyes of many foreign governments. Besides, the Depression was not over in most countries, and resistance to immigration fed in many places on fear of competition for jobs. Nonetheless, about 60 percent of the Jews of Germany and 67 percent of those in Austria managed to escape by the time World War II began.\n\nThe Nazi regime remained unsatisfied, largely because its foreign policy victories were negating its racial policy successes. As of September 1939, the annexations of Austria in March 1938, of the Sudetenland border region of Czechoslovakia in October after the Munich Conference, and of the remainder of the Czech provinces of Bohemia and Moravia in March 1939 had offset much of the reduction in the Jewish population of Germany proper by that date. On the eve of World War II, the Greater German Reich, including the annexed areas, contained around 350,000 Jews, far too many for the comfort of a Nazi regime that was about to invade Poland, the home of 3.3 million more Jews.\n\nAll of this was foreseeable in advance, but the fateful mathematics of German expansionism, the fact that the Reich could not drive out Jews faster than it planned to conquer them, seems to have dawned on German policymakers only during 1938 and contributed heavily to both the accelerated persecution of Jews at the time and to the regime's turn to overt violence. The math also accounts for the emergence in Nazi circles of a new vocabulary about the destiny of the Jews. Given the prospect of not being able to get rid of Jews faster than the Reich added them, officials began to give voice to the previously unthinkable.\n\nThe first documented emergence of a new word and a new prediction comes from a report of a Swiss diplomat in Paris of a conversation on November 14, 1938, less than a week after _Kristallnacht_ , in which the number two man in the German Foreign Ministry, Ernst von Weizs\u00e4cker, said, \"The remaining . . . Jews in Germany should immediately be deported somewhere. . . . If . . . no country will take them in, they surely are going sooner or later toward their complete annihilation.\" Ten days later, on November 24, _Das Schwarze Korps_ , the publication of the Nazi Party's elite SS formation, which now also controlled all German police, editorialized as follows: \"The German people are not in the least inclined to tolerate in their country hundreds of thousands of . . . impoverished Jews. . . . In such a situation we would be faced with the hard necessity of exterminating the Jewish underworld . . . by fire and sword. The result would be the actual and final end of Jewry in Germany, its complete annihilation.\" Finally, in January 1939, Hitler made the new vocabulary his. On the twenty-first, he told the Czech foreign minister, Frantisek Chvalkovsky, that the Jews of Germany would be \"annihilated\" unless other nations cooperated in deporting them. Nine days later, in a speech to the Reichstag on the sixth anniversary of his appointment as chancellor, he predicted \"the annihilation of the Jewish race in Europe\" in the event of a new world war. As yet, these remarks mentioned annihilation only as something that would happen under certain conditions, but for the first time the thought was out in the open. So much so, in fact, that the U.S. consul general in Germany, Raymond Geist, prematurely concluded and told the State Department on December 6\u2014weeks before Hitler uttered even the threat\u2014that \"[t]he Germans. . . . have embarked on a program of annihilation of the Jews.\"\n\nOn September 1, seven months after Hitler's address to the Reichstag, he launched the Second World War in Europe by invading Poland. Less than four weeks later, on the day that Warsaw finally surrendered, the SS created a new subdivision, the Reich Security Main Office (Reichssicherheitshauptamt, or RSHA), under the direction of Reinhard Heydrich and including a Jews Department ( _Judenabteilung_ ) headed by Adolf Eichmann. Initially, the German invaders shot fewer Jewish Poles than non-Jewish ones; as at home in 1933, the Nazi rulers were more concerned with punishing potential political opponents and resisters than attacking Jews per se. But sporadic attacks on Jews occurred and worse followed. The victorious Germans ordered ghettoization and the almost complete abandonment of Jews' possessions on September 21 as a means of concentrating Jews along railroad lines for eventual deportation and seizing most of their property in the meantime. Where were they to go? To what the Nazis explicitly called, in imitation of the history of the United States' policies toward Native Americans, a \"reservation\" ( _Reservat_ ), but where was it to be located? Initially, in an area called Nisko on the San River at the western edge of the Lublin district of the General Government (GG), the rump of Poland that Germany occupied but did not annex. Then, early in 1940, Hitler hoped to talk Stalin into accepting the more than two million Jews still in Greater Germany and occupied Poland, but the effort came to nothing. Finally, after France fell in June, the Germans focused on the French colony of Madagascar, a destination for Jews favored by European antisemites since the late nineteenth century. German planners actually began to work out how many ships would be needed over how long a time to deport the 3.25 million Jews now in Hitler's hands, and the Gestapo compelled several German Jewish leaders to find out whether American Jewish organizations would help to finance the exodus. But the German failure in the aerial Battle of Britain made transportation impossible, so a fourth destination gained prominence as 1940 turned into 1941: Siberia above the Arctic Circle, after victory in the impending invasion of the Soviet Union.\n\nThis transition in German policy from encouraging emigration, which remained possible, to planning deportations, marked a major turning point, for it amounted to a first step toward implementing annihilation. To be sure, the regime had not yet decided to kill every Jew, but it had chosen a course that entailed the death of a great many, either in the poorly provisioned ghettos or in the inhospitable designated destinations, for which the Jews would be physically unprepared and materially unequipped. In confirmation of this shift in policy, from September 1939 to June 1941, ghettos and forced labor camps took the lives of more than half a million Polish Jews. Still, as late as May 1940, Heinrich Himmler called \"the bolshevist method of the physical destruction of a people . . . un-German and impossible.\" He was referring in that remark to the treatment of Poles, but events soon made him reconsider whether such inhibitions applied also to Jews.\n\nSeveral developments in 1940\u201341 created incentives to find a \"total\" or \"overall solution\" ( _Gesamtl\u00f6sung_ ) to the Jewish question sooner rather than later. While the Nazi Gauleiters, the regional Party bosses, especially Joseph Goebbels in Berlin, clamored to begin deportations of the remaining German Jews to Poland, partly to free up housing for other Germans, partly as an end in itself, a logistical logjam developed in that conquered country. Himmler, freshly appointed as the head of the National Commission for the Strengthening of Germandom (the Reichskuratorium f\u00fcr die Festigung deutschen Volkstums, or RKFDV), had embarked on a massive program of demographic engineering there. It entailed the repatriation to the German-annexed parts of Poland of 500,000 _Volksdeutsche_ , people of German descent, from the Soviet Union and the Baltic states, pursuant to the agreement by which Hitler and Stalin had partitioned Eastern Europe in 1939. Simultaneously, at least twice as many Jews and Poles were to be expelled into the non-annexed but German-occupied General Government. But Hans Frank, the Nazi governor there, pushed back, claiming that his fiefdom should not and could not become a \"dumping ground\" for Jews, since conditions in the ghettos already were awful, and those conditions endangered the health of nearby populations. Himmler's views on the future of the General Government also appear to have evolved during the run-up to the invasion of the USSR. Since the occupied Polish region would no longer be at the periphery, but rather at the center of an expanded German empire, the GG now became in his eyes a potential area for Germanization, instead of the demographic \"trash heap\" that he had considered it earlier, and that meant the expansion of his aspirations for ethnic cleansing to the whole of Poland.\n\nMeanwhile, the victories in southeast Europe in early 1941, which brought German occupation of Serbia and parts of Greece and cemented the Reich's alliances with Hungary, Romania, and Bulgaria, multiplied the number of Jews within the Nazi ambit, thus increasing the pressure to do something about them on a continent-wide basis. The decision to attack the Soviet Union in 1941 threatened to do the same and to expose German troops to the imagined possibility of Jewish sabotage behind the advancing lines. Finally, that decision, plus Hitler's expectation that America would soon join the alliance against him\u2014the United States had broken off diplomatic relations with Germany in June 1941, and President Franklin Delano Roosevelt and Prime Minister Winston Churchill just had signed the Atlantic Charter, an implicit alliance, in mid-August\u2014meant that European Jews no longer had any value as hostages whose fate could be used to pressure the Allies or to intimidate other Jews abroad. In the euphoria of the initial German victories in Belarus and Ukraine, any reason for restraint toward the Jews fell away.\n\nIn other words, a combination of impatience, frustration, and hubris convinced the Nazi leaders that they had much to gain and nothing to lose by proceeding more radically now against the Jews rather than waiting until the victorious conclusion of the war. As a result, Hermann G\u00f6ring charged Reinhard Heydrich on July 31, 1941, to prepare \"an overall solution of the Jewish question in the German sphere of influence.\" But by the time he did so, the Germans already had taken the first step toward mass murder. In the course of July, their initial \"pacification\" efforts in conquered territory developed into a resolve to avoid a repetition of the Polish logjam and the administrative problems that the ghettos presented by bringing death to the Jews in the Soviet Union. The dispensers of this death began as four _Einsatzgruppen_ (Operations Groups), comprising fewer than 3,000 men, who were subdivided into eighteen mobile _Kommando_ units assigned to advance behind the German troops, foment pogroms, and shoot potential \"partisans\" and communists. Initially the victims were mostly Jewish men of military age, but the killing spread to women and children in late July 1941, only a month after the invasion began, and two brigades of 10,000 SS men plus 30,000 German Order Police were sent to the East to help do the job. Militias drawn from the local populations, the so-called _Schutzmannschaften_ , and security divisions of the regular German army stationed in areas behind the front supplemented these forces.\n\nThese disparate killing units slaughtered more than half a million Jews in the last six months of 1941 and perhaps one million by early 1942. Whereas in Poland some Jews had been killed and most ghettoized, in Ukraine, Belarus, and the Baltic states the pattern was reversed: Death became the norm, anything more than brief ghettoization the exception. The murders reached a crescendo between late August and late September, when 24,000 Jews were killed at Kamenets-Podolsk, 28,000 Jews at Vinnytsia, and nearly 34,000 at Babi Yar outside Kiev, in each case over two days. At these places and elsewhere in the occupied Soviet Union, most victims died, in a sense, one by one, by single shots to the back of the head or neck, not by machine-gun fire, because the killers wanted to be as sure as possible that they had not missed or wasted ammunition.\n\nEverywhere the cover for murder was _Partisanenbek\u00e4mpfung_ , combating partisans, even though few were at work in the early months of the war on the Eastern Front. And, everywhere from August on, the Germans claimed that women and children had to die, too, because they served as the eyes and ears of snipers and other guerrillas resisting the German advance. Alongside this military justification stood an ideological one, the Nazi conviction that Jews were the masterminds and wirepullers of Bolshevik rule. General Walter von Reichenau's order to his Sixth Army of October 10, 1941, rolled the legitimations together in the pronouncement that \"the soldier must have full understanding for the necessity of harsh but just punishment of the Jewish sub-humans. It has the broader objective of nipping in the bud any uprisings in the Wehrmacht's rear, which experience shows always to have been instigated by Jews.\" Hitler considered Reichenau's order outstanding and had it distributed to every German unit fighting on the Eastern Front.\n\nThe rapid growth in the number of victims is not surprising when one recalls that the Germans entered the USSR with a _Hungerplan_ that called for feeding their armies off the land and letting upwards of twenty million Soviet citizens starve to death. In keeping with the plan, the Nazi regime fed and provisioned the prisoners of war from the Red Army so poorly that 58 percent of those captured during the war, more than three million people, died in captivity, more than half of them in the first seven months of the German invasion. Reducing the number of mouths to feed in the conquered East was a consistently high priority for the Germans, and spreading the killing to ever more numerous groups of Jews aligned perfectly with military planning. But the food supply was a reinforcing, not a primary, motive for murder. Events proceeded along parallel lines in German-occupied Serbia during the summer and fall of 1941, with Jews being shot en masse in reprisal for partisan attacks even where provisions were not scarce. The Jews did not have to die because Nazi officials kept finding justifications for murder; the causal process ran the other way around.\n\nBy late summer 1941, Nazi policy had evolved from driving Jews from Germany's space to virtually forcing them to leave, to concentrating them for deportation and assuming many deaths along the way, to bringing death to the newly conquered. Only one step remained, bringing the already conquered Jews to death. The first tentative step in that direction occurred in mid-September, perhaps triggered by Stalin's decision to deport the remaining Germans in southern Russia to the country's interior. Hitler now finally agreed to require German Jews to wear a distinguishing Star of David on their clothing, a measure long since enacted in occupied countries but not yet in Germany itself. Marking the Jews was a preliminary to their deportation, as the Gauleiters had been demanding with increasing insistence, and all that stood in the way of making their departures end in immediate eradication was figuring out how to kill them en masse.\n\nGENTILE AND JEWISH RESPONSES\n\nHow was it possible for the Nazis to radicalize their assault on German and later European Jewry without appreciable interference? The question requires breaking down into three more precise subquestions: (1) Why did non-Jewish Germans, most of whom had not accepted antisemitism as a powerful political motive before 1933, act afterward as if it was exactly that? (2) Why did Jews in Germany not organize more effective countermeasures or at least all flee? (3) Why did foreign powers or entities not intervene on humanitarian grounds?\n\nThat more than half the Germans had not voted for Hitler by 1933 does not mean that these people rejected antisemitism. Some were faithful Catholics who had voted for the Center Party that was closely associated with the Church but also had absorbed its religiously based hostility toward Jews. Others did not believe that the Jews were the chief cause of the nation's troubles, as the Nazis insisted, but did not particularly like Jews, either. The main problem was that the number of antiantisemites was limited, and most non-Jewish Germans thought the fate of the Jews was secondary to their own concerns. Indifference and self-interest created opportunities for the Nazis to change people's behavior by a combination of carrot and stick, rewards for endorsing the new regime's ideology and punishment for not doing so. The punishment might be, but was not necessarily, violent. It might be only a slowing or blocking of a person's advancement in his or her career. The Nazi regime had numerous mechanisms that promoted conformity and corruption, and one of the most alarming features of the Holocaust is not only the rapidity with which these worked their effects on Germans but also the way in which these effects were replicated in virtually all the Nazi-occupied and -allied lands of Europe later, with disastrous consequences for Jews.\n\nEven among the segments of the German population that were best educated, most cosmopolitan, and most averse to violence, a process that could be called self-coordination ( _Selbstgleichschaltung_ ) set in remarkably rapidly in 1933 and led to a swift abandonment of organized efforts to protect Jews as a group. Several senior German diplomats, for example, considered resigning in early 1933 in protest against Nazi discrimination and brutality, but only one of them, Friedrich von Prittwitz und Gaffron, the German ambassador in Washington, actually did so. A group of leading business executives, including Carl Friedrich von Siemens, of the giant corporation that bore (and still bears) his family name, and Carl Bosch, of IG Farben, the huge chemicals conglomerate, met a few times during the year to draft a document intended to dissuade Hitler from antisemitic actions, but they never actually submitted it. Instead, the typical response of corporate executives was to knuckle under to Party attacks on Jews while seeking, at most, to shield a few valued individuals. Thus, Gustav Krupp von Bohlen und Halbach, the head of the National Association of German Industry, caved in to the demands of storm troopers who occupied his office in Berlin on April 1, 1933, and agreed to dismiss the Jews employed by his organization, along with anyone else the Nazi Party deemed politically unacceptable. Thus, too, Degussa, a firm that refined precious metals, responded to insinuations by Nazi newspapers that it was under Jewish influence by issuing notarized announcements that it had never employed Jews. In this fashion, the firm hoped to divert attention from the facts that several Jews had played a significant role in founding the enterprise seventy years earlier and six Jews still sat on the company's supervisory board in 1933.\n\nWhy did prominent, successful, established Germans fail to take a moral stand in 1933? There were many reasons. For one thing, the Nazi regime rapidly acquired a monopoly on political discourse and changed the moral valence of hatred from bad to good. Prior to 1933, antisemitism seemed crude and shameful in many quarters; now it was identified with patriotism everywhere. Conversely, expressing sympathy for Jews was now an unpatriotic act that could attract suspicion or condemnation. Attacking Jews was of far greater importance to the Nazis than defending them was to other Germans, so most such people decided that discretion was the better part of valor and said nothing. Besides, even Germans who found Nazi antisemitism distasteful approved of other aspects of the Party's program\u2014in other words, shared a partial identity of interests with Hitler's movement. Diplomats and military officers, for example, generally longed for the revision of the terms of the Versailles Treaty and the resurgence of the German army, and Hitler promised to deliver these things. Many corporate executives hoped for the suppression of the trade unions and recovery from the Depression, and Hitler embraced these goals, too.\n\nAbove all, in the rapidly changing and violent context of early 1933, most upper-class Germans took refuge in a delusional mix of fear for their livelihoods and a misplaced sense of responsibility. As Ernst von Weizs\u00e4cker of the Foreign Ministry wrote at the time, \"the specialist cannot simply quit the field.\" Instead, he had to give the regime \"all forms of support and experience . . . and help see to it that the . . . current revolution becomes genuinely constructive.\" Of course, Weizs\u00e4cker did not find this particularly difficult because he also deplored what he imagined as the nation's \"inundation with Jews\" since 1919. But even a somewhat more liberal figure, Fritz Roessler, the head of the supervisory board of Degussa, tried to put the best face on things in 1933 and concluded that people like him \"should recognize the good in the movement, ignore the human deficiencies associated with every revolution, and do one's bit so that this wild-grown juice becomes wine.\"\n\nAs in Weizs\u00e4cker's and Roessler's cases, a strong sense of duty in 1933 often blinded people in high places to the implications of their choices. In the long run, helping the Nazis \"in order to avoid worse,\" as the phrase of the day went, merely made them stronger and more dangerous. As the pastor of Kurt Gerstein, who later served in the SS and procured some of the Zyklon gas used at Auschwitz, told him in the 1930s, when he decided to join the Nazi Party and try to influence it from within, \"you reckon that you can still have a say in things. . . . [But] he who enters this tumbling avalanche only increases the plunging mass.\" Very few Germans were this farsighted.\n\nAmong younger people still working their way up professionally, the way the Nazis mixed intimidation and indoctrination in 1933 comes across very powerfully in Sebastian Haffner's memoir, called in English _Defying Hitler_. That title is melodramatic and sensational, but Haffner did flee his homeland in 1938 and make a new career in England as a journalist before returning to Germany after World War II. In his native language, he called his book simply _Geschichte eines Deutschen_ (Story of a German). Haffner, whose real name was Raimund Pretzel, was twenty-six years old when Hitler came to power and a law student preparing to take his bar exams. He paints vivid pictures of the marauding storm trooper units that beat up anyone in the streets who failed to raise a hand in the Nazi salute when a swastika flag passed by and of the day in the spring of 1933 when these thugs broke into the law library where he was studying, asked all the patrons, _\"Sind Sie arisch?\"_ (\"Are you an Aryan?\"), and assaulted those who said no or appeared to be lying. He walked away from that occasion deeply ashamed of himself for having answered the question truthfully with a yes. This was far from the only or even the first such assault on the legal system that spring.\n\nThat was the intimidation side of 1933; the indoctrination side came later, when the new regime ordered Haffner and all the other bar candidates to spend the summer at a kind of boot camp for future lawyers, where they were taught the Party's racist ideology and drilled endlessly. Searching for a word to describe what the experience had done to him and his peers, Haffner coined a neologism based on one of the words Party members used to address each other, _Kamerad_ , or comrade. He said the camp had _verkameradet_ these young men, which means \"comraded\" or \"comradified\" them. The militarization of German life by institutions and practices such as this discouraged critical thinking during the 1930s and encouraged group identification, solidarity, and obedience. So did the regime's relentless emphasis on the People's Community ( _Volksgemeinschaft_ ) and insistence that German citizens had moral obligations only to \"Us\" and no one else. A great, intoxicating glorification of \"belonging\" began to grip German life. Bernhard Rust, the new Nazi minister for education, explained the intellectual obligations this imposed in 1933, when he told a group of professors in Munich, \"From now on, it is not up to you to decide whether something is true, but whether it is in the interests of the National Socialist Revolution.\"\n\nThese stories illustrate how power magnifies the ideas of those who hold it because of the human tendency to seek safety in conformity. The only antidotes are conviction\u2014loyalty to a strong countervailing ideology\u2014and the freedom to express it. Where these are lacking, as was the case in Germany after 1933, ideologues quickly get the upper hand and call the tune for behavior. A minority of haters, backed by the authority of the state, thus becomes free to drive events forward, to make the lives of any targeted group ever more miserable.\n\nSelf-interest dictated to most other Germans that they should ignore what was happening to the Jews or treat it as merely the price of the apparently good things the Nazi regime was bringing. After all, by 1936, the Depression was over and unemployment a thing of the past; the Nazi regime had achieved the fastest economic revival in the world. By the same year, Germany had recovered the Saar region, which France had administered since 1919; had renounced the military limits imposed on the Reich by the Versailles Treaty; and had sent its soldiers back into the Rhineland, the formerly demilitarized western strip of territory that bordered the Netherlands, Belgium, Luxembourg, and France. Within the next two years, Hitler annexed Austria, brought the German speakers of the Sudetenland \"home\" to the nation of which they had never been a part, and occupied the rest of today's Czech Republic, all without firing a shot or losing a soldier in battle.\n\nSelf-interest also encouraged some people to seek to benefit from the persecution, which accounts for the many eager lawyers and brokers who acted as middlemen in the sale of Jews' assets and the numerous willing graspers for their medical and legal practices, their artwork, their houses and apartments, their furniture and carpets, and so on. Many non-Jews concluded that they could not stop the persecution, so they might as well get something out of it. Even Germans who did not exploit the situation in this fashion increasingly looked out for themselves by cutting off contact with Jewish friends and neighbors, thus both increasing their isolation and becoming deaf and blind to their suffering.\n\nBesides, the gradual nature of the Nazi escalation raised the general problem of seeing ahead that affected all parties, including non-Jewish Germans, Jewish Germans, and foreigners. Had people known that cruelty and discrimination would become starvation and slaughter, more might have balked. But even the Nazis did not know this in 1933, so why should anyone else have been sure? Instead of imagining where persecution might lead, Germans got caught up in the completely self-referential intellectual world that the Nazis created, where public information was tightly controlled, foreign publications were banned, the adjective \"cosmopolitan\" was a preferred term of abuse, and people were constantly reminded to \"work towards the F\u00fchrer,\" to imagine what Hitler would want them to do and then to do it. The public mind was, in other words, methodically poisoned, and the measuring stick of morality systematically shifted from general ethical principles like the Golden Rule to the specific matter of whether an action strengthened Germany or did not. This warping of people's thinking worked especially powerfully on young people coming of age during the 1930s, who seldom had an independent frame of reference. Teenagers were at the forefront of violent attacks on individual Jews and attempts to humiliate them and those who consorted with them during that decade.\n\nTwo caveats about this collective brainwashing need stressing. First, it did not necessarily change what older people thought, but it decisively changed what they would say or do. The Nazis defined public discourse and controlled the social reward system, and that was enough to limit open disagreement or dissent. Second, the corruption of people's sense of decency toward Jews did not happen overnight or without the occasional application of extra pressure. Another story about Degussa illustrates the latter point. The tale concerns the behavior of Ernst Busemann, the head of Degussa's managing board, toward two Jewish families, the Meyers and the Margulieses, who had sold majority interests in their firms to Degussa during the 1920s but retained 26 percent of the stock and management positions in the respective subsidiaries. In November and December of 1937, the NSBO chapter at the first of these subsidiaries wanted it to compete for the honor of being a National Socialist Model Factory. The union therefore petitioned the managing director to make this possible by buying out the Jewish members of the Meyer family and removing them from management. The director dutifully wrote to Busemann and asked what to do. Busemann's reply survives, and it is a remarkable document that begins with fulsome praise for the members of the Meyer family as old friends and upstanding businessmen, then expresses regret that he holds their fate in his hands, and finally delivers the crushing judgment that, nonetheless, \"it is pointless to swim against the stream\"\u2014the Meyers and their shareholding would have to go. To soften the blow, Busemann contrived a way to pay for their stock in the subsidiary with stock in IG Farben that had the same face value but a considerably higher market worth. In contrast, only a few months later, in April 1938, after the Nazis demanded the expulsion of the Jewish minority owners of the Degussa subsidiary in Austria, Busemann offered the members of the Margulies family only a fraction in cash of what the stock was worth and told them to take it or leave it. Why the abrupt and extreme change? The political danger of being discovered acting generously or even sympathetically toward Jews had become much greater in the aftermath of the annexation of Austria (the _Anschluss_ ) and G\u00f6ring's decrees accelerating Aryanization, and Busemann adjusted his behavior accordingly.\n\nThese stories from Haffner's memoir and the history of Degussa are indicative, but are they representative? What do we know about what most Germans thought about the persecution of the Jews, and how do we know it? We actually have quite a few sources, of which the following four are among the most important: the _Sopade-Berichte_ , periodic reports smuggled out to the Social Democratic Party in Exile in Prague by leftist opponents of the regime still in Germany; the _Stimmungsberichte_ , or \"mood reports,\" collected by Gestapo (secret state police) agents among the public and published decades later as _Meldungen aus dem Reich_ (an English translation of passages concerning Jews comes to 657 pages); numerous diaries kept by non-Jewish Germans and gleaned effectively by Peter Fritzsche in _Life and Death in the Third Reich_ ; and a brilliant, poignant diary kept by a baptized Jew with a non-Jewish wife, Victor Klemperer, who survived the Nazi regime, which has been published in English in two volumes under the title _I Will Bear Witness_.\n\nThese sources paint a complex, inconsistent picture, in which acts of kindness mix with extraordinary callousness, but the overall portrait is of a public split into three groups: people who endorsed the persecution of the Jews, people who merely accepted it, and people who disliked it but saw little point in protesting, even though they frequently expressed reservations or felt embarrassed about specific actions. The Gestapo reports vividly record both the bullying and harassment that Jews experienced on a daily basis and the distaste that such actions sometimes aroused. In September 1934, the office in Potsdam regretted to relate that \"the Jewish question is not the main problem of the German public. . . . Utterances on the Jewish peril are played down, and those engaged in enlightening the population are depicted to a certain extent as fools.\" The following July, the office in Kiel stated, \"It is noteworthy that, whenever there are actions against the Jews, these emanate chiefly from members of the Party and its affiliated organizations, whereas the majority of the population shows little participation.\" In October 1935, the office in Magdeburg had this to say about the public response to the Nuremberg Laws, enacted that year: \"all in all, it is accurate to note that the new laws have been received in part with indifference, and in part with very little appreciation and understanding outside the solid National Socialist-oriented population.\" Other offices reported precisely the opposite, however, contending that the public welcomed the Nuremberg Laws as finally creating clarity about the position of Jews in Germany.\n\nInsofar as one can generalize about the indications of adult German public opinion prior to _Kristallnacht_ , they record general acceptance of antisemitic policies except when they threatened the self-interest of non-Jews. Thus many Germans resented the Party's appeals to stay away from Jewish-owned shops, because they were perceived as often offering better goods at better prices, and many farmers had to be forced to break off their relationships with trusted Jewish livestock dealers. Similarly, but in a more abstract sense, many Germans feared damage to the nation's image abroad from antisemitic actions and from the prominence of virulent antisemitic publications, notably Julius Streicher's _Der St\u00fcrmer_. In the mid-1930s, it was posted conspicuously every day in special glass display cases in many towns and villages, but as time passed, public discomfort led to a decline in that practice. The reaction to _Kristallnacht_ itself reaffirmed this pattern, as numerous people in the street expressed shame and disgust on the morning after, though as much at the wasteful destruction of property and appearance of disorder as at the harm done to Jews. Whatever the mix of attitudes among the non-Jewish population, the decisive point is that violence and viciousness toward Jews increased steadily during the 1930s in Nazi Germany and in full public view, especially in small cities and the countryside, yet the pattern gave rise to too little rejection or revulsion to make the Nazi regime change course.\n\nOnce the war began, hostility toward Jews hardened. Rumors were rife about ghettoization and impending deportation from Germany to Poland, and little dissent emerged in the early years of the fighting. Many Gestapo reports in 1940 stressed the powerful impact on the populace of the propaganda film _Jud S\u00fcss_ , which clearly strengthened antisemitic feeling. In July 1941, the Gestapo office in Berlin commented on the public response to the first round of newsreels from the Eastern Front in these words, \"The images of the arrest of the Jews . . . have met with enthusiastic approval, and people say that the Jews here [that is, in Germany] are being treated with far too much leniency. The series of pictures on the forced deployment of the Jews in clearing operations were greeted everywhere with great delight.\" And, in September, local offices from all around the country chorused that the order for German Jews to start wearing identifying Stars of David on their clothing had been greeted with \"genuine satisfaction\" and \"gratification.\" Nonetheless, a month later, Goebbels lamented in his diary, \"our intellectuals and high society have once again suddenly discovered their humane feelings for the poor Jews.\" He therefore made sure that an announcement of new punishments for \"Jew-friendly behavior\" accompanied the next set of monthly ration books delivered to every German home.\n\nDespite such reminders, the Nazi regime felt the need to take additional precautions against sympathy arising toward German Jews after their deportation began. In Berlin during October 1941, the first contingents of people being sent \"to the east\" reported to the Levetzowstrasse synagogue in the Moabit neighborhood near the center of the city and then had to walk six kilometers in broad daylight to the loading point at the Grunewald freight railroad station on the far west side of town. When the shipments resumed in mid-1942, the authorities decided to expose fewer witnesses to the spectacle by conducting the marches in the middle of the night. Similarly, later that year, when Berlin Jews began being shipped from another, even more centrally located collection point in the Grosse Hamburgerstrasse to the ghetto camp at Theresienstadt in Bohemia, they made the first legs of the journey before dawn via streetcar to trains that left from the not yet bustling Anhalter railroad station.\n\nThe use of Theresienstadt (Terezin in Czech) as a destination for elderly and decorated German Jews also attested to the Nazi regime's residual desire to disguise what was happening. A formerly Austrian garrison town in Bohemia that had been turned into a holding pen for Czech Jews in November 1941, the site became after mid-1942 a supposed refuge for German Jews unable to perform the \"work in the east\" to which most deportees allegedly were being sent. In reality, this \"old people's ghetto\" proved to be a mere way station on the road to death for most of the 58,000 Jews from Greater Germany ever confined there. About 41 percent of them were sent on to death camps; a slightly larger share died on the site from cold, hunger, and disease; and only about 7,000 remained at liberation in 1945. Meanwhile, however, Nazi propaganda highlighted the mythical comforts of the installation in order, first, to mislead Germans about the regime's intentions, and then, in 1944, to delude the gullible representatives of the International Red Cross whom the Reich allowed to tour the temporarily prettified grounds.\n\nAt least with regard to two categories of German Jews, those descended from or in marriages to non-Jewish Germans, the regime was for a time also cautious. It introduced restrictions on them more slowly than on \"full Jews\" ( _Volljuden_ ) or people the Nazis counted as such because of their marital status or religious affiliation ( _Geltungsjuden_ ) and deferred expulsion, lest numerous non-Jewish German relatives protest. Still, essentially the same long discovery process that had occurred in making policy toward German Jews took place, only at a slower pace, toward those Germans who had one Jewish grandparent (second-degree _Mischlinge_ ; 40,000 people in 1939) or two but no other connection to Jews or Judaism (first-degree _Mischlinge_ ; 64,000 in 1939). Thus _Mischlinge_ , unlike Jews, had neither lost German citizenship nor been forbidden to have sexual relations with so-called Aryans under the Nuremberg Laws, though future marriages between Aryans and _Mischlinge_ were banned. _Mischlinge_ were barred from military service later than Jews and exempted from concentration in so-called Jew Houses and from deportation to ghettos or death camps until 1943. Thereafter the regime cracked down, exhibiting increased confidence or fanaticism in sweeping potential objections aside and encountering, in fact, very few. Roundups for incarceration in forced labor camps began in the spring of 1944, followed in early 1945 by the planned deportation to Theresienstadt of all remaining _Mischlinge_ and all of the approximately 21,500 German and Austrian Jews who still clung to precarious existence as part of mixed marriages. Victor Klemperer, the now famous diarist, escaped deportation in early 1945 only because the firebombing of Dresden, where he lived, occurred just before his scheduled departure, and the resulting chaos enabled him to conceal his identity as he and his wife fled the city. Many other prospective deportees were not so lucky. Although shipments from Berlin were impeded by the last Soviet offensive, trains from places like Frankfurt and Leipzig arrived at Theresienstadt, and some of those aboard did not survive the few remaining months of the war; many barely did so. Had the Third Reich endured or even lasted a little longer, most of the first-degree _Mischlinge_ and the Jewish spouses of non-Jews appear to have been destined for death and most of the second-degree _Mischlinge_ for sterilization.\n\nAs Germans grew steadily more hard-hearted toward Jews and steadily more receptive to Nazi propaganda about them after 1933, why did the Jewish community in Germany not defend itself better or at least get entirely out of harm's way? In a sense, the question, like the one often raised about Jewish behavior in the ghettos of Poland examined later in this book, is terribly na\u00efve and cruel. Jews were up against a Nazi movement that was both ruthless and shameless in what it would say about and do to them. They constituted a tiny share of the German population to begin with in 1933 and became ever fewer as time passed. They shared with everyone else an inability to see what was coming, all the more so as it involved behavior unprecedented on the part of a civilized country.\n\nAbove all, Germany's Jews, like those of occupied Europe later, were not monolithic and conspiratorially united, as the Nazis claimed, but divided among themselves about what the Nazi onslaught signified and therefore how to respond to it. About two-thirds of them were liberal, acculturated, often somewhat secular or entirely non-observant Jews, either members of or in sympathy with the Centralverein deutscher Staatsb\u00fcrger j\u00fcdischen Glaubens, the Central Association of German Citizens of the Jewish Faith, a name that signified their desire to be integrated into the German nation and to have the same rights as all other German citizens. For this group, the Nazi attack was difficult to comprehend and especially painful to experience because it seemed such an unwarranted rejection of their loyalty to Germany.\n\nThe other two principal groups, the Orthodox, who accounted for perhaps 20 percent of Jews in Germany in 1933, and the Zionists, who then constituted 5\u201310 percent, were not so hurt by the Nazis' hostility, because they expected it. To the Orthodox, it was the work of an inscrutable God but probably a punishment for the apostasy of so many German Jews. The answer was to pray harder. To the Zionists, advocates of settling and founding a Jewish state in Palestine, endemic hostility of gentiles toward Jews was the assumption on which their movement rested. The Zionist answer to German persecution was to work with the Nazis on the basis of a common conviction that Jews and Germans constituted separate nationalities in order to achieve one partially shared objective: emigration of Jews from Germany. Partially shared, not identical\u2014because the Nazis wanted to drive all Jews out of Germany; but the Zionists knew that the _Yishuv_ , the Jewish settler community in Palestine, could afford to take only some Jews in, preferably young and fit ones who could speak Hebrew and were willing to do hard physical work on collective farms, the _kibbutzim_. Moreover, even while the Nazis promoted the Zionist goal of Jewish immigration to Palestine, they opposed the Zionist objective of founding a Jewish state there.\n\nThis overlapping interest in emigration resulted in the controversial _Ha'avara_ , or Transfer Agreement, of August 1933. It created a modest escape route for German Jews during the 1930s, eventually financing the emigration to Palestine of about 20,000 of the 52,000 German Jews who got there by 1939, and contributed to the increasing popularity of Zionism among German Jews during the 1930s. But the Transfer Agreement was morally questionable, hotly debated at the time, and consequently not generally imitated by or for Jewish communities elsewhere. Basically, the agreement set up a system by which Jews seeking to leave Germany for Palestine had their possessions in Germany appraised and then handed them over to the German state. Germany thereupon paid some individual \u00e9migr\u00e9s whose wealth exceeded a certain minimum in reichsmark at least 1,000 Palestinian pounds sterling, the threshold level of cash assets for unrestricted entrance to Palestine. The Reich then was supposed to pay the remainder of all admitted German Jewish emigrants' wealth to the Jewish Agency in Palestine in the form of German goods that the agency could sell for the benefit of these or other new settlers. The _Yishuv_ got people out, and Germany got most of the Jews' property, along with increased production for export that buoyed employment at home and thus strengthened the Nazi regime. For a while, this system seemed to offer something to both Zionists and Nazis, but its economic value to Germany declined rapidly. Beginning in 1935, the Nazi regime steadily raised the reichsmark minimum for issuing Palestinian currency and reduced the range of goods available for resale. In the end, exiting German Jews got to retain less than 1.5 percent of their property via the agreement, and it remained operative until World War II began only because Hitler did not wish to abandon any device that might encourage Jews to leave Germany.\n\nAs to other forms of emigration, German Jewish leaders at first hesitated. The Central Association discouraged emigration in 1933\u201335 because leaving amounted to surrendering claims to Germanness and abandoning those Jews who could not get out. But after the enactment of the Nuremberg Laws, the Central Association changed its attitude and began to encourage emigration. The organization remained a proponent of the diaspora over a Jewish state but conceded that German Jewry had no long-term future by renaming itself in 1936. Dropping the reference to German citizenship, the group became simply the J\u00fcdischer Centralverein, the Jewish Central Association. By 1937, as noted above, most German Jews had begun seeking an exit, even though they had limited prospects. But some people had better chances of being accepted elsewhere than others. Broadly speaking, age worked against a person, youth worked for him or her: 84 percent of German Jews under the age of twenty-four in 1933 got out alive, compared to 60 percent of the total population; by 1939, one-third of the remaining Jews in Germany were sixty or more years old, and just more than half were over fifty. A person possessing the few skills needed elsewhere had a better chance than someone whose abilities threatened to compete with residents of other countries. This often meant that people with artisanal or agricultural training had better prospects than professionals. Wealth sometimes enabled people to leave early because other countries were more open to persons bringing money, and in the early years of Nazi rule, Jews could take a larger share of their assets with them than later was allowed. But wealth also tempted people to remain, since the Nazis generally targeted large firms and their owners last, and then such people generally lost almost everything. Men had better chances of going abroad than women, but the fact that women made up 60 percent of the remaining German Jewish population in 1939 almost certainly reflected something else\u2014namely, that they more often assumed caretaker responsibilities for aged parents or disabled or handicapped relatives than did men, given the prevailing gender roles of the day. A good many of the Jews still in Germany in 1939 simply could not leave someone behind who depended on them.\n\nThe legend that German Jews faced the persecution passively or incredulously is just that, a legend. They fought back the only way they collectively could: by equipping as many people as possible with skills that would help them get out and by mutually sustaining all those who remained. Already in 1933, they organized a Central Welfare Office of German Jews and a national organization, the Reichsvertretung der deutschen Juden, the National Representation of German Jews. These groups collected and disbursed funds for labor offices, cars for traveling salesmen, legal aid clinics, and the like. From 1933 to 1937, such welfare offices at the national and local levels spent 26.3 million reichsmark from their own resources, plus 7.5 million donated from abroad. Special groups for doctors, lawyers, and artists came into being and worked to find new positions for unemployed colleagues abroad or at Jewish institutions within the country. Some 140 retraining institutes were established, through which 30,000 people passed by 1938, two-thirds of them younger than twenty. As the government cut Jews off from the state welfare system, they depended increasingly for support on contributions from the shrinking population of Jews who still had work. Already in 1935, one-third of the Jews in Germany relied on such help, and Jewish soup kitchens across the country dispensed 2.5 million meals. But in subsequent years, both the number of people and the percentage of the population that the community could sustain dropped along with the size of the remaining population. Jewish self-help was fighting a losing battle, but it was an effort that did credit to the people who undertook it.\n\nIn 1939, the Nazi regime dissolved the Reichsvertretung and all other Jewish communal organizations and replaced them with a new entity that enrolled all remaining Jews in Germany. This was called the Reichsvereinigung der Juden in Deutschland, the National Union of Jews in Germany. Its leaders continued the heroic struggle to sustain Germany's remaining and increasingly aged and impoverished Jewish population, but the effort proved hopeless as the persecution escalated toward murder. By the time deportations began in October 1941, most of the remaining Jews in Germany were in a beleaguered and wretched state. Crammed at least two people to a room into Jew Houses with communal kitchens and baths and scattered around the worst neighborhoods of the big cities, deprived of their radios and even their pets, allowed fewer ration coupons for food and other goods than those allotted to non-Jewish Germans, and permitted to shop only in the final hours of specified days, by which time stores often had sold out, many Jews were on the edge of starvation and despair. Their leaders in the National Union were subordinated directly to the RSHA and sought to protect themselves, as did their counterparts in occupied Europe, by carrying out the SS's instructions. The Reichsvereinigung thus degenerated into an instrument by which the Nazi regime kept track of all Jews left in Germany, plundered what was left of their possessions, and then managed many aspects of the deportations, including identifying eligible Jews according to selection criteria set by the Reich Security Main Office. In 1942\u201343, the National Union even sent its own personnel, called _Ordner_ , or auxiliaries, to collect the people assigned to each transport if they did not comply with a summons to report on the preceding day. In Vienna the name given to these Jewish helpers of the SS was more descriptive; they were called \"lifters\" ( _Ausheber_ ).\n\nAs was the case in the ghettos further east, such submissiveness resulted from desires for both self-preservation and amelioration. Cooperation with the SS seemed the only available way for Jewish leaders to stay alive and to alleviate the plight of deportees by providing food and blankets to them at the collection and departure points. But behind the actions of the Reichsvereinigung was something else that also operated farther east: direct intimidation. The Nazis took fierce reprisals against recalcitrance or resistance. Emblematic of the viciousness were the actions that followed an attempt in May 1942 by a group around a Jew named Herbert Baum to burn down a propaganda exhibition against the Soviet Union in Berlin. The Gestapo caught thirty-three conspirators almost immediately and executed not only those people but another 250 Jewish men, who were rounded up and sent to Sachsenhausen, just outside the city. Another 250 Jewish males then also disappeared into that camp, the families of all 500 men immediately were deported \"to the east,\" and Goebbels stepped up the timetable for making Berlin \"Jew-free.\"\n\nHow did Hitler manage to ratchet up the persecution of Germany's Jews during the 1930s without provoking foreign interference or even intervention? He did this, in part, by phasing in restrictions and even occasionally holding out the prospect that some Jews could remain in Germany\u2014or at least in Theresienstadt\u2014in the long run. Nazi leaders kept people guessing about their intentions and said just enough contradictory things to make at least some outsiders believe that the worst would not happen. That some outsiders wanted to believe this is the second key piece of an explanation. In Britain and France, the two nations best positioned to alter Hitler's behavior before German rearmament had reached dangerous proportions, homegrown antisemitism combined with wishful thinking to argue for noninterference in Germany's internal affairs, however barbaric they might seem. That wishful thinking propelled the policy of appeasement, which amounted to the belief that protecting the rights of others, whether German Jews or the Czechs at the time of the Munich Conference, was not worth the risk of another world war and the terrible carnage that Britain and France had experienced. Until _Kristallnacht_ and sometimes beyond, many appeasers actually were inclined to blame Jews for poisoning relations with Germany rather than to blame Germany for persecuting Jews.\n\nHitler played brilliantly throughout the 1930s on fear of war in the Allied nations, and he invited them repeatedly to buy him off with concessions that he later announced were insufficient. This tactic worked so well for him until he occupied the Czech provinces in March 1939, only six months after he promised to leave them independent at the Munich Conference, that the Allies recurrently declined to let the fate of Germany's Jews upset the quest for peace. Hitler and his propaganda agencies also played shrewdly on the antisemitism present in Britain, France, and also the United States. He blackmailed these countries into reticence or silence by the simple trick of claiming that they were tools of the Jews and then citing any protest on their behalf by these countries as proof of his charge. Fearing to seem to confirm his propaganda and thus to arouse domestic antisemites, the Allied governments generally fell into a Nazi trap and pulled their punches, at least until _Kristallnacht_. Even after the pogrom\u2014in fact, less than a month later, on December 6, 1938\u2014France signed a new treaty with Germany reaffirming the integrity of the border between the two countries. Meanwhile, Joseph Lyons, the prime minister of Australia and a vigorous proponent of appeasement, resolutely refused to condemn the atrocities in Germany, lest doing so interfere with his efforts to head off war. Only one nation, the United States, exercised the usual diplomatic form of expressing revulsion at the Nazi rampage by calling America's ambassador home \"for consultations.\"\n\nThe Nazi regime was adept before the war at constructing choices that looked bleak either way for both Germany's Jews and the Allied states. German Jews rapidly recognized that they faced a constant choice between complying with Nazi actions and making them worse. They opted to do the best they could under barbaric circumstances and to play for time. The Allies constantly had to choose, at least after 1936, between accepting both Nazi territorial demands and Nazi mistreatment of German Jews or a bloody war that Britain and France expected would weaken their holds on their empires and, as Neville Chamberlain explicitly predicted, put them hopelessly in debt to the United States. Even if they won, the Allies stood to lose, and after 1945, they did, as Chamberlain's fears came true. Britain, after all, suffered under food rationing into the early 1950s because the war did such damage to its economy, and the British, French, Dutch, and Belgian empires melted away following the war.\n\nAs the persecution of the Jews escalated, the Nazi regime presented another group with unpalatable alternatives, namely the owners of foreign direct investment in Nazi Germany. Ford, General Motors, IBM, Standard Oil, and many other American corporations all possessed significant German subsidiaries during the 1930s, as did several large Dutch, Swedish, and Swiss enterprises. Recent books have criticized the American firms for not divesting their holdings in protest against mounting Nazi discrimination and brutality and, instead, letting their offshoots in Germany become complicit in German rearmament and in some cases in the persecution of the Jews. Some authors have spoken of a \"strategic alliance\" between American corporations and Hitler, of corporate \"collaboration\" and \"pacts\" with the Nazis.\n\nSuch overblown charges overlook a number of aspects of the situation the parent companies confronted. Divestment for political or moral reasons was a virtually unknown practice in the 1930s, which is the principal reason why almost no major corporation with holdings in Germany, regardless of the country in which its headquarters stood, suspended operations or sold out and withdrew. The exceptions were a few of the Hollywood film distribution companies, notably Warner Bros., which closed its German sales operations in 1933, and United Artists, Universal, RKO, and Columbia Pictures, which followed suit fairly quickly. But only Warner's gave up completely on the German market. The other four companies preserved special arrangements with German partners, and MGM, Paramount, and Twentieth Century-Fox kept trying to get their films introduced into German theaters and making the compromises that seemed necessary to that objective right up until World War II began. And these were not manufacturing firms with major fixed investments. Though businessmen like to say that \"all past costs are sunk,\" meaning that the chief criterion for continuing an enterprise is its future returns, not the capital previously committed to it, few firms in this or any other era have found acting on that maxim palatable, especially when the asset in question is even only slightly profitable. The prevailing tendencies among businessmen were to retain what they had in the hope that political conditions would improve in the future and meanwhile to try to extract the returns that had been the goal of the original investment.\n\nMoreover, financial controls established by the Nazi regime blocked the repatriation of income earned in Germany. Both while a company continued and in the event of its sale, all net proceeds had to be reinvested in the Reich or converted into government bonds. This reinforced the reluctance to divest, since the only comparably profitable investments were likely to be at least as implicated in German government policies as the ones the parent companies already possessed. In the event of divestment, then, the foreign investor faced not quite a total loss, but declining control over assets without appreciable moral gain. Finally, most foreign-owned companies in Germany spent the 1930s fighting and largely losing a rearguard action precisely against this declining control. In almost every case, managers from the owning country gave way to Germans, who took pains to position the subsidiaries as German firms in order to hold onto business and who acted increasingly independently of their home offices, not least because Nazi mandates regarding economic secrecy restricted what the local managers even could report about their activities. As a result, headquarters in Detroit in the case of the car companies and New York in the case of IBM had little influence over day-to-day operating decisions in their German affiliates after 1938 or 1939 at the latest; the same was true of Lever Brothers of the Netherlands, one of the largest foreign investors in Nazi Germany. For all of these reasons, as well as the general difficulty of seeing ahead, the Nazi persecution of the Jews did not encounter the sort of economic pressures successfully brought to bear some fifty years later on the apartheid regime in South Africa.\n\nIn any case, IBM's rebellious subsidiary, the _Deutsche Hollerith Maschinen Gesellschaft_ , managed by the spiteful German who formerly owned it, did not play the roles in identifying and later rounding up the German Jews or in managing slave labor that the parent firm's critics have maintained. From 1933 to 1943, the Gestapo used the card files efficiently compiled and regularly updated by the Reichsvertretung and its successor to keep tabs on the nation's Jews and their residences. The SS experimented briefly in 1944 with using Hollerith cards and tabulators to steer the deployment of camp inmates to work sites but soon gave up on the idea. GM's Opel division became complicit, in that it began building thousands of trucks for the German army and then aircraft engines for the Luftwaffe well before the United States and Germany went to war in 1941 and the company's plants were placed under a German trustee. But this acceptance of government contracts began only after the Nazi regime threatened to expropriate the firm. In 1939\u201341, Ford-Werke in Cologne produced fewer trucks for the Wehrmacht than Opel, but some were used in the invasions of Austria and Bohemia-Moravia, and the local management gave in, not to threats but to desperation to offset declining sales of civilian vehicles.\n\nAfter World War II ended, the economic appeasers who clung to their foreign investments in Germany could claim, like the political appeasers but with more positive results, that events had vindicated their course. The parent companies recovered their assets west of the iron curtain and even such profits as these had accumulated. Perhaps alone among all the groups confronted with poor options by the Nazi regime during the 1930s, the American owners ultimately found playing for time a successful strategy.\n\nIn sum, the years 1933\u201341 taught Hitler and his followers that neither Germans nor foreigners were inclined to interfere with Nazi actions toward Jews. In the context of the regime's inability to expel them faster than it conquered them, such passivity added impetus to ever more radical persecution.\nCHAPTER 4\n\n[ANNIHILATION:  \nWhy This Swift  \nand Sweeping?](contents.xhtml#ch_4)\n\nONE OFTEN AND surprisingly overlooked feature of the Holocaust is its combination of shocking temporal and spatial compression with sweeping extent. Although the Nazis kept killing Jews until the Third Reich crumbled, and although it rounded them up all over Europe to kill them, several striking fractions give a sense of how concentrated the time and place of the massacre was, as well as how encompassing. Three-quarters of the nearly six million victims were killed within only twenty months, from June 1941 to February 1943, and half of the total victims died within only the last eleven months of that time frame. Moreover, three-quarters of those killed lived before the war in only three countries: Poland, Lithuania, and the USSR (mostly in the northeast quadrant of the European continent, demarcated on figure 4 by dotted horizontal and vertical lines going east and north from Vienna), and probably nine-tenths of the victims died in those places, since that is where the _Einsatzgruppen_ , the Order Police, the Reserve Police Battalions, and the great bulk of the Wehrmacht operated and where Germans placed the death camps. Altogether, at least three-quarters of the Jews who ever came within reach of Nazi Germany and its allies were killed, constituting in the end two-thirds of the Jews of Europe (six million out of nine million when World War II began; the oft-quoted total of eleven million given in the minutes of the Wannsee Conference was an exaggeration or included converts as well as their children and grandchildren). For Jewish children sixteen or younger, the mortality rate was almost nine-tenths.\n\nWhy was the Holocaust so concentrated in these ways? How could the Nazis come so close to killing all the European Jews\u2014and do so at the average rate of 225,000 people per month, from mid-1941 to early 1943, and 325,000 per month (more than 10,000 _per day_ ), at the frenetic peak of the Holocaust in 1942\u201343?\n\nFIGURE 4: THE GEOGRAPHICAL COMPRESSION OF THE HOLOCAUST\n\nFROM BULLETS TO GAS\n\nIn a sense, the heart of the answer to these questions is technical. By 1941, the Nazis had a motive to kill the Jews of Europe\u2014namely, the deep-seated ideological conviction that they were implacable enemies\u2014and an opportunity to do so\u2014the chance to slaughter under the guise of military action. The expansion of the conflict added new rationales to remove Jews from German territory, such as the desire to resettle the _Volksdeutsche_ and the need to conserve scarce food supplies, and removed restraints on Nazi action, since a regime already or about to be at war with the whole world had little left to lose. Considerations like these led the Third Reich to decide on a policy of mass murder in the occupied Soviet Union, but there alone, at first.\n\nWhat seemed to be missing before Nazi Germany took the final, fateful step toward total annihilation of the Jewish population in Europe was the means to accomplish it. But during the late summer and early fall of 1941, in the months of September and October, Hitler and Himmler came to recognize that they already had these. The war had spawned possibilities for carrying out mass killing, and all that remained lacking were installations at which to apply these possibilities. The Nazi leaders knew that they could not employ the methods being used in the lands conquered from the USSR in Central or Western Europe. Simply shooting Jews and burying them in pits was likely to arouse revulsion and opposition there and thus to increase resistance to German rule, which would raise the military costs of maintaining it. Besides, Himmler quickly came to fear the effect on his men of having to shoot women and children hour after hour, day after day. Indeed, at least one of the _Einsatzgruppen_ commanders, Erich von dem Bach-Zelewski, later suffered a nervous breakdown, though only briefly. What the Nazi regime needed was a way of killing people that was inconspicuous or, as the SS planners put it, \"noiseless\" ( _ger\u00e4uschlos_ ), and that was more, again as they put it, \"humane\" . . . to the perpetrators.\n\nThis is the context in which to interpret the letter of July 31, 1941, that G\u00f6ring sent to Heydrich, authorizing him to find \"an overall solution to the Jewish question in the German sphere.\" Heydrich already had authority over \"emigration and evacuation,\" as the letter noted. He had no need for new authority unless he was being given a new assignment, and this document extended his competence to the entire \"German sphere\" and asked him to identify a \"total solution,\" implicitly in addition to the partial solution already being enacted in Russia. In other words, this letter is the surest sign that the Nazi state already was looking for a comprehensive method to apply continent-wide, and Heydrich's task was to find it.\n\nIn fact, the regime had possessed such a method since early in 1940. Beginning in 1938 with a single case, Hitler had authorized subordinates in his personal Chancellery to grant parental petitions to kill German children born mentally handicapped, and his regime followed this up in August 1939 with a decree requiring hospitals to report all births of deformed, paralyzed, or mentally deficient children to Berlin. During the same summer, he directed his staff to consult with medical doctors and professors from some of Germany's leading universities to devise a procedure for extending euthanasia to adults in the event of war, when Germany would need to free up hospital beds for military casualties. None of the experts balked at participating, but the matter was legally murky, since Hitler declined to issue a law justifying the killing, lest Germany's enemies use that as propaganda against the Reich. So the Chancellery officials felt the need for a way to assure the people involved of immunity from criminal liability and therefore asked Hitler for some form of written authorization. The result was a letter, signed by the Nazi F\u00fchrer on his personal, not his official, stationery and backdated to the opening day of World War II, directing the leader of his personal medical staff, Karl Brandt, and the head of the personal Chancellery, Philipp Bouhler, to expand the practice of granting a \"mercy death\" to irreversibly disabled people in state institutions. This written instruction, unlike any document ever discovered about the Holocaust, connects Hitler directly and in writing to a murder operation, the so-called Euthanasia Action. Known bureaucratically as T4, an abbreviation of the street address of its main office after April 1940, at Tiergartenstrasse Nr. 4, in the center of Berlin, this heavily camouflaged program proceeded under the day-to-day direction of Viktor Brack, one of Bouhler's aides. Though the Euthanasia Action continued for the duration of the Third Reich, the operation had two distinct phases, the first of which, from October 1939 to August 1941, was a direct forerunner of the Holocaust, the second, from 1942 to 1945, an extension of it.\n\nThe Nazi regime had prepared the German public for such an action by a propaganda campaign in the 1930s that stressed the drain that handicapped people, described as \"useless eaters\" and \"life unworthy of life,\" represented for the national economy and food supply. But Hitler favored the program, the evidence indicates, not so much for practical as for ideological reasons. He wanted to cancel out the \"negative selection\" that wartime casualties would mean for the Aryan race by accompanying the inevitable attrition of young, vital, and fit Germans with the compulsory reduction of the number of those who were genetically deficient. With the onset of war, he expected potential religious objections to decline or fall away.\n\nThe children who became the first victims of T4 perished from overdoses of medicines that induced illnesses or physical conditions on which deaths could be blamed. As the program expanded, starvation and direct injection into the heart of poisonous substances, usually phenol, became supplementary murder methods. Usually doctors did the killing in this initial phase. The general procedure was to move the institutional inhabitants whom physicians selected for death to one of six designated sanatoria spread around the country\u2014no more than four of which were operational at the same time\u2014and then to carry out the executions there. By January 1940, the MDs in charge of the program had decided that establishing small gas chambers at the institutions would be more efficient\u2014that is, would allow them to kill more people in less time and with fewer personnel than the injection method. They soon rigged up rooms that resembled shower facilities with piping that carried carbon monoxide (CO) instead of water into the chambers. An institute within the Reich Security Main Office bought the carbon monoxide in large metal flasks from the BASF division of the IG Farben conglomerate and supplied them to the sanatoria, where they merely had to be hooked up to the pipes. The gassing method was not Hitler's idea but adopted upon the recommendation of an advisory group of pharmacologists. In fact Brandt, the F\u00fchrer's physician, initially opposed using gas and argued for death by \"medical means.\" This information undermines the causal connection drawn, in the filmed German dramatization of the Wannsee Conference (1984) and the televised and star-studded Anglo-American version (2001), between the use of gas chambers and Hitler's remark, in _Mein Kampf_ , that more Jews should have been exposed as soldiers in World War I to poison gas.\n\nIn the annexed parts of Poland, an SS man named Herbert Lange soon modified the killing process in a consequential way. His assignment was to empty formerly Polish mental institutions and sanatoria, and he had no interest in going to the trouble of shipping the condemned residents to the six killing facilities in Germany. So he retrofitted large moving vans, disguised as Kaiser's Coffee delivery trucks, with space near the driver for the flasks of CO, which were connected by tubes to the rear compartments of the vehicles. He used these during 1940 to pick up the targeted people and kill them as the trucks drove away toward mass gravesites in concealed forest areas or toward local crematoria that burned the bodies.\n\nIn April 1941, a new operation with the code number 14f13 extended the T4 program to inmates of Germany's concentration camps judged unable to work. This extension caused the construction of relatively small gas chambers at Dachau, Sachsenhausen, Mauthausen, and several other sites. But most of these installations gassed people only infrequently until the frenetic final months of the war, when overcrowding, epidemics, and food shortages led to increased utilization. Until early 1945, for example, the Dachau camp appears to have used its gas chamber primarily to fumigate clothing. Most of the 20,000 camp inmates who perished in Action 14f13 were transported to die at Sonnenstein, Bernburg, and Hartheim, three of the sanatoria where T4 executions were carried out.\n\nThe continued operation of T4, combined with the new 14f13 program, created a supply and a secrecy problem for the Nazi state. BASF could barely keep up with the demand for bottled CO as of 1941, and applying it on a large scale in occupied Poland or further east raised transportation issues. Persuading BASF to increase production would require giving it some assurance that demand was likely to continue, and that might lead to awkward questions about what the product was being used for. These concerns prompted the SS and the T4 operation to explore jointly whether carbon monoxide produced from stationary internal combustion engines could kill patients as efficiently as, and perhaps more cheaply than, bottled carbon monoxide. Tests on mental patients in the conquered Belarusian cities of Minsk and Mogilev in September gave an affirmative answer.\n\nThe transfer of the euthanasia killing system to the murder of the Jews already was being prepared at about the same time as these tests. By early 1941, rumors about the euthanasia program had spread across Germany, and many of the relatives of the victims had grown suspicious of the standardized postcards that notified survivors of the deaths. The usual cause was given as pneumonia or appendicitis, even when the victims no longer had appendixes, and the notifications invariably included the statement that the body had been cremated to avoid the danger of an epidemic. A number of Protestant leaders began to speak up, and then so did Clemens Graf von Galen, the Catholic Bishop of M\u00fcnster. Because mercy killing violates Catholic teaching that only God may give and take life, Galen issued pastoral letters and delivered sermons denouncing the practice, something he never did with regard to the deportation of the Jews, whom he regarded in the typically Catholic fashion of the time as dangerous agents of modernity and Bolshevism. Fearful that Galen's protest would arouse public opinion and harm the war effort, Hitler formally put an end to the first phase of the T4 Action on August 24, 1941. By then it had taken the lives of between 71,000 and 80,000 people. Murders of disabled and handicapped people resumed a few months later but now in more widely dispersed locations and on a slower, better concealed basis until the end of the war. The killers usually reverted to their original methods of injection or overdosing, but gassings did not entirely cease; indeed, camp inmates, some Gypsies, some half-Jewish children, select groups of forced laborers, and even some Germans driven mad in bombing raids subsequently died that way in several sanatoria. In this second and longer phase of the T4 operation, nearly as many people perished as during the first.\n\nLess than three weeks after Hitler acted, Himmler approved the transfer to the command of SS Police Leader Odilo Globocnik, in Lublin, of many of the operational T4 personnel, eventually some 121 men who had been responsible for bringing handicapped victims to their places of execution and for disposing of the bodies. Most of these men did not begin applying their murderous technical expertise in the conquered areas of Eastern Europe until early 1942, following brief service in hospitals on the Eastern Front, but already by October 25, 1941, officials in the Ministry for the Occupied Eastern Territories were discussing setting up \"gassing devices\" in Riga and Minsk and murdering in them deported German Jews found incapable of work. Around the end of the same month, construction work began on the Belzec death camp, in a village southeast of Lublin that already was the center of a complex of forced labor camps populated mostly by Jews. The new camp's first commander was Christian Wirth, a veteran of not only the T4 Action but of its first gassing, at Brandenburg in 1940, who came under Globocnik's authority on October 14. Also in October 1941, Herbert Lange, the inventor of the gas vans, identified the derelict manor house that soon became the center of the Chelmno death camp, thirty miles northwest of Lodz, in the so-called Warthegau, part of the land annexed from Poland.\n\nAt just about the same time, the mechanics of the Security Police motor pool in Berlin, working under the direction of Walter Rauff, solved the carbon monoxide supply problem. They demonstrated the ease with which a T joint could connect the exhaust pipes under a van to its rear compartment and thus replace bottled CO with that produced by the vehicle's motor. In early November, the SS tested the process on forty Soviet prisoners of war at Sachsenhausen; all of them died within half an hour. The motor pool then ordered from a local supplier thirty converted trucks with rear compartments measuring about sixteen feet long by six and a half feet wide, plus a few smaller versions. Some of these were intended for and briefly used by the _Einsatzgruppen_ in Belarus and Ukraine, but that practice proved short-lived because the generally poor roads there led to frequent breakdowns and because the German personnel actually preferred shooting people to the gut-wrenching process of unloading the gassed bodies from the vans.\n\nWhile Himmler, Heydrich, and their henchmen were discovering that T4 had provided them with one means of disposing of Europe's Jews, a group of SS men recognized that Germany's chemical industry had supplied them with another. The setting was Auschwitz, where a concentration camp for Polish political prisoners had existed since May 1940 on the site of a former Polish military base. In August 1941, anticipating the arrival of increasing numbers of Soviet prisoners of war, Commandant Rudolf H\u00f6ss apparently told one of his subordinates, Karl Fritzsch, to explore means of killing sick or weak prisoners in bulk. Fritzsch hit on the idea of applying Zyklon, a powerful vaporizing pesticide that the camp normally used to fumigate barracks, as a potential poison. He knew that it was lethal to humans\u2014in fact, seventy milligrams, or 1\/3000th of an ounce, which is to say a whiff, will kill a 150-pound person within two minutes\u2014and he already had a substantial quantity of the stuff on hand. Although this product is generally referred to as Zyklon B, the label usually said only Zyklon. The \"B\" sometimes appeared on sales invoices, but the designation was mostly internal to the manufacturers, since it merely distinguished the product's chemical formula from an earlier, very short-lived one.\n\nIn the early days of September 1941, Fritzsch tested the efficacy of Zyklon on two groups of Soviet prisoners of war locked into the basement of one of the original stone barracks at Auschwitz. He learned that Zyklon killed reliably, but for maximum effectiveness, the product needed a more open space than the subdivided barracks basement. Quickly thereafter, he and H\u00f6ss discerned two more things: The substance was evidently plentiful and rather cheap in relation to the damage it could do. At 5 reichsmark per kilogram (that is, per 2.2 lbs.) and an overdosage of 5\u20137 kilograms for each group of 1,500 victims, the usual practice according to the postwar testimony of Commandant H\u00f6ss, the average cost of murder per head ultimately came out to about two German pfennig (pennies) a person, which is to say less than one U.S. cent in 1942.\n\nThus by late October, the SS leaders knew that they had not one but two effective ways of killing large numbers of people, and this knowledge set in motion a series of pivotal events that mark the onset of what the Nazi regime called the Final Solution of the Jewish Question ( _die Endl\u00f6sung der Judenfrage_ ). First, on October 23, 1941, Himmler issued an instruction to the Gestapo and the SS that forbade further emigration of Jews from the European continent. This document clearly signaled the end of the policy of driving Jews away, either now or later, and suggested that the Nazis had found a new approach to the Jewish problem.\n\nSecond, in November, the regime expanded upon the initial deportation of about 20,000 German Jews to Lodz in mid-October by beginning to ship even more German Jews to the Baltic states and Belarus, where some of them were shot upon arrival, and subjected virtually all the Jews already in concentration camps to the 14f13 murder program. Then, on the twenty-ninth, Reinhard Heydrich issued invitations for various ministerial representatives to gather at a villa along the Wannsee, a lake on the western edge of Berlin, to discuss the final solution. He enclosed with the invitations copies of G\u00f6ring's letter to him of July 31. Originally scheduled for December 9, the meeting did not take place then because of two surprising events that threw the German capital into confusion, the Soviet counterattack around Moscow on December 5 and the Japanese bombing of Pearl Harbor two days later. Beyond the addition of two officials of the General Government to the initial invitation list, no evidence suggests that the agenda for that meeting changed between its canceled and actual occurrence, on January 20, 1942, when Heydrich laid out a plan \"to comb Europe from west to east\" of Jews, deport them to Poland, put them to work at hard labor, and subject those who survived this ordeal to \"special handling\" ( _Sonderbehandlung_ ). The SS leadership probably already envisioned all or most of this when the first round of invitations went out. Eleven days earlier, on November 18, Alfred Rosenberg, the Minister for the Occupied Eastern Territories, had briefed trusted German reporters on deep background and spoken of the \"biological eradication of the entire Jewry of Europe.\"\n\nThird, on December 12, 1941, the day after Hitler declared war on the United States in solidarity with his Japanese ally, he met with the Nazi Party Gauleiters at his private apartment in Munich and informed them that the Jews would have to pay \"with their lives\" for the war they had inflicted on Germany\u2014indeed, that they already were doing so. As historian Peter Fritzsche has remarked, \"this is as close to a Hitler order as historians will get,\" meaning the closest counterpart to the euthanasia letter he signed that we are likely to find to connect Hitler personally with the command to kill the Jews.\n\nTo sum up what we know about the decision-making process that produced the Holocaust: By August 1941, the Germans were engaged in slaughtering the Jews of the Soviet Union, including women and children. By October, the Nazi leaders knew they had the means to kill people en masse in gas chambers, began constructing sites to do so, and tried to close the escape hatches from Europe. By November, the key figures were ready to bring the German press on board by leaking what was coming and to inform\u2014and implicate\u2014the bureaucracy while seeking its cooperation at the Wannsee Conference. And, in December, Hitler let the Gauleiters in on the change in policy. The Final Solution, the annihilation of the Jews of Europe, was in motion.\n\nImplementation became the next order of business. As it happened, Europe was not combed from west to east, as Heydrich predicted at Wannsee, but almost in the reverse direction. Nazi ideology designated Eastern Europe as the destined living space for an ever growing German _Volk_. Propelled by this expansionist vision, murder gathered mass and momentum faster there than elsewhere because a majority of the continent's Jews still lived in or around the old Pale of Settlement, and it was the conquered region where Germany had least reason to worry that killing Jews would arouse objections from other inhabitants. Accordingly, the six death camps set up in 1941\u201342 were all within prewar Poland, and each initially concentrated on killing the Jews who lived in its vicinity. Nor was this the only respect in which developments did not proceed according to plan. As the pioneering scholar of the Holocaust Raul Hilberg emphasized, the Holocaust bore the characteristic features of many Nazi initiatives: little foresight or preparation, rocky coordination of participating agencies, and even haphazard budgeting. Yet the killing of millions of people turned out to require no better.\n\nThe six death camps divided into two groups. Group 1, consisting of four camps that employed carbon monoxide gas, like the T4 Action in which all of their initial commanders had participated, predominantly killed Jews from designated portions of Poland's prewar territory and operated only as long as any of these people were left. The first such camp was Chelmno, and it was the only one to use gas vans exclusively, certainly because Lange, its first commander, was so experienced with them. Chelmno began operations with two converted Dodge trucks on December 8, 1941, and then expanded its fleet and its death toll. Each truck carried fifty to seventy people and made five to ten return trips per day from the camp to body disposal areas in a nearby forest. By December 31, 1942, the operation had killed 145,301 people, according to the SS's tabulation, nearly all of them drawn from the part of western Poland annexed to Germany. Closed in March 1943, Chelmno reopened in 1944 to liquidate about 7,200 inhabitants of the Lodz ghetto, and that brought total documented mortality on the site to 152,000 people. This is surely the minimum figure; itemizations of the transports that went to Chelmno suggest at least 20,000 more victims, and the most recent Polish research indicates that the number may have reached 225,000.\n\nThe other death camps that used carbon monoxide became operational in 1942 and used stationary gas chambers, initially rather jerry-rigged edifices made airtight by a layer of sand between the inner and outer wooden walls and an external coating of tar paper. Soon, brick or concrete buildings replaced these, but the new structures were still very simple, easy to put up and easy, later, to take down. Like Chelmno, the three sites were chosen for their remoteness, but unlike it, all were located on branch rail lines on the eastern edge of the General Government. In order of foundation and coincidentally from south to north, these were Belzec, which began gassings in March 1942; Sobibor, which came on line in May of that year; and Treblinka, which followed in July. All were conceived as the instruments of Operation Reinhard, the name the Nazis gave at mid-year, following the assassination of Reinhard Heydrich in Prague, to the annihilation of the Polish Jews. All three camps used captured Soviet tank engines to generate the carbon monoxide, and all usually operated with stunning efficiency under the initial direction of veterans of the T4 operation.\n\nBelzec killed at least 434,000 people, but perhaps as many as 600,000, in the only ten months that it was open, an average of up to 2,000 people per day, more than two-thirds of them from southern and southeastern Poland and the rest Jews from other parts of Europe who had been deposited in ghettos in and around Lublin. Sobibor consumed between 167,000 and 200,000 people during its seventeen-month life span, most of them from Poland, but some from prewar Czechoslovakia, many from France and the Netherlands, and a few from Greater Germany, Belarus, and Lithuania. Treblinka, the last to close, wiped out up to 925,000 people in the eighteen months before Operation Reinhard ended in November 1943, which made it almost as lethal as Belzec on a daily basis. However, at the time of its peak murderousness, from July 22 to August 27, 1942, Treblinka killed 280,000 people, an average of 56,000 per week, or 8,000 per day. During one of those five weeks, the daily average reached 10,000. Nearly all of Treblinka's victims came from central and northern Poland, but about 32,000 Czech, Greek, and Macedonian Jews also died there. All three Reinhard camps were in operation simultaneously for only four out of the six months from July to December 1942, yet in that half-year the three sites killed more than one million Jews, which is more Jews and nearly as many people all told as Auschwitz-Birkenau wiped out in four years. Altogether, these three places devoured between 1.5 and 1.8 million human beings. Including Chelmno, the four CO camps killed up to 2 million people. Fewer than 400 Jews ever emerged alive from all four sites, and of these only somewhere between 90 and 150 outlived World War II.\n\nThe second group of death camps consisted of only two installations: Auschwitz-Birkenau and Majdanek, which were different from Group 1 in three respects: (1) they primarily used Zyklon, not CO, to kill people (though Majdanek also sometimes employed bottled CO and had a gas van); (2) they were dual-purpose camps\u2014both death and slave labor camps\u2014and thus had larger ongoing inmate populations; and (3) they were not closed until the Soviet armies approached, and thus they were the principal destinations, Auschwitz especially, for Jews from outside of Poland, and the only death camps still open in 1944. Their importance as labor reservoirs began as part of the plans for an SS agricultural research center at Auschwitz and a complex of SS-owned factories at Majdanek, but then greatly expanded because they stood at or near the ends of the Polish part of Durchgangstrasse IV, the long highway that the Nazis were building from Silesia to the Caucasus as the lifeline of their power in conquered Ukraine. The need for labor for this project inspired the addition of Birkenau to Auschwitz in October 1941 and of Majdanek to a nearby preexisting labor camp in Lublin. Both were built for Soviet prisoners of war as the prospective workforce but later populated primarily by Jews\u2014in Auschwitz's case throughout its existence, in Majdanek's only until November 1943, when nearly all of the remaining Jews were shot to death, not gassed.\n\nOver time, other labor needs arose to sustain the importance of each camp. Auschwitz became the geographical center of frantic industrial development because it was near coal and water supplies and out of reach of Allied bombers based in Britain. The biggest plant located in the region was the IG Farben installation three miles east at Monowitz, where at least 27,000 prisoners died while constructing a factory for synthetic fuel and rubber and operating the firm's coal mines in the area. But tens of thousands of other inmates labored at more than forty branch camps in the region, including the giant synthetic fuel factories at Blechhammer and Heydebreck and numerous mines. Majdanek became the hub of the SS's plans to process and recycle the goods collected from the people killed at Reinhard camps, especially the hundreds of thousands of leather shoes that one can still see filling warehouse barracks on the site.\n\nBoth Auschwitz and Majdanek had another distinguishing feature: gas chambers built to last. The three at Majdanek were relatively small, solid stone structures, and they are still there. Auschwitz initially turned a small munitions magazine at the edge of the main, original camp into a crematorium that also could be used for gassings, then converted two peasant cottages on the plain near Birkenau into gas chambers, and finally constructed and opened in 1943 four large brick buildings in the Birkenau or Auschwitz II camp that contained both gas chambers and crematoria to dispose of the bodies at the rate of 4,000 to 8,000 per day. The first, small chamber at the main camp remains today; the cottages are gone, and only ruins of the brick buildings survive. Since the chambers could kill faster than the crematoria could incinerate, bodies sometimes also burned on open-air pyres. If the Nazis had been able to ship all the remaining Jews in Europe to Auschwitz in 1945\u201346\u2014that is, if the war had gone on and the impediments to rounding up the remaining Jews been pushed aside\u2014Auschwitz could have killed them all by early in the latter year. As it was, some 1.3 million people arrived at the camp between its opening in May 1940 and its evacuation in January 1945, of whom approximately 1.1 million died\u2014there or in one of the subcamps. Perhaps half of the survivors died at other installations before World War II ended, and only 100,000 emerged alive from the conflict. Majdanek was far less lethal, especially for Jews, and recent research findings have driven down the probable number of Jews killed there from some 145,000 to about 59,000, perhaps one-third of whom were gassed.\n\nThe death camps were distinct from three other principal kinds of Nazi camps:\n\n(1) The main SS concentration camps, such as Dachau and Buchenwald in Germany and places like Natzweiler in Alsace-Lorraine and Stutthof along the Baltic coast and their more than 1,100 satellite installations. These were murderous places, especially in the last year of the war, but they were not \"factories of death,\" and their populations did not consist primarily of Jews. A partial exception in the former regard was Mauthausen, founded in 1938 near the city of Linz, Austria, and the subcamps it spawned at nearby military production installations. Reserved for \"incorrigible . . . and barely educable\" political opponents and criminals, this harshest of the concentration camps killed 52 percent of its almost 16,000 inmates in 1941 and almost 10 percent of its constantly replenished prisoner population every month between mid-1941 and April 1943. By the time American troops liberated the camp, more than half of the almost 200,000 people ever held there had perished, some of them in a gas chamber on the premises that used Zyklon, some in gas vans, and others at the nearby Hartheim sanatorium. About 25 percent of the victims were Jews.\n\n(2) So-called transit camps, where particular groups of people were collected, generally in order to be exchanged later with the Allies. The best known of these was Bergen-Belsen, in northern Germany. These were relatively benign places until the German supply system collapsed toward the end of the war, at which point they became murderous centers of infection and starvation.\n\n(3) Labor camps, of which tens of thousands came into existence by the end of the war. Here, the inmates could be and were treated viciously, but the goal of production exerted some, though limited, protection against large-scale killing. But one must draw a distinction within that distinction. Labor camps in the East were far worse than those even in the General Government, let alone Germany. The ones established for Jews along Durchgangstrasse IV were little more than delayed murder stations, and the same was true of Janowska, a camp in Lviv that began as a labor site in late 1942 but turned into such a voracious venue for the mass shooting of Jews that it may have taken more of their lives, all told, than Majdanek, without possessing a gas chamber.\n\nOne of the most chilling aspects of the history of the Holocaust is that so much carnage could occur without any serious ill effect on the German war effort, in fact with little diversion of manpower, mat\u00e9riel, and money. Aside from the loss to Germany and the gain to Britain and the United States of the Jewish scientists and other loyal citizens driven to flee during the 1930s, the Reich hardly had to pay a price for all the pain and suffering it dispensed. Yes, it came to miss the labor of most of the last remaining Polish Jews, some 300,000 of whom the SS massacred in 1943, but otherwise the balance sheet of murder was strikingly favorable to Germany, at least in the short run, which was the only time horizon that mattered to the Nazi regime.\n\nIn the first place, the camps took in enormous plunder as well as payments for the laborers that they leased to industries and government offices. Although enslaved camp inmates were not paid, they were paid for. In part as a result, Auschwitz, the biggest labor vendor, made a profit of 100 percent in this fashion from 1941 to 1945. It took in sixty million reichsmark in fees for workers, whereas it spent only thirty million, all told, to feed and house them. Globocnik's office in Lublin calculated that its net loot from Operation Reinhard, after deducting all the personnel and other costs associated with the deportations and murder, came to almost 179 million reichsmark, conservatively estimated, including more than 80 million reichsmark in cash, 52 million reichsmark in jewelry and precious metals, and 46 million in recyclable clothing. Because the T4 people at those camps sent additional amounts directly to the F\u00fchrer's Chancellery and to the Reichsbank, the overall income clearly was much more. We do not know how much plunder Chelmno collected because that booty was shipped to the Lodz ghetto administration and mixed in with its other extortions from Jews. But one document from May 1942, a year before Chelmno suspended operation, speaks of needing 900 trucks to transport clothing the camp delivered for reuse.\n\nIn the second place, the Germans did not pay for transporting the Jews to the camps; they made Jewish community administrations do this, just as they usually made them, at least in Western Europe, Germany itself, and the Polish ghettos, do the dirty work of identifying potential deportees or even drawing up lists of them whenever the Nazis dictated a certain number or category to be shipped out. Even the offices from which the killing orders came had been Jewish-owned property, now repurposed for murder. SS-Obersturmbannf\u00fchrer Adolf Eichmann coordinated deportations from the former premises of the Jewish Brethren Society, a charitable organization, in Berlin's Kurf\u00fcrstenstrasse 116; the euthanasia program's headquarters at Tiergartenstrasse 4 had belonged to relatives of Max Liebermann, a famous Jewish German painter. Meanwhile, the Reich raked in enormous sums in confiscated bank accounts, jewelry, art works, and other fungible forms of property from Jews in all the occupied countries. As a result, the Holocaust as a whole was not only a self-financing but also, like Auschwitz standing alone, a profit-making enterprise. Consider the example of the Netherlands. Here, Nazi Germany reaped more than one billion guilders from the sale of property stolen from Jews, most of which went directly into the occupation administration's coffers or into the accounts of front organizations that bought German and Dutch government bonds and thus helped support the German war effort. A tiny share of the income\u201425 million guilders, or less than 2.5 percent of the total\u2014was expended to expand and maintain the two Dutch transit camps at Vught and Westerbork and to pay for the roundups and deportations. About 75 percent of the Dutch Jews were killed, some 105,000 people, at a cost that came to a small fraction of what the German state seized from them.\n\nIn the third place, the costs of murder that Jews did not pay were quite low. Aside from Auschwitz from 1943 on, the death camps were remarkably low-tech, non\u2013capital intensive entities. Chelmno consisted of a rundown manor house surrounded by a wooden fence. Jews came in the main gate on trucks, descended from these on one side of the house, lost what was left of their possessions as they passed through its basement, and walked into vans at the back entrance. After Jewish prisoners closed and barred the doors, the vehicles either idled or drove until the people inside died of the exhaust fumes, and then delivered the bodies to a forest clearing, where other Jewish prisoners burned the corpses in pits. Even at Auschwitz, the first gas chamber was a preexisting building, and much of the construction material for the barracks and fencing was obtained from IG Farben in a barter agreement of steel, bricks, and barbed wire for workers and gravel. So improvised were the first two gas chambers at Birkenau, the converted peasant cottages, that they lacked mechanical ventilation and thus could not function in rapid succession. Treblinka and the other Reinhard camps were Potemkin villages of building facades, plus a few workshops, around square reception areas where the arriving victims disembarked and undressed. The rear side of the square led to a \"tube\" ( _Schlauch_ ), a narrow passageway framed by wooden sawhorses, covered in barbed wire and pine boughs, and into the gas chambers. None of this cost much to erect.\n\nMoreover, the operating costs of these sites were low. Gasoline to generate carbon monoxide was inexpensive and not in short supply until after Operation Reinhard ended, and the motors used came from captured Soviet tanks. The nearly 32 metric tons of Zyklon sold to Auschwitz and Majdanek in 1942\u201344 cost just under 160,000 reichsmark, or about 64,000 U.S. dollars at the time. Only about one-fifth of this Zyklon actually was used for gassing\u2014the rest went to fumigating barracks and the like or simply spoiled on the shelves\u2014so the quantity needed for murder was even less expensive, probably costing only about 30,000 reichsmark, or U.S. $12,000 at the time.\n\nNor was it expensive to staff the places. Auschwitz was the only camp with a large, nearly all German guard force. Its average size during the life of the camp was about 2,500, and some 7,000 Germans served there from 1940 to 1945, which is about one-third as many men as the German armed forces shot for desertion during World War II. But Belzec and Sobibor needed only about twenty Germans at any one time, as did Treblinka initially, though its German staff rose in 1943 into the thirties. The rest of the guards, 90\u2013130 men at each site, were Eastern European _Hiwis_ (an abbreviation of _Hilfswillige_ , which means \"volunteer helpers\"), usually recruited from starved Soviet prisoner-of-war camps, and offered uniforms, room and board, low pay, and the chance to pillage the Jews in return for serving as support troops for the Germans. A special camp at Trawniki in Poland trained 4,750 of these people by the time it closed in September 1943. The Germans at the death camps earned substantially more, in fact something like ten times their nominal monthly pay of fifty-eight reichsmark, thanks to a special daily allowance of eighteen marks, a loyalty bonus, and a \"Jew murder supplement\" paid from the budget of the T4 program. Even so, that program also operated in the black thanks to the proceeds on the dental gold extracted from victims' mouths and the practice of routinely waiting for about ten days after an execution before entering the death notice in the records, meanwhile assessing per diem charges to the person, agency, or insurance company responsible for maintaining the now deceased disabled person.\n\nFinally, legend has it that the deportation trains to the camps must have impeded the German war effort. Nothing could be further from the truth. Very few deportation trains were in transit at any one time, and they had the lowest priority on German railroads, which means they were never allowed to obstruct or delay troop movements or supply trains. That is one reason why the trips from Western Europe to the death camps, and even the ones in the early stages of the deportations from Warsaw to Treblinka in 1942 that traveled only sixty miles, often took as long as three or four days and arrived carrying numerous suffocated, starved, parched, and in winter frozen corpses. Boxcars usually were used in the East, and either closed cargo wagons or third-class passenger cars from Western Europe, but in both cases, the transports nearly always consisted of dilapidated equipment. Even the locomotives were relics. Loading each transport of 1,000 people or more generally required only ninety Germans, and the guard personnel en route usually consisted of only fifteen, since sealed boxcars required little supervision. Indeed, the Germans preferred them in part for that reason.\n\nAll told, the Germans used about 2,000 trains to move three million people to camps over thirty-three months in 1942\u201344, which works out to sixty trains per month or two departing per day, on average. In contrast, the German Reichsbahn carried 6.6 _billion_ passengers in 1942\u201343 and ran 30,000 trains _per day_ in 1941 and 1942 and about 23,000 per day in 1944. In that final year, the Nazi regime needed only 147 trains over eight weeks, an average of fewer than three per day and never more than six, to deport almost 440,000 Hungarian Jews. Allocating even that many trains in a short time for a murder operation was unprecedented, and it happened only because the deportations had a subsidiary purpose directly tied to the war effort. Auschwitz was supposed to extract 100,000 able-bodied workers from the deportees, 10\u201315 percent of the initially anticipated total, and ship them immediately on to the Reich, where they were to labor on the massive effort to put Germany's war production plants underground. Even so, at the height of the deportations from Hungary, those trains constituted no more than 1\u20132 percent of the daily railroad traffic in that country. They employed an infinitesimal one-fifteenth of 1 percent of the functioning locomotives and one-tenth of 1 percent of the operating rolling stock under the jurisdiction of the German Armaments Ministry at the time. Clearly, the shares of German railroad equipment and activity devoted to the Holocaust were tiny, both in total and at any particular time.\n\nAs sometimes happens in historical writing, the most conclusive demonstration that the deportations had no significant impact on the German war effort is a book that purports to prove the opposite, Yaron Pasher's _Holocaust vs. Wehrmacht_ (2014). Pasher examines four German military defeats, each of which occurred at approximately the same time as a wave of deportations: the failure to take Moscow in 1941 as the first transports of Jews were leaving Germany; the failure to relieve Stalingrad in 1942\u201343 during Operation Reinhard; the debacle of the Battle of Kursk in the summer of 1943 shortly after the suppression of the Warsaw Ghetto Uprising; and the successful Allied invasion of and breakout from Normandy in June to August 1944, which partially overlapped with the massive deportations from Hungary. At each juncture, Pasher asserts that the primary reason more troops and supplies did not arrive at the German front lines was a shortage of trains to carry what was needed, that shortage having been caused by the use of rolling stock to deport Jews. In the process, he makes statistical calculations that count, for example, each journey by the same one or two slow and rickety trains with sixty boxcars going back and forth between Bialystok and Treblinka and between Theresienstadt and Auschwitz every two to three days in early 1943 as potentially the trip of a fully loaded and speedy supply train to the Eastern Front. His estimates, in each instance, of what the trains that carried Jews instead could have brought to the German armies still fall drastically short of his own understated tallies of what the Reich's soldiers lacked in men and mat\u00e9riel compared to their adversaries. In all four cases, Germany's defeat was massively overdetermined. For that reason, repeatedly asserting, as Pasher does, that \"every train counted\" is not nearly the same thing as showing that every train mattered.\n\nSo how could the Nazis achieve such an extensive massacre in so short a time? The first piece of the answer is: because they perfected a low-cost, low-overhead, low-tech, and self-financing process of killing with great speed. We turn now to a second component of the answer: because the Nazi movement and state generated and unleashed remarkably dedicated killers.\n\nPERPETRATORS: THE \"GENERATION WITHOUT LIMITS\"\n\nThe Holocaust involved tens of thousands of people who participated in it directly\u2014the SS guards, the _Einsatzgruppen_ , the Order Police, the regular military units that often helped with rounding up Jews and killing them, and the thousands of bureaucrats and officials who planned the murders and made the death-dispensing system function\u2014as well as hundreds of thousands of German civilians who facilitated the persecution at some remove from the process. How can we explain their behavior? How could they do these things?\n\nBroadly speaking, two schools of thought dominate attempts to answer these questions, the volitional and the situational schools, and each gets deployed to account for behavior at two different levels, subordinate and senior. The volitional school holds that people persecuted and killed because they chose to; the situational school argues that they acted in response to their immediate context, not their convictions. Recently, a number of German-educated authors have laid the basis for a powerful and persuasive synthesis of the two points of view.\n\nWith regard to the subordinates who actually did the killing in the shooting units and gassing installations, the classic formulations of the volitional and situational points of view are, respectively, Daniel Goldhagen's _Hitler's Willing Executioners_ (1996), a bestseller that the public loved and most historians panned, and Christopher Browning's _Ordinary Men_ (1992), which won academic acclaim as well as a popular audience. Goldhagen insists that Germans killed Jews because they wanted to; they wanted to because they universally hated Jews; and they hated Jews because Germans always had\u2014their nation's culture had been thoroughly and pervasively antisemitic for hundreds of years. On the basis of postwar trial testimony by the former shooters of Reserve Police Battalion 101, Browning maintains that antisemitic convictions had little to do with the readiness of Germans to commit murder; rather, they acted out of loyalty to one another. Their sense of group solidarity made them unwilling to let one another down by showing weakness. In making his case, Browning draws heavily on two sets of social psychology experiments. The first, conducted by Stanley Milgram in New Haven in 1961, led volunteers to believe that they were administering electric shocks upon orders from a supposed scientist. The second, Philip Zimbardo's at Stanford in 1971, simulated relations between prison guards and inmates. Each experiment highlighted human tendencies to defer to or to abuse authority.\n\nBoth Goldhagen's and Browning's analyses have drawbacks: Goldhagen's picture is static; it contains no change over time; the attitudes of Germans in 1642 are identical to the attitudes of Germans in 1942 and just as uniform, which is implausible. Moreover, Goldhagen makes no allowance for the stark fact that power magnifies the ideas of those who hold it. Thus he underplays the decisive importance, with regard to German behavior, of the period after Hitler came to power. Browning, on the other hand, relies a good deal on his protagonists' descriptions of their motives, which he acknowledges is a risky practice. Not for nothing do lawyers say that \"no one can be a witness in his or her own cause.\" In this instance, as is usually the case in court proceedings, some of the protagonists had a reason to lie. They gave their testimony in a potential West German murder investigation. Under German law, a murder conviction required proof that a person acted with a \"base motive,\" such as greed or hatred, or exhibited sadistic zeal. That made former shooters reluctant to admit to antisemitism or to ascribe it to a comrade, even though anyone indicted was likely, given German legal practice at the time, to be charged as an accessory to murder, which entailed less severe punishment.\n\nAlthough Browning has the better of the argument with regard to the men of Police Battalion 101, and his findings have chilling implications regarding the general susceptibility of men in certain situations to inflict hideous violence, two sorts of considerations, one theoretical and one empirical, suggest that more remains to be said about why most German killers acted as they did in 1941\u201345. In the first (theoretical) place, Goldhagen and Browning probably tried to be too precise in capturing motives that may have been diverse, mixed, and variable over time. Moreover, given the assignments doled out to the shooting units and the ideological environment in which they lived, many shooters may have embraced antisemitism at the time as a conveniently available form of legitimizing what they had been ordered to do. In other words, they did not kill because they hated their victims, but they decided to hate them because they thought they had to kill them. Psychologists call this sort of mental mechanism, in which beliefs conform to behavior rather than the other way around, a response to \"cognitive dissonance,\" and it may have been just as important as animosity or sadism in explaining why so many Germans showed or expressed pleasure in torturing and killing Jews. Hatred and even glee became ways to ease the task at hand, and we know that it was not easy, at least not initially. Himmler called what he thought the SS had to do \"a repulsive duty\" and \"a horrible task.\" The _Einsatzgruppen_ and the foreign auxiliary units often had to get drunk to carry out the slaughter. German women serving as nurses and soldiers' aides on the Eastern Front reported repeatedly that men who returned from massacres \"all had an intense need to talk\" about what they had done.\n\nIn the second (empirical) place, Edward Westermann has demonstrated conclusively that Police Battalion 101 was not typical of the police units sent east to kill Jews. Some 80 percent of these personnel were not reservists at all, as the men in Police Battalion 101 were, and most units did not consist, as it did, of middle-aged men who had matured before Hitler came to power. On the contrary, the battalions generally comprised young, heavily indoctrinated career policemen who saw themselves as \"political soldiers\" in service to Nazi racial ideology. They were not workaday civilians placed in unfamiliar and extreme circumstances or typical Germans of an earlier era but rather military creations of the Nazi regime, schooled in the need for racial purification. Although Browning's work shows that even \"ordinary men\" were prepared to kill in the German-occupied east, most of the killers there in the early 1940s were not ordinary men.\n\nLike Omer Bartov, who wrote _The Eastern Front, 1941\u201345_ , Westermann stresses the role of ideological indoctrination in shaping the behavior of the police shooters, but unlike Bartov, Westermann thinks these units did not need to experience the increasing barbarization of warfare over time in order to become hardened killers. They were ready to act as such from the first day of their arrival in the east. Waitman Beorn's _Marching into Darkness_ (2014) reaches a similar conclusion about the regular German army units that began massacring Jews in Belarus in the fall of 1941, well before encountering serious resistance or partisan activity. His close examination of several mass shootings reveals that relentless propaganda about the Jewish-Bolshevik menace disposed most of these men to slaughter virtually from the beginning of the invasion of the USSR.\n\nAmong the most insightful works on this topic are studies by the German scholars Harald Welzer ( _T\u00e4ter_ , 2005), Felix R\u00f6mer ( _Kameraden_ , 2012), and Thomas K\u00fchne ( _Belonging and Genocide_ , 2010). (Thomas K\u00fchne now teaches in the United States.) Using somewhat different sources and analytical approaches, these scholars agree in highlighting the Hitler regime's success in developing, among Germans, \"a Nazi self\" with an inverted value system that offered a host of justifications for cruelty. The Third Reich redefined morality and turned humiliation, persecution, and murder into virtues. Overcoming scruples against inflicting pain became a sign of moral progress, not of indecency. If a person had difficulty doing this, so much the better, since that engendered more self-pity than pity for the victims, and thus made Germans more willing to lash out at the people whose existence was causing such discomfort. K\u00fchne provides some memorable phrases to describe what happened: He says that the Nazis created a \"dichotomist ethics\" of Us vs. Them and a \"moral grammar of comradeship\" that glorified acts of solidarity and shamed ones born of individualism. He reminds us of Browning's observation that even the members of Police Battalion 101 who said that they could not shoot did not raise moral objections; instead, they just said that they were \"too weak\" to do what was asked. The same pattern held for the exceptional regular army personnel who asked to be excused from killings, according to Beorn. As he writes, \"By claiming weakness or sentimentality as their reason for non-participation, soldiers . . . avoided directly challenging the actions of their comrades. This allowed them to remain within the community of their peers.\" Even when saying no, individual Germans partially affirmed the collective purpose. And most Germans ordered to kill did not say no. R\u00f6mer's study, which is based on the bugged conversations of some 3,000 German prisoners of war who passed through Fort Hunt outside of Washington, DC, concludes that even when they professed to believe that \"extreme violence against defenseless civilians, women, and children . . . cross[ed] a line, they were always capable of such violence, the minute group pressure or the circumstances demanded it.\" That reflexive readiness owed a good deal to the pervasiveness among admired and veteran junior and noncommissioned officers of a \"particular military mentality\" that, in turn, reflected what Welzer calls a \"particular National Socialist morality.\"\n\nWelzer's, R\u00f6mer's, K\u00fchne's, and Beorn's findings demonstrate that the situational can become volitional; beliefs adjust to circumstances, and power magnifies the ideas of those who wield it. Ordinary Germans could and did _become_ willing executors of Nazi persecution and even in many cases willing executioners. In a book called _Experten der Vernichtung_ (Experts of Annihilation, 2013), Sara Berger has reached a similar conclusion regarding the T4 participants who went on to staff the Operation Reinhard camps. Having closely studied their records and postwar testimonies, she stresses that they did not become killers on their own initiative, but that they became willing and increasingly identified with the Nazi regime's justifications for murder. As a result, none of them exercised their option to transfer back to their previous postings.\n\nThe treatment of the two known railroad officials who declined to participate in transports confirms a point established in numerous postwar examinations of the military and SS records and reinforced by Browning's research: Opting out of the killing process went unpunished in Nazi Germany but was nonetheless rare. Richard Neuser, a conductor based in Bialystok, asked to be relieved of having to work on transports to camps, and he was reassigned without penalty. Alfons Glas worked in the main passenger train office at Gedob, the organization that ran the railways in the General Government, and he learned from subordinates in the field enough about what was happening to trains carrying Jews that he asked for a transfer, which he received without any disadvantage to his career. But these were highly exceptional cases. The behavior of German railroad personnel paralleled that of police and other uniformed organizations. The senses of group solidarity and\/or professional obligation and\/or ideological conviction outweighed any reservations or compunction people might have felt. Similarly, the German postwar trials of Operation Reinhard death camp personnel produced only two documented instances of SS guards who asked to transfer out of direct involvement with the killing process. Both succeeded without adverse consequences.\n\nOskar Gr\u00f6ning, an SS bookkeeper at Auschwitz who was interviewed by the BBC in 2005, explained his own behavior with reference to compartmentalization and indoctrination. He had volunteered for the SS in 1940 and then worked in a paymaster's office until transferred to Auschwitz in 1942, when he was twenty-one. There he tallied the money taken from the camp's victims. Although upset by instances of brutality that he saw, he generally endorsed the need to wipe out the Jews as Germany's mortal enemies who had defeated it in World War I and would try to do so again. He therefore regarded their murder as necessary. But he felt detached from the killing; his unit carried out the desk job side of life at Auschwitz, not the murders, and he considered the two activities more or less separate. So he stayed until September 1944, when the SS granted his request for transfer and sent him to a Waffen-SS unit that later fought in the Battle of the Bulge.\n\nAt the camps, key elements in explaining guard behavior are the small numbers of perpetrators involved, the sorts of people they were, and the ways they delegated the worst of the killing process and thus distanced themselves from it. The small number of perpetrators required made them easy to find. Remember, only twenty Germans and Austrians were at Belzec at any one time; fewer than five hundred ever were at all three camps of Operation Reinhard. Each camp crematorium required only five to twelve German supervisors. Even if we assume that they were all psychopaths, we have to concede that recruiting that few cannot have been difficult. The guard staffs were often very poorly educated; for example, at Auschwitz only 30 percent of the SS men who served in the garrison ever got beyond grade school. Except at Auschwitz, the guard personnel consisted largely of foreign auxiliaries\u2014the _Hiwis_ \u2014with a strong interest in satisfying their German masters. Each Operation Reinhard camp had 90 to 130 such men. At Auschwitz, _Volksdeutsche_ eager to prove that they were just as tough and German as their native-born comrades made up a large percentage of the garrison.\n\nMoreover, the Germans were adept at insulating themselves from the worst aspects of the killing processes. In the ghettos, they often made the Jewish police forces do the dirty work of rounding up people who did not appear for deportation when scheduled to do so. In the camps, they used other Jewish prisoners in _Sonderkommandos_ to empty the gas chambers, burn the bodies, and, in the case of Crematorium III at Birkenau, to hold open the heavy lid of the chute through which an SS man poured the Zyklon pellets. Finally, among the camp guards, as in the shooting squads, a fateful element was self-centeredness, a preoccupation with one's own challenges rather than the pain being inflicted. For the guards, the daily problem was to manage large numbers of prisoners, and brutality was always the easiest method available. The basest elements of people's temperaments were elicited by the nature of the camp system, where the rules encouraged such things as goading prisoners into trying to escape so a guard could shoot them and thus earn an extra day's leave.\n\nSo what do all these explanations add up to? Why was there no shortage of Germans ready to participate in the torture and killing of Jews? Above all, because the Nazi regime succeeded in creating a closed mental world, an ideological echo chamber in which leaders constantly harped on the threat the Jews supposedly constituted and the need for Germans to defend themselves against it. The war itself, the air raids on German cities, the snipers at sentries in the occupied east\u2014everything was the work of the Jews. At the same time, the regime degraded the Jews so thoroughly in ghettos, camps, and transports that they came to resemble the vile picture that the regime painted of them as dirty, disease-bearing, self-seeking, and uncivilized creatures, which fostered German contempt for them and readiness to inflict harm. Nazi propaganda and power combined to turn antisemitism into a relentlessly self-fulfilling feedback loop, and rank-and-file Germans behaved accordingly.\n\nWendy Lower's _Hitler's Furies_ (2013) reinforces this line of analysis with evidence concerning a previously largely unstudied group: the half-million German women sent into occupied Eastern Europe as wives, secretaries, nurses, teachers, settlers, Red Cross volunteers, and radio operators, and in many other capacities. Some 300,000 German women served as auxiliaries in Gestapo and police offices and in prisons in the occupied east, another 10,000 in the German civil administration, and 3,500 more as camp guards. Almost all of these women were between the ages of seventeen and thirty. They saw a very great deal of persecution and murder; most of them facilitated it in one respect or another, such as typing up liquidation orders, and some of them perpetrated it, entering ghettos and shooting inhabitants or helping men root Jews out of hiding. As Lower points out, \"In favoring perceived duty over morality, men and women were more alike than different.\" They were also alike in succumbing to the temptations of absolute power that Germans enjoyed in occupied Eastern Europe. One of the killers, Erna Petri, who presided with her husband over a confiscated estate in eastern Poland from 1942 to 1944, summed up many of their intertwined motives when she said after the war, \"I did not want to stand behind the SS men. I wanted to show them that I, as a woman, could conduct myself like a man. So I shot four Jews and six Jewish children. I wanted to prove myself to the men. Besides, in those days in this region, everywhere one heard that Jewish persons and children were being shot, which also caused me to kill them.\"\n\nWhen all these impulses to conformity failed, when expressions of human sympathy or solidarity somehow asserted themselves among Germans in uniform, the Nazi regime resorted to violent retribution. Opting out of murder qualified as understandable weakness, and a German officer could get away with arguing, as Major Karl Plagge did as head of a repair yard for army vehicles in Vilna, that military needs justified keeping Jewish workers and their families alive for the moment. But overt assistance to Jews constituted sabotage punishable by death. Thus, on April 9, 1942, Anton Schmidt, a forty-two-year-old member of a rear echelon ( _Landessch\u00fctz_ ) battalion, wrote a farewell letter to his wife shortly before his execution in Vilna. He told her that, shocked by the massacres there, including the killing of babies by slamming them against tree trunks, he had used his position as leader of a straggler collection point throughout the fall of 1941 to facilitate the escape of more than 100 Jews from the city's ghetto (postwar research established that the real number may have exceeded 300). Exposed in January 1942 and court-martialed, he explained to his wife, \"you know how it is with me and my soft heart,\" adding that \"in my room are six men aged 17 to 23 who have the same fate. Condemned for desertion and cowardice in the face of the enemy. Jews too are the enemy\u2014that's just the way it is.\" Though outcomes of this sort were rare, even their possibility dampened humane inclinations on the part of Germans in the field.\n\nIf the most convincing explanations of the readiness of subordinate Germans to behave viciously toward Jews blend situational and volitional elements, that is not the case with regard to the senior figures who designed and gave the orders for the Final Solution. Fifty years ago, Hannah Arendt tried to use the figure of Adolf Eichmann to argue that these people were faceless and, as she put it, \"thoughtless\" bureaucrats who acted out of personal ambition more than ideological conviction and thus represented what she called \"the banality of evil.\" Almost no historian believes this anymore. As Tom Segev wrote in his study of concentration camp commanders, _Soldiers of Evil_ (1987), what characterized them was not banality, \"but rather inner identification with evil.\"\n\nDetailed prosopographical studies (collective biographies) have shown that perpetrators at this level were almost all highly educated, enthusiastic, and conscious proponents of murder and true believers in Nazi ideology. The most powerful such study is a book by Michael Wildt available in English under the title _An Uncompromising Generation_ (2009). This is a rather wan translation of the German title, _Generation des Unbedingten_ , which means something like the \"generation without limits or restraints.\" Wildt examined the life histories of 221 people who occupied leading positions in the RSHA, the SS office most responsible for carrying out the Holocaust, either during 1939\u201341, when the organization took shape, or for at least eighteen months in a later period. He found that 60 percent of them were born between 1900 and 1910, and another 17 percent were even younger. That means that most of them were in their thirties or, at most, their early forties during the Holocaust. In this respect, they were like their most prominent leaders. Heinrich Himmler, dubbed the \"architect of genocide\" by one scholar, was born in 1900, as was Rudolf H\u00f6ss, the commandant at Auschwitz during most of the camp's existence. Ernst Kaltenbrunner, the head of the Reich Security Main Office from 1943 to 1945, came into the world in 1903; Reinhard Heydrich, Kaltenbrunner's predecessor and the man who launched the Final Solution, in 1904; Adolf Eichmann, who arranged many of the deportation trains, in 1906; and Joseph Mengele, the doctor who sorted arrivals at Auschwitz between life and death and who conducted vicious medical experiments on them, in 1911. Similarly, those 121 T4 personnel who helped staff the Reinhard camps were remarkably young: more than 83 percent of them were born between 1900 and 1914.\n\nThe RSHA leaders were usually youthful, upwardly mobile men on the make, eager to prove themselves, to make a mark and a difference. Most were well educated\u2014one-third of them had PhDs, as did all four of the first _Einsatzgruppen_ commanders, and many had studied at Germany's best universities, notably Heidelberg, Leipzig, and T\u00fcbingen. Most had long records, dating to their student years in the 1920s, of involvement in extreme nationalist, antisemitic, and violent politics, and most had dedicated themselves to remaking the world by avenging the wrongs supposedly done to Germany. Imbued with a romantic view of war and a hunger for action, they were men on a mission who scorned sentimentality. _Gef\u00fchlsduselei_ was the word they used for all forms of human empathy, and the literal translation into English, which is \"spraying of feelings,\" conveys a sense of the contempt they expressed. They knew exactly what they were doing, and they believed completely in their utterly Germanocentric vision of national redemption through revenge and racial cleansing. Although the T4 personnel generally came from lower down the social scale, they also constituted a highly indoctrinated group.\n\nTo this mix of idealism and careerism, the RSHA and T4 people added a hard-hearted form of professionalism, a cold-blooded determination to do their jobs well. The phrase in German for someone who will stop at nothing is \" _sie\/er geht \u00fcber Leichen_ ,\" \"s\/he walks over corpses,\" and it applies literally as well as figuratively to these men. They found the language of \"duty\" very convenient; in its name, almost anything was justifiable as long as it served the German _Volk_. Invoking duty not only relieved them of personal responsibility, it made murder into a higher calling. Higher because they also claimed that the Reich's expansion to the east was part of a civilizing process that expanded European culture at the expense of supposedly barbaric Asia. Hitler once called Eastern Europe \"our India,\" and on more than one occasion he likened Germany's eastward expansion to America's westward one. The men atop RSHA believed deeply in this missionary vision, and they expected to have to kill millions of people to realize it.\n\nIn short, most German perpetrators of the Holocaust fit a pattern of militarily inspired, nationalist young men who seized on the opportunities for advancement and fulfillment that were created by the enormous increase in the ranks of the SS in the late 1930s, especially as it absorbed the police, and by Germany's expansion. They also hailed disproportionately from areas the Reich had lost after World War I or from border regions, which is to say from environments that heightened senses of national consciousness and competition. Very few of them were new to political violence or mere draftees. As the sociologist Michael Mann has summarized the evidence, \"the majority of Nazi genocide . . . was accomplished by ideological, experienced Nazis. . . . The vast majority of those involved in actual killing knew what they were doing, [and] most thought there was a good reason for it.\"\n\nZealotry is especially characteristic of the chief perpetrators, namely Himmler, Heydrich, Eichmann, H\u00f6ss, Kaltenbrunner, and two men not previously mentioned, Oswald Pohl and Hans Kammler, the leaders of the SS Economics and Administration Main Office (WVHA), the organization that ran the Nazi slave labor system. Heinrich Himmler rose to power and exercised it as the embodiment of the SS's motto: \"My honor is called loyalty\" ( _Meine Ehre hei\u00dft Treue_ ). Even though he became a Party member before the Beer Hall Putsch of 1923, having already imbibed the mixture of romanticism about Germany and animosity toward foreigners, Jews, and leftists that characterized the movement, he was initially closer to other early Nazi leaders than to Hitler. But after becoming head of the F\u00fchrer's personal bodyguard in 1929, Himmler made himself into Hitler's reliably ruthless agent in dealing with people or groups that Nazism defined as enemies. As a result, the main paper trail that connects Hitler to the Holocaust runs through Himmler's appointment books for 1938\u201342. They reveal how closely radicalizations of Nazi policy toward Jews followed meetings between the two men.\n\nNearly everyone who ever met Himmler\u2014or who has written about him since\u2014has commented on his unprepossessing appearance and colorless personality. Short, unathletic, and nearsighted, he hardly embodied the Nazi ideal. In fact, a Gauleiter once remarked, \"If I looked like him, I would not speak of race at all.\" Yet beneath the exterior lurked two driving, apparently contradictory characteristics that also have struck most observers: his absorption in a fantasy world\u2014including faith in astrology and herbalism, pleasure in torchlight rituals, the conviction that he was the reincarnation of German Emperor Heinrich I (\"the Fowler,\" who died in 936), and the dream of populating the colonized German East with interlinked settlements of Teutonic warrior-soldiers ( _Wehrbauern_ )\u2014and his methodical attention to practical bureaucratic details. The combination underpinned his \"success\" as a mass murderer. He demanded organized, thorough, and \"merciless\" translation of his Aryan supremacist dream world into reality, and that demand animated the organizations responsible to him: the SS, the RSHA, the German police, the _Einsatzgruppen_ , and all their auxiliaries.\n\nReinhard Heydrich came to the Nazi Party relatively late for one of its main leaders. He initially pursued a naval career that was cut short by his court-martial for having an affair with a woman other than his fianc\u00e9e. The woman's family turned out to have powerful connections, but what really led to his dismissal from the navy was the arrogance he displayed before the court. Though he had been active in conservative nationalist groups in the 1920s, the fianc\u00e9e, whose portentous name was Lina von Osten (Lina from the East), pushed him, beginning in 1931, toward the Nazi Party and membership in the SS. Physically, he was the model SS man: tall, blond, blue-eyed, long and thin in the face, athletic, and graceful. As one of his German biographers noted, \"[I]f National Socialism had looked in the mirror, Reinhard Heydrich would have looked back.\" Emotionally, too, he fit the mold: tough, decisive, hard-driving, persistent, relentless, and risk-taking. His favorite adjective was \" _unerh\u00f6rt_ ,\" unheard-of or unprecedented, and he strove to make his actions earn that description. Carl Jacob Burckhardt, a Swiss diplomat and historian, said after their first meeting that Heydrich was \"a young, evil god of death.\" At his funeral after his assassination by Czech resistance fighters in 1942, Hitler called him \"the man with the iron heart.\"\n\nHeydrich's manifest conceit and cold-bloodedness increased as time passed, probably in compensation for his late entrance into the Party, his scandalous eviction from the navy, and the persistent rumors, which proved false but led to a humiliating internal Nazi investigation in 1932, that his mother's parentage was Jewish. These impetuses, along with his close personal friendship with Himmler and his considerable organizational talent, turned him into a murderous executor of Nazi ideology. He became the epitome of the Nazi belief that only Germans counted; everyone else was simply outside his moral universe and expendable. Some of his biographers contend that he adopted Nazi ideology merely as a vehicle for his urge to power, but this is too simple. His conviction was genuine, as was his emotional addiction to military life and violence. Also genuine was his belief, typical of Nazi perpetrators, that he was innocent, high-minded, and self-sacrificing in fulfilling the tasks assigned to him. As he reportedly told his wife, \"I feel free of all guilt. I make myself available; others pursue egotistical goals.\"\n\nAdolf Eichmann was in some respects a rather pathetic figure, which did not prevent him from becoming an extraordinarily destructive one. His family moved from an industrial city not far from D\u00fcsseldorf to Austria in 1913, when he was seven years old, and he never managed to graduate from either an academic or a vocational high school. Helped by his father's business contacts and by his stepmother's Jewish relatives, he got jobs as a salesman for first an electric company and then an oil firm, but lost the latter post in May 1933 during the Depression. By then, he already had joined the Nazi Party, impelled largely by his Protestant, pro-German family milieu, and this new political affiliation led him to return to Germany after the Austrian government cracked down on the Nazis in mid-1933. There he volunteered for the SD, the Security Service of the SS that Heydrich had started a few years earlier, and received an assignment to keep tabs on Freemasons in Germany. He moved on to the SD's Jewish Department in 1935, and by 1938 was in charge of the agencies in Vienna dedicated to driving the Jews out of the city and confiscating their wealth as they left. Responsibility to handle Jewish affairs within the RSHA followed in 1939, along with the task of arranging the deportations of the Poles and Jews that Himmler wished to push out of the parts of Poland annexed to Germany into the General Government. Later, his portfolio expanded to include transportation to the ghettos and\/or death camps of all the Jews of Europe except those already inside the General Government\u2014their removal was the job of another SS officer, Hermann (Hans) H\u00f6fle.\n\nWhen Hannah Arendt described Eichmann as the embodiment of the \"banality of evil,\" the bureaucrat without convictions who saw no difference between shipping cargo and shipping people, she fell for the cover story that he constructed for himself in preparation for, during, and after his trial in Jerusalem in 1961. He knew that his only conceivable defense was to portray himself as a mindless cog in the machine, someone who merely had obeyed irresistible orders. In truth, he had come, during the 1930s, to believe deeply in Germany's need to fight the Jews. That belief hardened, following the conquest of Poland, into a readiness to kill and then into a determination to do so that had become so intense by November 1944 that he circumvented a direct order from Himmler to stop renewed deportations from Hungary. Thanks to the assiduous research of Bettina Stangneth, who examined Eichmann's many recorded utterances to fellow Nazis and their sympathizers while he was hiding in Argentina between 1950 and 1960 and assembled them in _Eichmann Before Jerusalem_ (2014), we now know how proud he was of his SS service in retrospect and how thoroughly he rationalized it, not as conscientiously carrying out an allotted task as a dutiful civil servant but as creatively and energetically defending his nation against perfidious attacks by Jews. Antisemitism was a means to his advancement, but it was not only that.\n\nRudolf H\u00f6ss was a rather different sort of person and perhaps the one leading perpetrator who most closely resembled Arendt's depiction of a \"thoughtless\" Nazi desk killer. H\u00f6ss came from a deeply religious family and felt attracted to military life because it offered a comradely antidote to his lonely upbringing and temperament. After service in World War I as only a teenager, he joined a right-wing paramilitary unit, got caught up in the murder of a comrade, served five years in jail, and emerged in 1928 lost and adrift. Hoping to start a farm, he joined a rather mystical agricultural group called the Artamanen, where he met Heinrich Himmler. In 1934, his invitation drew H\u00f6ss into the SS and concentration camp work, which offered the attraction of a quasi-military life. Once in, H\u00f6ss sought to win commendation by accomplishing whatever he was asked to do, without regard to its content. He remained Himmler's man throughout his career, not least because others in the camp system hierarchy disliked H\u00f6ss intensely.\n\nOne of his biographers has called him \"a functionary in the true sense,\" a man so empty that he found meaning only in carrying out directions and serving values that were created for him. He was a monument to what Germans call \"the secondary virtues\": selflessness, loyalty, diligence, helpfulness, and order, all displayed without reflection on the purposes to which they were being put. In a succession of camp command posts, culminating with Auschwitz, H\u00f6ss demonstrated neither pleasure nor discomfort in inflicting suffering. Whether his many victims deserved their fate was a subject on which he, in his own devastatingly self-incriminating words, \"had never really wasted much thought.\" Duty was his only concern, and at the end he therefore depicted himself, not the people he killed, as a victim of the fate that had cast him in the role of Auschwitz camp commander. None of these comments means that H\u00f6ss was a robot. Within given policy parameters, he was inventive and energetic. But he appears to have thought entirely within the box of pleasing his superiors and performing his assigned tasks\n\nErnst Kaltenbrunner, who imbibed his politics, including intense and vocal antisemitism, from his extremely right-wing father, joined the Nazi Party in 1930, eight years before his native Austria became part of the Reich, and the SS only a year later. He promptly recruited Adolf Eichmann, and then spent the 1930s brawling with political opponents and agitating for the _Anschluss_. In its aftermath, he became the chief of the SS and the police in Vienna from 1938 to 1943, when he moved up to succeed Heydrich as head of the Reich Security Main Office. Kaltenbrunner referred to Himmler as his _\"\u00dcbervater\"_ \u2014that is, his ideal and role model. Even after the war, Kaltenbrunner gave vent to his fervent Nazism by attesting that the Party presented \"a world view encompassing life in its entirety,\" that the idea of race constituted \"the divinely inspired building block of mankind,\" and that the Jews, especially in Eastern Europe, were \"really the only stratum that possessed enough intellectuality to provide the enemy with the necessary actors to execute his plans.\"\n\nThe last two figures in this rogues' gallery, Oswald Pohl and Hans Kammler, directed the murderous slave labor system, the former with responsibility for administration and finance, the latter for engineering and construction. Both were veterans of right-wing paramilitary formations, and both had joined the Nazi Party before Hitler became chancellor in 1933. They harbored dreams of an industrial empire that would provide building materials for the massive architectural expressions of the new Germany, furniture and knickknacks for German settlers in the conquered East of the continent, and roads to connect them. All of this was to contribute to the demographic transformation of Europe and the creation of a new state-owned economic sector. Like the other killers described above, Pohl and Kammler were ideologically inspired creators of a Nazi New Order, imbued with a spirit of activism and with \"ideals\" of racial supremacy. Neither had any hesitation in carrying out Himmler's instruction to work the concentration camp inmates like the Pharaoh's slaves.\n\nPerhaps the most remarkable feature of the mentality of the Nazi perpetrators was their self-delusion, their capacity to distract themselves from what they were doing by calling it something else. Perpetrators never owned up to torturing and slaughtering; they always professed to be serving a sanctified purpose that immunized them from the charge of immorality. The epitome of this stance was Himmler's speech to the assembled SS commanders at Posen in October 1943. He summarized the philosophy of the SS bluntly: \"honest, decent, loyal, and comradely must we be to members of our own blood and to nobody else.\" He congratulated his men for having waded through gore but nonetheless \"remained decent.\" He referred to their deeds as a \"never to be written page of glory\" in Germany's history. Of course, he was not just saying that the end justified the means, though he was saying that. He was also congratulating his subordinates on being people who could, to use contemporary phraseology, bite the bullet and do what had to be done. He was praising them for understanding that \"winning is the only thing.\" When we put his language into ours, we are reminded of how common such self- and principle-abandoning thinking is in the world. Maybe Stanley Milgram and Philip Zimbardo were right after all in suggesting that \"How could people do such things?\" is a na\u00efve question.\n\nA nation is not only what it does, Kurt Tucholsky, the great German satirist, wrote in 1934, but also what it puts up with. What of the ordinary Germans who did not carry out the killings directly but witnessed the deportations, sometimes photographed them for local histories, frequently took over the possessions left behind, and heard the rumors that abounded about the fate of not only Germany's Jews but also those in the east? What did they know of the murders, and how did they respond? Awareness of the self-dug graves and shootings by the _Einsatzgruppen_ , the Order Police, the foreign auxiliaries, and the German army was widespread, thanks to letters home and troops on furlough. Indeed, such information was sufficiently plentiful as time passed that more and more Germans spoke with open dread of the reprisals or retribution that they expected to experience once the tide of the war turned. A representative expression of this view, as well as of slightly more complete knowledge, is this diary entry by Curt Pr\u00fcfer, a semiretired diplomat and an antisemite who had purchased property formerly owned by Jews. On November 22, 1942, he wrote the following\u2014mostly in French, as if to conceal what he was saying: \"Men, women, and children have been slaughtered in large numbers by poison gas or by machine guns. The hatred that inevitably must arise from that will never be appeased. Today every child knows this in the smallest detail.\" Already in March of that year, the isolated diarist Victor Klemperer recorded that he had heard of a place called Auschwitz where Jews were worked to death rapidly; by October, he could describe it as a \"swift-working slaughterhouse.\" Meanwhile, in April 1942, he had written that his wife heard an eyewitness report of mass murders of Jews in Kiev, a reference to the killings at Babi Yar seven months earlier. Several months before Germany surrendered, Klemperer, again quoting only what his \"Aryan\" neighbors had told him, knew even the approximate death toll of the Holocaust. He wrote in his diary for October 24, 1944, \"six to seven million Jews . . . have been slaughtered (more exactly: shot and gassed).\"\n\nKnowledge of the Holocaust in Germany was extensive because, as Peter Fritzsche shrewdly has noted, \"the Nazis wanted to manage, but not entirely conceal, the facts.\" After all, Goebbels announced in the journal _Das Reich_ on November 16, 1941, that \"world Jewry . . . is now gradually being engulfed by the same extermination process that it had intended for us.\" On April 30, 1942, the _V\u00f6lkischer Beobachter_ , the official mouthpiece of the Nazi Party, reported \"the rumor\" that \"it is the task of the Security Police to exterminate the Jews in the occupied territories. The Jews were assembled in the thousands and shot; beforehand they had to dig their own graves.\" Hitler reminded Germans of his prophecy that a world war would bring about the annihilation of the Jews in no fewer than seven major speeches: on January 30, 1941; on January 30, February 24, October 1, and November 8, 1942; on February 25, 1943; and on January 1, 1945. By one scholar's count, the F\u00fchrer referred to the wiping out of the Jews in at least a dozen wartime public speeches or pronouncements. If such partial revelations had a purpose, it was to secure loyalty by reminding people of their complicity. Having allowed such brutality, Germans could expect nothing but reprisal, so they had best fight tooth and nail to sustain the Third Reich. For the most part, this strategy succeeded.\n\nWhatever the state of their knowledge, the German public's willingness to help Jews was exceedingly limited. Jews who went underground, who refused to answer the order to appear for deportation and then hid their identities and tried to survive within the Reich, were called U-boats, after the German word for submarines. Perhaps 10,000 people tried this means of outliving and outwitting the Nazis, about half of them in the city of Berlin; both there and nationwide, somewhere between 30 percent and 50 percent of them made it to 1945. The mortality rate was high, and the numbers involved small. But for every person who did survive, the number of non-Jewish Germans who helped at one time or another had to be substantial. Sometimes that help was active, as in the creation of forged identity documents or the offer of a place to live; sometimes it was passive, as when an old acquaintance recognized a U-boat on the street but did not expose the person. Konrad Latte, whose father and mother had converted to Protestantism, spent the months from March 1943 to May 1945 as a U-boat. Before he died in 2005, he named fifty people who protected him in one way or another, only one of whom was ever caught and punished. Arthur Arndt, a Jewish doctor hidden with his wife and two children in Berlin, cited exactly the same number of non-Jews on whom the family's survival had depended. Max Krakauer, still a third successful U-boat, put the number in his case at sixty-six.\n\nDespite such numbers, heroic behavior of this sort was rare. That makes it both admirable and a standing reproach to the general attitude of the German population, which to the very end of the war viewed the persecution of the Jews only through the self-interested lens of the benefit or punishment Germans were likely to receive because of it. Until the fronts began to close in on the Reich in 1944, the benefits greatly outweighed the potential costs, as Germans profited from the Holocaust in ways that ranged from the government revenue obtained from stealing the Jews' precious metals to the individual allocation of the furniture from their apartments to Reich citizens who had been bombed out. In Hamburg alone from 1941 to 1943, the authorities auctioned off some 4,000 shipping containers holding the goods of Jews who had emigrated, and the Nazi state took in 7.2 million reichsmark in proceeds. In 1942\u201343, forty-five shiploads of goods taken from Dutch Jews went to the same German port city. A German scholar of the subject estimates that between 1941 and 1945 \"at least one hundred thousand\" inhabitants of the town and its environs bought household property confiscated from Jews. Similarly, the occupation of Europe generated enormous benefits to Germans in the form of food and goods shipped home by far-flung troops, most of it bought by soldiers flush with local currency but some of it stolen. Returns on conquest and murder such as these did much to preserve loyalty to the Nazi regime well into 1945.\n\nHow little effective help most Jews could expect from the German public is demonstrated by an event that some commentators cite as evidence for not only the opposite point, but also the potential of popular opposition to alter Nazi racial policy. To be sure, the Rosenstrasse protest of February 27 to March 6, 1943 in Berlin constituted the only outbreak of popular resistance to deportations of Jews in the history of Nazi Germany, but the events were far less consequential than legend has it. The trigger was a push finally to make Germany virtually _judenrein_ (cleansed of Jews) by rounding up all remaining Jewish forced laborers at their workplaces and then deporting all except those in mixed marriages to Auschwitz or Theresienstadt. Across Germany, Jewish spouses in those marriages who got caught up in the Gestapo raids were released immediately, and in Berlin more than three-quarters of them were. But the SS detained some 2,000 such men in a Jewish community building on the Rosenstrasse in the middle of the city in order to double-check their marital status against the records deposited there and to identify personnel suitable for future assignment to nearby Jewish institutions as replacements for _Volljuden_ , or \"full Jews,\" the regime intended to (and did) deport a few weeks later. As these processes dragged on, several hundred of the worried non-Jewish wives and female in-laws of the detained men gathered around the building seeking information about their relatives, occasionally crying out for their release but mostly, as one participant reported, standing in \"silent protest,\" and in defiance of repeated police efforts to disperse the crowd. Once the releases from the building gathered pace, the assembly dwindled, and the episode came to a close.\n\nThe Rosenstrasse protest required considerable courage of the women who carried it out, but two telling aspects of it deserve emphasis. First, it was limited to a few hundred relatives of the rather small number of men affected, not joined by other so-called Aryans, and not accompanied by any popular resistance to the deportation of thousands of other Jews from Berlin and the Reich at this time. Second, the protest accomplished little in protecting men whom the SS intended to use in the near term and dispense with later. With the partial exceptions of the spouses transferred to Jewish community institutions, the Jewish parties to mixed marriages became subject to increasingly severe measures in the ensuing months. Not allowed to return to their factory jobs, they were condemned \"to the hardest manual labor,\" increasingly driven with their non-Jewish spouses into vacated Jew Houses, shipped off to work camps, and finally included in the directive that consigned all part-Jews, or _Mischlinge_ , to Theresienstadt in early 1945. The scant remaining statistical evidence suggests that fewer than half the mixed marriages of 1943 still existed when the war ended.\n\nFar from demonstrating what greater popular resistance to Nazi persecution might have accomplished, the Rosenstrasse incident showed that overt protest had little impact on the direction or pace of the regime's relentless course. Ironically, in Nazi Germany the prospect of popular opposition sometimes stayed the regime's hand, as clearly happened in dissuading Hitler and his entourage from promulgating a law automatically dissolving all mixed marriages, but the reality of resistance generally goaded the Reich into more radical action, not only in Germany but also in occupied countries.\n\nAs World War II drew toward its close, and the returns on persecution turned adverse for Germans, few of them paused to reflect on the horror they had inflicted. Instead, they devoted most of their attention to the supposed injustice of their own suffering, either at the hands of Allied air raids or as the likely result of the regime's crimes when vengeful enemy troops rolled in. The self-pity and sense of victimization that gave rise to Nazi rule also outlasted it.\n\nENSLAVEMENT\n\nThe most drawn-out and agonizing, though numerically least lethal, form of murder, after gassing and shooting\u2014namely, the system of slave labor\u2014accounted for at least one-half million deaths in the Holocaust. Why and how did the Nazis develop this system? Why did they bother to keep some Jews alive for labor for at least some period of time? Why did they treat such laborers so apparently counterproductively? With regard to these questions, perhaps more misinformation has accumulated than concerning any other aspect of the Holocaust. This is so for an ironic reason: Many of the lawyers who in recent decades worked hard to obtain compensation for former slave laborers sullied a good cause by frequently misrepresenting how the system came into being and how profitable it proved.\n\nSlave and forced labor were two parts of a common system. Forced laborers were non-Jews recruited or rounded up in occupied countries during World War II and brought to work in Germany for nominal wages. They were often, though not always, badly fed, housed, and treated and kept segregated from the German population. Collected and supervised by a Nazi _Gauleiter_ named Fritz Sauckel, they made up 15 percent of industrial workers in Germany in 1942, a figure that rose to 30 percent in 1944, but 20\u201350 percent of the labor force in the largest and most militarily important German firms during that time frame, and more than half the people working in German agriculture. In August 1944, they included almost 1.3 million French people, over 580,000 Italians, almost 2.8 million Soviet citizens, and almost 1.7 million Poles. Their number peaked at 6.8 million at the end of 1944, but altogether 13 million people did forced labor in Germany from 1939 to 1945, 4.6 million of them prisoners of war and 8.4 million of them civilians. This was a staggeringly large system of exploitation.\n\nSlave laborers, who numbered some 1.1 million people during the whole of World War II, of whom about 714,000 were toiling at the beginning of 1945, were inmates of ghettos and concentration camps, mostly but not always Jews. Indeed, the number of non-Jews among them rose during the final year of the war, especially as more and more Eastern European women were put into camps like Ravensbr\u00fcck and Sachsenhausen and then parceled out to labor sites. The Economics and Administration Main Office of the SS supervised and controlled most slave laborers and leased them to government agencies or private industries for a set price per person per day. In other words, they were not paid, but they were paid for. And, contrary to legend, they were not necessarily cheap. The SS charges in many cases exceeded what a German civilian laborer, especially a construction worker, would have received; even when this was not the case, the productivity of slave laborers often was so limited that it offset their low wages. After all, few slave laborers had done manual labor before, especially on construction projects. All this gave the employers a perverse incentive to economize on food and housing for slave laborers, to drive them excessively hard, and to work them long hours, at least so long as ample numbers were available to replace people who died of maltreatment. In this respect, the term \"slave labor\" is actually misleading. Slaves are bought, and their owners thus acquire an economic interest in their survival. But camp and ghetto inmates were rented by the day. The renter had little interest in their long-term survival unless they were highly skilled. Meanwhile, the employer could send any flagging workers back to the camp they came from and trade them for fitter workers.\n\nWhat difference this made is illustrated by the relative fates of the men and women slave laborers used at a plant of a Degussa subsidiary at Gleiwitz in Upper Silesia between 1943 and 1945. Only two females out of 209 in the workforce died, and they committed suicide the day the SS took over supervision of the laborers' barracks in 1944. But a substantial share\u2014probably about one-third\u2014of the more than 1,000 men put to work on the site expired. Why? The men worked on construction and were of no interest to the firm once the plant was finished, but the women were indispensable to its manufacturing, at least as long as the war lasted. The surviving statistics indicate that the company was indifferent to the working conditions and fates of the men but very concerned to retain the women. Food and medical help must have been better for the women than the men, because relative working conditions alone\u2014the men did heavy labor outside, the women worked indoors mostly packaging the output\u2014are not enough to explain the discrepancy in survival rates. One scholar who has examined mortality rates of slave laborers meticulously has concluded that those put to work on construction projects were five to ten times more likely to die than those employed on assembly lines, but at Gleiwitz the men were 150 times more likely to die. This example illustrates a general pattern: Firms could make a difference to the survival chances of their slave laborers, but tried to do so only when self-interest commanded such action.\n\nHow and why did these systems come into being? The forced labor system was rooted in the mathematics of the German labor force during World War II: The Reich called up eleven million men for military service, and a larger percentage of German women were employed already in 1939 than was ever the case in Britain or the United States during the war, which meant that relatively few German women were available as replacements. Yet the war created demand for enormous increases in output. Germany therefore faced a choice between farming out production to the occupied countries or importing replacement workers. For the most part, the Reich opted for the latter to guard against sabotage and\/or the loss of industrial secrets. The forced labor program that developed drew on two precedents for compulsory work in Nazi Germany: first, the conscription of unemployed Germans and those with jobs in nearby factories into work columns to build new highways (the Autobahnen) and fortifications in the Rhineland (the Westwall) in the 1930s; and second, the use of primarily Polish and French POWs as supplementary workers beginning in 1940.\n\nThe slave labor system, however, had its roots in Nazi antisemitism, which contended that Jews avoided manual labor and thus should be forced to do it, and in the economic interests of the SS, which wanted to become financially self-sustaining. The system had two forerunners. First, the Reich inaugurated a compulsory labor program for German Jewish males on Hitler's birthday in April 1939. Cut off from other gainful employment and the German welfare system, Jews were supposed to \"earn their keep\" in road-building and street-cleaning projects and in private industrial assignments, notably at the large Siemens plant in Berlin. The Nazi regime extended this program to all Jews in Poland in October 1939, and many died when forced to do river dredging and straightening projects and airfield and road construction under brutal overseers. Two of the later death camps, Belzec and Treblinka, began as labor camps for Jews put to work digging tank traps and other fortifications along the nearby border with the Soviet Union following the partition of Poland. Second, in 1936\u201339, the SS set up a web of its own companies that used camp inmate labor to generate revenue. The holding company was called the German Economic Plants (DWB). One of its subsidiaries was the German Equipment Works (DAW) that made weaponry. Another, the German Earth and Stone company (DEST), made bricks at most camps in Germany and operated an infamous quarry at Mauthausen in Austria that supplied much of the building material for the Nazi Party Grounds in Nuremberg.\n\nAlthough these were the precedents, they were not the actual triggers for the vast expansion of the slave labor system during World War II. Three developments set that process in motion. First, ghettoization created both labor pools that attracted German firms and an incentive for the Nazi administrators to develop revenue-generating initiatives that would make the ghettos pay. Second, the Reich decided in the Fall of 1940 to build a road in southern Poland that would link the Autobahn from Berlin to Upper Silesia with the highway they envisioned (Durchgangstrasse IV) running across Ukraine all the way to the Black Sea after the invasion of the U.S.S.R. This was the impetus for the formation of the Organisation Schmelt, named after the SS officer who commanded it, which developed the system of wage rates, barracks, underfeeding, and severe treatment that later characterized the slave labor program everywhere. A simultaneous project connecting Berlin to Lodz led to the first use of slave labor by German private industry, in this case the construction firm Philipp Holzmann. The route through southern Poland stimulated the expansion of the Auschwitz and Majdanek camps, which were to be the sources of labor for the construction. When Heydrich referred, at the Wannsee Conference, to the use of able-bodied Jews on road building in the East, Durchgangstrasse IV was the undertaking he had in mind. It ultimately consumed the lives of at least 25,000 Jewish construction workers, who toiled without the assistance of machinery and were brutally mistreated. Third, in early 1941 two of the largest corporations in the Reich, Volkswagen and IG Farben, chose to deviate from industry's earlier refusal to hire camp inmates. Volkswagen agreed to set up a concentration camp on the factory grounds in Wolfsburg, in northwest Germany, ultimately to construct an aluminum foundry, and Farben agreed to build a huge synthetic rubber plant just east of the town of Auschwitz and to lease camp inmates as construction workers.\n\nFrom these small beginnings, the use of slave labor mushroomed, especially after September 1942, when the SS broadened its usual policy of hiring out inmates only for production in and around concentration camps by agreeing to expand upon the Volkswagen precedent with the establishment of satellite sites near important factories. The most voracious consumers of slave labor became the Eastern Front, for military installations and factory reconstruction; the French Atlantic coast, where inmates built most of the defenses; Upper Silesia, the preferred location of massive new factories for fuel and rubber because Allied bombers could not reach the area from bases in Great Britain; and the Project Giant ( _Projekt Riese_ ) site in the Owl Mountains of Lower Silesia, a warren of underground passages that began as a huge prospective bombproof headquarters for Hitler and then morphed into military production lines. All told, slave labor camps in Nazi-occupied Europe numbered in the tens of thousands, and they extended from the island of Alderney, in the English Channel, to the farthest reaches of German penetration into the Soviet Union.\n\nDespite (or because of ) the size of the system, it was never efficient or well managed. Half the inmates of Auschwitz never even got labor assignments. The SS companies were neither profitable nor usually successful in their joint ventures with private enterprises to manufacture military equipment inside camps, though one initiative, involving the construction of fighter planes at Flossenb\u00fcrg with Messerschmitt, made money and contributed to the German war effort. Until the turn of 1943\/44, Jewish slave laborers were generally kept out of Germany proper, and projects were brought to them in occupied or annexed territories\u2014the inmates supplied to Volkswagen in 1941 had included only a few Jewish political prisoners\u2014but the Nazi regime reversed this practice as labor shortages mounted and British and American air raids took a toll on the Reich. This change in German policy had major consequences for the survival chances of people arriving at Auschwitz. Up until late 1943, the camp primarily wanted men to work on construction, so fewer women were selected for admission to the camp than men. Combined with the fact that women generally outnumbered men on transports into the camp, this meant that the female mortality rate upon arrival was much higher than the male. Beginning in late 1943, however, demand rose for women to work on assembly lines, so the number of them selected caught up with and sometimes exceeded the number of men. This is why the young women from Hungary who arrived at Auschwitz in 1944 had better chances of surviving the camp than almost any other Jewish group.\n\nOne can get a sense of the variable horrors of the slave labor system by looking at two examples from occupied Poland of production sites that continued to operate long after most other installations using Jews had been liquidated: Starachowice and Skarzysko-Kamienna. Both lay south of Radom in the middle of the General Government, and both endured because they produced munitions. The two sites also had a common and peculiar feature that proved decisive in the survival of some of their slave laborers: Neither plant was incorporated into the SS camp system under the jurisdiction of the WVHA. Both remained largely governed by pragmatic factory managers who behaved erratically and unpredictably but, on the whole, less ruthlessly than the SS.\n\nStarachowice came into existence as a camp on October 27, 1942, following the liquidation of the surrounding ghettos, during which two-thirds of the inhabitants were sent to death at Treblinka and one-third brought into the new, hastily constructed camp. The installation lasted twenty-one months, until July 28, 1944, and the transport of the workers to Auschwitz. Shifts were either eight or twelve hours long, depending on the strenuousness of the work and not counting marching time to and from the camp to the factory. Output quotas were high, but working conditions depended heavily on the character of the German or Polish foremen, which varied immensely. The predominant recollection of survivors is of the extreme filth that prevailed. One former inmate said that when he got to the Monowitz camp alongside the IG Farben factory near Auschwitz, he found that wretched site much cleaner than what he was used to at Starachowice, where he had not showered for months on end.\n\nSkarzysko-Kamienna operated from April 1942 to August 1944 on the site of several former Polish state ammunition plants that a German munitions producer, the Hugo Schneider AG (HASAG), had taken over. Some 25,000 Jews passed through the camp during its life, and about four-fifths of them perished. The inmates worked in two shifts, day and night, without special work clothes or adequate sanitary conditions. In the shell department, women workers were expected to carry 180 nine-pound shells to each polishing machine during each hour in a ten-hour shift\u2014in other words, three per minute. In the antiaircraft department, supervisors whipped workers who produced defective pieces. In the mine department, packers had to cram explosives into the shells by hand with no gloves or aprons to protect them. Those who worked with picric acid found that their hands turned black and their hair turned green; those who worked with TNT saw their skin turn reddish-pink. As the TNT was being prepared, women had to stir it while it boiled at a rate of 1,800 stirs per hour and 21,600 stirs in a twelve-hour shift, all while standing. The food was the usual watery soup, ersatz coffee, and crusts of bread. The workers wore wooden clogs. The bunk beds had no mattresses or blankets and were lice-infested. Typhus was rampant, and weak prisoners were shot weekly until the spring of 1943, when the Germans began to worry about running out of them. Yet the camp and its factories continued to operate and some Jewish inmates continued to live until the Soviet army appeared on the horizon in late July 1944, when the sick were killed and everyone else shipped out to HASAG plants in Germany. Their survival was highly unusual, and it resulted from the fact that even Himmler could not bring himself to order the deaths of the people who in 1944 produced one-third of the German infantry's ammunition.\n\nBeginning in late 1943 and with gathering speed during 1944, the Germans reversed the policy of keeping Jews out of the Reich and began to bring more and more concentration camp inmates to work in Germany. The model for what could be done became the Dora-Mittelbau site in the Harz Mountains, where V-rockets were to be produced. Sixty thousand prisoners passed through this installation in 1943\u201345, and more than 40 percent of them had died by the time the war ended. The SS installed an assembly line in two large shafts that had been driven into Kohnstein Mountain since 1937 to create a huge storage installation for aircraft fuel. The shafts were not straight lines, but S-shaped, each about a mile long, about 30 feet wide and 23 feet high, just under 300 feet apart, and connected every 100 feet or so by somewhat smaller cross-shafts, creating a sort of curved ladder design. The original idea was to lay railroad lines down in each shaft, to put the storage tanks in the cross-shafts, then to bring trains into the mountain to fill their barrel cars with fuel, and finally to drive the trains out the other side. This conception lent itself readily to conversion to rocket assembly lines, with weapons moving down the tracks and the 20,000 different components of each, which were stored in the cross shafts, applied in succession. But only one of the shafts actually passed completely through the mountain and out the other side, so the assembly-line plan had to be altered somewhat. Even so, the scale of the underground production facility was vast, coming to more than one million square feet.\n\nThe project began in August 1943, with a non-Jewish labor force drawn from Buchenwald concentration camp, and the camp sent an additional 800 workers per week in the first months. Fed a meager and watery diet, they were quartered in the stinking, dusty, lice-ridden, and overcrowded cross-shafts, which were never quiet because the assembly work was continuous in two twelve-hour shifts. The prisoners had no safety gear and little protection against outbreaks of disease. Oxygen in the interior of the shafts was in short supply, cold water accumulated on the floors and chilled the bootless workers, and the interior temperature never rose above 59 degrees Fahrenheit. When production of rockets began in January 1944, the Dora camp adjacent to the site held more than 10,000 inmates, and about 4,000 of them were working in the shafts. Over the next three months, they turned out about 300 rockets, most of them defective because of design flaws, and the camp acquired a terrible reputation for mortality. By the beginning of April 1944, when most of the production problems were ironed out, 34 percent of the cumulative population to date of just over 17,000\u2014that is, almost 6,000 people\u2014had died, at a rate that had reached 20 to 25 inmates per day. That death rate was the highest of any concentration camp at the time. Another 20,000 prisoners died in the next twelve months, making total mortality among the people who assembled V-1 and V-2 rockets about two-thirds greater than the total number of English and Belgian citizens killed by them.\n\nDora-Mittelbau was the prototype of what became, in March 1944, the Fighter Staff Program ( _J\u00e4gerstab-Programm_ ), a massive effort to bury German arms-producing factories so that Allied bombing could not damage them. Junkers aircraft motor factories and assembly lines were installed in the northern end of the Mittelbau shafts and in other caves in nearby mountains. By September 1944, 12,000 Dora inmates, now including Hungarian Jews, were at work on these sites in central Germany, and tens of thousands of laborers from other camps were carving caves into the steep banks of the Rhine or pouring and camouflaging concrete hangers in open Bavarian fields. As the workforce at Dora grew, the SS created a new concentration camp consisting of some ninety buildings outside the south end of one of the tunnels, where the production of V-1 rockets was concentrated after September 1944.\n\nNo one has ever succeeded in precisely tabulating the total number of people killed across Germany in this crazed attempt to protect plants from bombing, or in the slave labor program altogether. One-half million deaths is the best rough estimate. We know that mortality rates fluctuated: They were high in 1942\u201343, when laborers seemed so numerous as to be expendable; they dropped in 1943\u201344, and then they surged again during the Fighter Staff Program and the collapse of Germany. The number of former Jewish slave laborers still alive in 1945 may have been as low as 150,000.\n\nThis was a state-driven system, not one propelled by private greed, as is often implied. The principal reason private enterprises asked for slave laborers was the absence of alternative ways to meet rising production targets or, late in the war, to salvage their machinery by getting it underground. Of course, if Germany won the war, the companies expected to gain in the form of having new plants that slave laborers had helped construct. But corporate executives generally fixed their eyes on more short-term objectives: doing their national duty, protecting their market or political positions, and continuing to produce. At Auschwitz, IG Farben remained wedded to using and paying for slave labor, even though camp inmates accomplished only about 15 percent of the construction work, primarily as a disguised form of bribing the SS for future favors. Very few companies, in the end, made much money off the system, not least because much of what they built was lost in the war or afterward. For example, IG Farben's plant near Auschwitz and Degussa's at Gleiwitz produced for only a few months before being overrun by the Red Army. The beneficiary of both turned out to be the Polish Communist state, which nationalized the factories after 1945 and operated them until the fall of communism in 1989.\n\nIn other words, the use of slave labor by German companies was criminal, but not because it was profitable, which it often was not. The principal profiteer from the slave labor program, as from Aryanization in general, was the German state, which collected fees on the labor, estimated at 600 to 700 million reichsmark in 1943\u201344 alone, commissioned most of the projects into which that labor went, and consumed most of the products that the labor ultimately generated.\n\nProbably the most murderous phase of the slave labor program was the final one, the interval between January and May of 1945, when the retreat of the German army on all fronts prompted the regime to try to salvage slave labor for the Reich by marching camp inmates back into Germany. This effort to save the laborers turned into a massive destruction process, to which about 35 percent of the people involved succumbed in the last five months of World War II. Often columns of prisoners set out from camps with no clear sense of how to get where they had been told to go, and confusion was compounded by the rapid movement of Soviet or other Allied forces that often blocked previously open escape routes. Most of these evacuation columns carried little food with them and consisted of ill-shod and ill-clad people marching in the dead of winter. Massive casualties resulted, as the guards, terrified of being captured if the columns slowed down, shot anyone who faltered or straggled. In the evacuation of Auschwitz in January 1945, prisoners marched through the snow on either of two routes, both over thirty miles long, until they reached a passable railroad line and were loaded onto open freight cars in subfreezing temperatures. Amazingly, the death toll in this first round of retreat was relatively modest, something like 7,000 out of 56,000. But 15,000 of those survivors went to the Gross-Rosen camp, which was abandoned, in turn, in February, and in that retreat the mortality rate was much higher, amounting to perhaps 50 percent of the 97,000 prisoners marched out.\n\nAmong the most horrible of the death marches were those launched from the Stutthof camp, on the Baltic coast, near Danzig, in January 1945. Almost 69,000 prisoners, most of them Jews and over half of them women, each carrying only eighteen ounces of bread and four ounces of margarine, and many of them barefoot, left the camp in six marching columns on the morning of January 25. The lucky columns were the ones the Soviets caught up with; the others marched westward for hundreds of miles, growing thinner by the day, or suffered a more swiftly murderous fate. In Palmnicken, a village thirty-one miles west of K\u00f6nigsberg where one of the prisoner columns with about 3,000 inmates bivouacked in a factory building for a few nights, the guard force and the local Nazi Party leader decided that they did not want the town to contain inmates when the approaching Russians arrived. So the Germans marched the prisoners, most of them women, some three miles to a row of high bluffs overlooking the Baltic seashore and machine-gunned them into the freezing water below.\n\nThese ghastly retreats also had calamitous ripple effects, as the camps that received retreating prisoner groups swiftly became unable to feed or otherwise maintain them. Throughout the concentration camp system, all semblance of sanitation and sustenance collapsed. As a result, the overwhelmed guard staff at Neuengamme, near Hamburg, began killing the sick with poison injections; at least 8,000 died this way from February to April 1945. At Dachau, conditions became so horrendous that 4,000 inmates died of typhus in February of that year. At Buchenwald, the prisoners arriving from elsewhere were stuffed into a sector called the Little Camp; its population rose from 6,000 in January to 17,000 in April, even as some 5,200 inmates of the site died during that time span. At Ravensbr\u00fcck, Sachsenhausen, and Mauthausen, and possibly at Dachau, the response was to set up gas chambers or to activate the small ones left from the 14f13 operation for sick, infirm, and troublesome prisoners. About 10,000 inmates were asphyxiated at these places from February to April 1945, mostly with Zyklon but some perhaps in gas vans. The last gassing of the Holocaust occurred at Mauthausen on April 29, the day before Hitler killed himself.\n\nBy far the worst conditions prevailed at Bergen-Belsen, in northwestern Germany, not far from Hanover. Once a small site that held Jews who were to be exchanged for Germans in Allied hands, the camp ballooned to 15,000 inmates by November 1944, most of them sick prisoners dumped there from other camps. By March 31, 1945, the population had reached 44,060, even though the mortality rate had averaged between 250 and 300 people per day in the preceding four weeks. And this was before six convoys containing 20,000 prisoners arrived from Dora-Mittelbau in early April. As far as historians can reconstruct from the records, approximately 35,000 people died from disease and starvation at Bergen-Belsen in the final months of the war. This was an instance of what one might call unplanned annihilation, though one should add that intention was clearly present, since the humane thing to do was to leave the prisoners in camps for the Allies to capture. The decisions to withdraw them under horrendous conditions and then to try to maintain control of them for as long as possible were, in effect, murderous, and the number of resulting deaths was about as large as in the massacre of Hungarian Jewry in the spring of 1944.\n\nThese decisions were Heinrich Himmler's. Hitler had favored slaughtering all the camp inmates and blowing up the sites, but the leaders of the WVHA, the SS economics division, who had been put in charge of jet aircraft as well as V-rocket production, wanted to hold on to the labor supply as long as possible, and Himmler hoped to keep some Jews alive as a bargaining chip with the Allies. Although he vacillated somewhat between preservation and massacre during the final months, evacuation was a way of accomplishing both goals simultaneously, and his instruction of mid-April that \"no inmate may fall into the enemy's hands alive\" left the final choice up to camp commanders. Not all of them opted to send their inmates meandering around the Reich's shrinking territory, but most did. Thus, Bergen-Belsen fell to the British in mid-April without prisoners having been pulled out. But Buchenwald's 48,000 inmates were sent off in trains and on foot to Dachau and Flossenb\u00fcrg only a few days after Belsen was captured; at least one-third perished in the following three weeks. At Neuengamme the SS also began dispersing the prisoners, sending 10,000 of them to the port city of Neustadt, where they were loaded onto three vessels anchored in the harbor. When the British bombed the city on May 3, the ships caught fire, and at least 7,000 of the prisoners burned, drowned, or were shot by German guards while trying to swim to shore. At Flossenb\u00fcrg, evacuations began even as prisoners from Buchenwald were coming in; of almost 46,000 inmates sent mostly southward toward Dachau, at least 7,000 died in the ensuing three weeks. Finally, in late April, the SS emptied Sachsenhausen and Ravensbr\u00fcck and forced the prisoners to march northwest toward the Baltic coast. American troops liberated approximately 20,000 of them in Schwerin. About 40,000 others endured the last days of the war in an open-air camp in a nearby forest, where thousands died of exposure and starvation.\n\nAt the end of April 1945, Bavaria and Austria remained under Nazi control, and they contained two large camp complexes, those of Dachau and Mauthausen, each with numerous subcamps. As the SS abandoned the most distant of Dachau's satellites, the guards simply burned down the barracks, with the sickest and weakest inmates inside. But once the dispersals from the main camp began in late April, the columns had no place to go, and those that set out were intercepted so quickly by American troops that only about 1,500 inmates died en route. Back in the Dachau camp, however, conditions were far worse for those inmates left behind or arriving on trains pouring in from elsewhere, and the last-minute ravages of hunger and disease were considerable. As for Mauthausen, it and its subcamps at Gusen, Ebensee, and Gunskirchen contained some 85,000 prisoners in early 1945, even though the mortality rates on the marches from other camps toward these sites had been devastating. Of 76,000 Jews handed over to Germany by Hungary at the former Austrian border at the turn of 1944\/45, for example, at least 45,000 died on the way to Mauthausen in early 1945, often at the hands of civilians along the route or the _Volkssturm_ militia units assigned to guard the prisoner columns. Those who reached the camp still faced long odds against survival. About 15,000 Jews were sent from Mauthausen to Gunskirchen in late April 1945; on May 4, the arriving American forces found 5,419 survivors, and of them, a soldier bleakly wrote, \"many of the living people look dead. Bones covered in skin with almost no sign of flesh, sunken cheeks and deeply sunken eyes and a glassy expression, the expression of the living dead.\" One of those people was Theodore Zev Weiss, the man whose name is on the professorship I held at Northwestern for sixteen years. As of this writing, he is eighty-five years old and living in Wilmette, Illinois. Neither he nor any other inmate was supposed to survive. If the GIs had arrived even a week or two later, none would have.\nCHAPTER 5\n\n[VICTIMS:  \nWhy Didn't More Jews  \nFight Back More Often?](contents.xhtml#ch_5)\n\nWE TURN NOW from the perpetrators of the Holocaust, and the questions of why and how they killed so many, to the victims of the Nazi murder campaign, the surrounding populations, and the international community, and the question of why these groups could or did not do more to stop the carnage. First, the sensitive and controversial matter of the response of the Jews themselves: \"Why didn't more Jews fight back more often?\" is a common question that succeeding generations have posed from the comfort of living in liberal and law-observing societies. Why did the Warsaw ghetto's inhabitants not rebel against the Germans until April 1943, the inmates of Treblinka and Sobibor until August and October of that year, and the _Sonderkommando_ of Jews detailed to operate the crematoria at Auschwitz until the fall of 1944\u2014in each case only after the Germans' intention to kill the last of them became unmistakable?\n\nThe question is not quite fair, since flare-ups of armed resistance did occur when the Nazis began deportations from particular places. For example, in Cracow in December 1942, a Jewish group blew up a caf\u00e9 favored by German officers in an effort to slow the transports. Two months earlier, an inmate killed a German staff member named Max Bialas at Treblinka. Jews were involved in an attempt to free the roughly 1,000 deportees on the twentieth transport from Belgium to Auschwitz on April 19, 1943, which actually enabled seventeen people to escape from one boxcar, ten of whom were not recaptured. But, as that small number suggests, these incidents had very limited consequences and were easily snuffed out. Perhaps, as various scholars contend, armed Jewish underground movements came into existence in five to seven of the large Polish ghettos, forty-five smaller ones, five death or concentration camps in Poland, and eighteen forced labor sites, but even so, their ultimate effectiveness was slight. On the whole, the Jewish response to the Nazi onslaught was to comply with German demands and orders in hopes of preventing them from getting worse.\n\nCOMPLIANCE AND RESISTANCE\n\nTowering figures in the study of the Holocaust, notably Raul Hilberg and Hannah Arendt, have addressed the matter of this Jewish response in highly provocative form. The very first page of Hilberg's monumental _The Destruction of the European Jews_ , both when first published in 1961 and again when an expanded third edition appeared forty-two years later, speaks of \"the Jewish collapse\" in the face of the Nazi assault and calls this \"a manifestation of failure.\" He goes on to argue that the efforts of Jewish communities to sustain themselves, to maintain order, and to placate the Nazis actually helped the Germans to achieve annihilation. Hannah Arendt's famous work of 1963, _Eichmann in Jerusalem_ , pushed this point further. She called \"the role of the Jewish leaders in the destruction of their own people . . . the darkest chapter of the whole dark story.\" In her opinion, \"without Jewish help in administration and police work . . . there would have been either complete chaos or an impossibly severe drain on German manpower.\"\n\nThe charge by both Hilberg and Arendt has two parts. The first is that Jews did not resist because the only meaningful resistance would have been armed action, in which relatively few Jews engaged. The second is that Jews actually made things worse by trying to survive in ways other than fighting. The Israeli historian Yehuda Bauer has rejected both arguments emphatically. He defines Jewish resistance as any undertaking designed to frustrate the Germans' purpose of harming or killing the Jewish people. He invokes the Hebrew word _amidah_ to describe the many forms this unarmed resistance could take, from smuggling food to organizing schools and cultural events, and he insists that all of these actions were the best Jews could do with a hopeless situation, a testament to their dignity and will to live against enormous odds. Bauer is determined to avoid blaming the victims for their fates, and if that means he sometimes stretches the definition of resistance to include ordinary acts of self-preservation, his position is nonetheless preferable to Hilberg's and Arendt's. Their harsh accusations have not stood up to historical analysis over the past forty years. Above all, they underestimate the forms of resistance that Jews participated in, and they overestimate the possibilities of armed resistance or even noncooperation that were available to Jews, either upon initial contact with the Nazis or later.\n\nWith regard to the underestimation, Hilberg is probably right that the Germans lost no more than a few hundred men, dead and wounded, in the course of the destruction process, and that one cannot identify many incidents in which Jewish resistance appreciably slowed or impeded the killing machinery. Still, up to 25,000 Jewish fighters operated in Lithuania, Belarus, and the occupied Soviet Union, and several thousand more in the mountains of Greece and Yugoslavia. Diverse estimates describe the share of Jews among French resistance fighters as declining from 40 percent early in the occupation to 15\u201320 percent later, partly as a result of attrition, partly because more non-Jews began to take up arms. At either figure, the overrepresentation of Jews in comparison to their proportion of the French population (less than 1 percent) is striking. Jews in Charles de Gaulle's Free French Forces were six times more numerous than predicted by that figure. These are not huge numbers, but they are not nothing, either. Even so, Benjamin Ginsberg, the author of _How the Jews Defeated Hitler: Exploding the Myth of Jewish Passivity in the Face of Nazism_ , apparently knows that such statistics are not enough to make his case. He includes Jews in the American, British, and Soviet armies and intelligence services among his Jewish resisters, which is rather like moving the goalposts, since these people were not subject to anything like the same constraints, were not generally acting as Jews but rather as parts of national war efforts, and were not necessarily volunteers.\n\nTo understand the degree of overestimation, one has to begin by looking at how the Germans proceeded against the Jews in occupied Eastern Europe, where the bulk of the killing occurred. In the first place, the Nazis applied in remarkably short order all the lessons they had learned from the persecution of the German and Austrian Jews in prior years. Even before the conquest of Poland was complete, on September 21, 1939, Chief of the German Security Police Reinhard Heydrich directed his subordinate offices in occupied Poland to enforce \"the concentration of the Jews from the countryside into the larger cities. . . . which either are railroad junctions or at least lie on railroad lines.\" So far as possible, responsibility for the implementation of not only this policy but also all subsequent German orders regarding the new areas of residence was to be imposed upon Jewish Councils of Elders ( _Judenr\u00e4te der \u00c4ltesten_ ), modeled on the body that the Nazis had created in Vienna in 1938 and composed of community leaders. Six days later, as we have seen, Heinrich Himmler, acting as head of the SS and of the German police, created the Reich Security Main Office under Heydrich and entrusted him with overall responsibility for the Jewish question. Within this organization, Adolf Eichmann, who recently had supervised the fleecing and expatriation of thousands of Austrian Jews, assumed control of the \"Jews Department\" that was to handle the logistics of the incipient ghettoization.\n\nIn short, less than one month after invading Poland and adding approximately two million Jews to its realm, the Nazi regime had devised a system of segregating these people from the surrounding population, positioning them for swift roundup later, stripping them of all their immovable and most of their movable property in the process, and turning the leaders of their communities into the executors of German policy.\n\nThis last feature of German policy, the assignment of responsibility for carrying out German instructions to Jewish Councils, was a diabolically effective means of minimizing the resources Germany would have to use to police the Jews and making them complicit in their own persecution. In effect, the Nazis applied the tried-and-true colonial practice of indirect rule through favored natives who got privileges or exemptions from punishments in exchange for helping to control everyone else. This tactic of dividing and conquering turned out to be almost impossible to resist, because it was coupled with force. When the first Jewish Councils were appointed in towns and villages, often before ghettoization had begun, those who declined to carry out distasteful or cruel German orders were simply shot on the spot; sometimes the first round of council members was shot for no reason other than to intimidate the members of the second round. In Lodz, for instance, twenty-two of the first thirty council members were killed to set an example. Serving on the councils and executing German orders were the first iterations of the \"choiceless choices\" (Lawrence Langer) with which the German occupation repeatedly confronted Jews. The appointees could refuse and die now or consent and perhaps die later or not at all. Almost everywhere, the designated members of the councils, like the inhabitants of the ghettos as a whole, chose the latter and played for time.\n\nAlthough the Germans conceived of the ghettoization program rapidly, they translated it into practice in Poland unevenly and haltingly. Events moved fastest in the regions annexed to the Reich, namely eastern Upper Silesia, West Prussia, and the Warthegau. The last-named included the city of Lodz, which became, on May 1, 1940, the site of the first large-scale ghetto to be sealed off from the outer world. Initially with 163,177 residents crammed into 2.4 square miles of a slum district that mostly lacked indoor plumbing and sewers, the Lodz ghetto became, under Hans Biebow, its German administrator, and Chaim Rumkowski, its Eldest of the Jews, the most self-sustaining and the longest-lasting of the Jewish population centers, even though it was now officially within Germany. In contrast, Warsaw's ghetto in the General Government was not closed off until November 1940, and its staggering congestion\u2014by March 1941, more than 460,000 Jews were confined to less than one square mile\u2014made it less manageable and more lethal. Further to the east, in Lublin, the gates did not shut on some 40,000 Jews until April 1941, and the permeability of the ghetto boundaries remained much greater. This was also the case at many of the smaller sites and even at Czestochowa, the second largest ghetto in the General Government. In fact, in the many villages of the largely rural Lublin district of the GG, a majority of the Jews were still in their own homes in 1942.\n\nThe variability of ghettoization had a number of causes. The chaotic and contradictory nature of German population policy in Poland slowed implementation, as did shortages of personnel and transportation. German administrators squabbled about whether and how ghetto inmates were to be kept alive and thus about how much trade they could do with their environs and with the occupying regime. Among the SS men put in charge of the ghettos, the group scholars call \"attritionists\" thought that the inhabitants should just be allowed to die off, whereas the so-called productionists encouraged economic activities by which the ghettos could earn their keep. Above all, no German planner seemed to know how long the ghettos were to last and where the denizens someday were to be sent. Nazi leaders spoke consistently of eventually consigning the Jews to a \"reservation\" but kept changing its location. With each change of venue came a deferral of deportation and thus, among the German occupiers, a declining sense of urgency about completing the ghetto system\u2014but also declining patience with its existence.\n\nAmong the Jewish inhabitants, the result was the opposite: The longer the ghettos lasted, the more the illusion of their permanence developed, and people settled into the hope that they could create sustaining institutions that could preserve at least some share of the population. By early January 1942, before the liquidations began, the populations of the Lodz and Warsaw ghettos were about the same size as when their gates closed in May and November of 1940, respectively. As figure 5 indicates regarding Lodz, new arrivals had offset thousands of deaths from starvation and cold, especially from the three predominant diseases in the ghettos: tuberculosis stoked by hunger and dank conditions; typhoid caused by contaminated food or water; and typhus or spotted fever, spread by the ubiquitous lice. Although conditions were wretched, the possibility of sustenance seemed real, at least for those who had money, jobs, or positions in the ghetto administration. Such prospects became weapons in the hands of the Germans, however. Subjected to ever-mounting scarcity, Jews were pitted against each other in the struggle for food, clothing, shelter, and sheer survival, and their ability to sustain one another both materially and morally eroded steadily. On May 30, 1942, Dawid Sierakowiak, an eighteen-year-old boy trapped in the Lodz ghetto, recorded one of the more extreme consequences in his diary, as he told of how his own father seized and ate both Dawid's and his mother's bread rations, and then devoured all of the family's small allotment of meat and whey. If even family ties snapped, imagine what happened to solidarity among unrelated people.\n\nFIGURE 5: THE FATE OF A GHETTO: LODZ, 1940\u201344\n\nDATE| POPULATION| DEVELOPMENTS  \n---|---|---  \nMay 1, 1940| 163,177| Ghetto sealed; in an area of only 2.4 square miles, the Jewish population exceeded that of either Bohemia-Moravia or the Netherlands when World War II began.  \nMarch 31, 1941| 150,436|   \nMay 1, 1941| 148,547| On October 9, the daily mortality rate dropped to its lowest point to date: 11. From 16 October to 3 November, 21 transports arrived, bringing 19,883 Jews from Germany, Austria, and Bohemia.  \nJanuary 1, 1942| 162,681| \"Resettlement\" began on 16 January; 55,000 people deported by the end of May.  \nJune 1, 1942| 104,469| More than 15,000 people sent to Chelmno in the second large round up, September 1942.  \nJanuary 19, 1943| 87,164|   \nJuly 1, 1943| 84,495|   \nFebruary 8, 1944| 79,777|   \nJuly 1, 1944| 73,217| Liquidation of the ghetto began on 23 June.  \nJanuary 19, 1945| 877|\n\nApproximately 45,000\u201350,000 of the people who entered the ghetto died of starvation, disease, brutality, or some combination of those causes in a period of forty months. At least 140,000 were massacred, mostly at Chelmno but in the final stage also at Auschwitz, during the nine months when deportations took place (January to May and September 1942, and June to August, 1944).\n\nInternal disunity among Jews aggravated the situation. They were even more divided in the ghettos than were the Jews in Germany during the 1930s, though along somewhat different lines. The major cleavages ran between (1) the secular, socialist, nonseparatist, primarily urban populations associated with the Bund (Alliance) Party; (2) the Zionist groups, which splintered among religious, secular, general, revisionist, and Marxist factions; (3) the traditionalist Orthodox groups; (4) the ecstatic Hasidim; and (5) a smattering of communists. All of these strains of opinion had their own institutions, networks, and longstanding difficulties in communicating with each other, and their differences did not disappear in the crucible of Nazi persecution. Indeed, as ghetto communities tried to decide on the proper response to the German onslaught, groups took divergent positions. Unlike Zionists, Bund members generally rejected service in the ghetto administrations, but also discouraged attempts at overt or armed resistance, unless these occurred in partnership with gentile groups outside the ghettos. Generational differences overlaid the political and religious ones, with the various forms of Zionism, especially the more militant ones, gathering a growing following among younger ghetto inhabitants.\n\nFinally, class and regional conflicts arose: Working-class Jews tended to resent the dominance of middle-class and elite professionals in certain councils; people who had been sent to ghettos from elsewhere sometimes felt disadvantaged by the original residents, especially in obtaining favorable work assignments. Professionals felt a loss of status unless they could obtain positions in the ghetto administrations, while a frequently ostentatious clique of nouveau riche smugglers and traders sprang up and aroused envy. Even before the deportations began, gradations in wealth and status frequently made the difference between survival and starvation. According to Mordechai Lensky, a physician who survived the Warsaw ghetto by escaping in the nick of time with his family to the \"Aryan side\" of the city, \"When deportations started in July 1942 . . . the community's social structure disintegrated [and] the upper economic and social classes sacrificed the lower classes to save themselves.\"\n\nInternal competition to survive was perhaps the strongest impediment to organized resistance within the ghettos, but it was not the only one. Just as the Germans staggered or spaced out the formation of ghettos and thus prevented Polish Jews from grasping exactly what was happening to them in 1940, so were the liquidations of the ghettos done in such a fashion during 1942\u201343 that word of them spread slowly, and Jews could not immediately recognize that wholesale massacre was unfolding. Deportations from Lodz and Lublin, at opposite corners of German-dominated Poland, began in early 1942, but Warsaw's turn did not come until the summer of that year, and Bialystok's not until February 1943. There followed the liquidation of Cracow's ghetto in March, Lviv's in June, Minsk's and Vilna's in September, Riga's in November 1943, and finally the ghettos of Kovno and Lodz in the summer of 1944. Even when inhabitants of one place got wind of murderous events in another, people could cling to the hope that their fate would be different and continue to play for time. The same delusion operated even within ghettos once the liquidations began, because they were carried out in phases, as figure 5 (above) shows in the case of Lodz.\n\nThe urge to grasp at straws of hope was powerful within the ghettos because mass murder seemed not just unimaginable but downright irrational. Why would the Germans kill people who could be useful, especially in those ghettos that set up productive workshops and factories? This conviction that the Germans would not act against their own interests has much to do with the remarkable refusal of ghetto residents in both Lodz and Bialystok to believe that deportees were being killed, even after the trains that took them away returned to the ghettos with the clothing and personal identification cards of inhabitants who had left only recently. Calel Perechodnik, who served for a time as a Jewish ghetto policeman and later briefly as a resistance fighter, left behind at his death in 1944 a remarkable testament that includes this vivid passage conveying the extent of Jews' denial in his little town in central Poland at the beginning of 1942:\n\nThey say . . . that in Slonim they gathered in the town square fourteen thousand people\u2014women, children, men\u2014and all were machine-gunned.\n\nI ask you . . . is it possible to believe such a thing? To shoot without reason women, innocent children just like that in full daylight? After all, even the worst female criminal cannot be sentenced to death if she is pregnant\u2014and here they apparently killed small children. Where can you find people, fathers of families, who would have the courage to aim their machine guns at helpless, small children? Where is the opinion of the cultured world? . . . How can the world remain silent? It is probably not true.\n\nFollowing this news comes another one, even more monstrous: In Wilno [Vilna], they killed sixty thousand people; in Baranowicze, twenty thousand. People stop understanding this; in truth, they believe it, but they can't visualize that one day someone can come to murder my two-year-old daughter, who scarcely can talk yet, only because she was born to a Jewish mother and Jewish father.\n\nFinally, we hit on an explanation. Those Jews were killed because they were Soviet citizens and probably because they fought against the Germans. But we are citizens of the _General Gouvernement_ ; such a thing cannot happen here. Moreover, there is martial law there, whereas here we have a civil administration.\n\nIn the space of these four paragraphs, disbelief turns into discounting, as people desperately sought and found ways to immunize themselves to the rumors that flew.\n\nWhat else stood in the way of organized resistance to the deportations, once they began? First, the Nazis went to great lengths to camouflage what they were doing. Sometimes they exempted the ill and hospitalized ghetto residents from deportations in order to imply that the people being shipped out really were going to work camps further east; sometimes they made a great show of exchanging local or ghetto currency for other forms of money before people got on the trains; and sometimes the Germans even sent postcards back to the points of departure, supposedly from recent deportees, to reassure those left behind about the destinations. This was a particularly common practice with regard to deportees from Western Europe; most of the cards were postmarked from Leipzig in Germany, but some even came from Auschwitz and Birkenau.\n\nSecond, the Nazis mixed the carrot and the stick, bait and threats, to assure compliance with deportation orders. Soup, bread, and jam were offered at assembly points and prospective deportees were told they could have certain privileges with regard to baggage and rations if they showed up when ordered to, but that these would be taken away if they failed to appear. Conversely, Adam Czerniakow, the Jewish Council head in Warsaw, was told that his wife would be shot if he impeded deportations in any way; Joseph Parnes, a Jewish leader in Lvov, was killed when he declined to designate people for deportation to a labor camp. In Amsterdam, the Nazis told the Jewish Council that failure to cooperate in the deportations \"for labor in the East\" would result in shipment to concentrations camps such as Mauthausen instead, which initially sounded much worse.\n\nThird, the delegation of the dirty work to the Jewish Councils gave them an illusion of some control over what was happening and saddled them with responsibility to minimize the damage. In most ghettos, just as was the practice in Amsterdam and the Westerbork transit camp, the Nazis simply told the Jewish Council how many people to assemble for deportation on a given day and left the choice of the people, until the very end of most liquidations, to the council. In Warsaw, the SS demanded delivery of the first 6,000 people on July 22, 1942, and the same number by 4:00 every subsequent afternoon until further notice. We know in what sort of position this put the Jewish authorities in the Lodz ghetto because of a remarkable record of a visit by a German named Friedrich Hielscher in the spring of 1942. He talked with the head of the Jewish police, Leon Rosenblatt, who admitted to knowing that the deportees were being sent to be gassed and then spoke as follows:\n\nI have to choose people for this. If not, I will be shot. That for me would be a simple solution. What will they do then? The SS already told me. Then _they_ will choose. That is, the strong ones, the pregnant women, the Rabbis, the learned ones, the professors, the poets\u2014they will be the first for the oven. But if I stay where I am, I can take the volunteers. Often they demand to be taken, and sometimes I have as many as I have to deliver, and sometimes they are few, and then I take the dying that Jewish doctors tell me about, and if these do not suffice, I take the seriously ill. If these, too, are not enough, what shall I do? I can take the criminals. . . . Who will be the judge? I asked the heads of the community, the Rabbis, the learned people; all of them said: You did the right thing by staying at your post. . . . Tell me\u2014should I remain at my post, or should I prefer to be killed?\n\nThe same logic of \"better us than them\" propelled the conduct of Abraham Asscher and David Cohen, the co-chairs of the Jewish Council in Amsterdam, when confronted in May 1943 with a German request for a list of 7,000 council employees (about 40 percent of the total) who were to be deported next. Ignoring the pleas of colleagues to destroy their central card registry of all remaining Jews rather than comply, the council leaders and some staff members worked frantically for two straight days and nights to designate and provide the names.\n\nRosenblatt, Asscher, and Cohen may have thought that they were adhering to Jewish religious law, but they were not. According to David Daube's careful examination of pertinent passages of the Talmud, handing over a person specifically demanded by name by an oppressive power is permissible as compliance with a threatening order, but handing over \"simply any odd person for execution\" is not because that involves choosing the victim and thus amounts to taking on personal guilt.\n\nThe most extreme example of the excruciating position in which German procedures put the councils occurred on September 4, 1942, when Chaim Rumkowski addressed the assembled ghetto population in Lodz:\n\nA severe blow has befallen the ghetto. They are asking from it the best it possesses\u2014the children and old people. . . . I never imagined that my own hands would have to deliver the sacrifice to the altar. In my old age, I must stretch out my hands and beg: Brothers and sisters, give them to me! Fathers and mothers, give me your children! . . . Yesterday during the day, I was given a command to send twenty-odd thousand Jews out from the ghetto; if not\u2014\"We will do it.\" And the question arose: \"Should we take it over and do it ourselves, or leave it for others to carry out?\" But being dominated not by the thought \"How many will be lost,\" but by the thought \"How many can be saved,\" we, i.e., I and my closest co-workers, came to the conclusion that as difficult as this will be for us, we must take into our own hands the carrying out of the decree. I have to carry out this difficult and bloody operation. I must cut off limbs in order to save the body! I must take the children because, if not, others could also, God forbid, be taken. . . . One needs the heart of a bandit in order to ask for what I am asking of you. But put yourself in my position and think logically, and you yourself will come to the conclusion that you cannot act differently because the number of the portion that can be saved is much larger than the part that must be surrendered.\n\nThis passage illustrates how perfectly and diabolically the system of divide and conquer worked, and so do the lists of people excepted from the initial deportation orders and from all others prior to the very end. Most of these were people performing valuable labor functions for the Germans, but two other groups were conspicuous among those exempted: people who worked for the Jewish Councils in the administration of the ghettos, of whom there were almost 13,000 in Lodz and 6,000 in Warsaw, and members of the Jewish Order Service, the police force in the ghettos, who totaled 800 men in Lodz and 2,000 in Warsaw. Some of the police were recruits from the prewar Jewish communities of these cities, but most had arrived from elsewhere and thus had few local ties to inhibit them. Joseph Szerynski, the head of the Jewish police in Warsaw, had converted to Catholicism, did not consider himself a Jew, and had no bonds with the local community. He and his men were so hated that the underground in the ghetto wounded him badly in an attempted assassination and succeeded in killing his successor. Paid little or nothing, ghetto policemen became increasingly corrupt and extortionist, demanding bribes to keep people off the lists for forced labor or deportation or routinely seizing attractive possessions. When the final stages of a liquidation arrived, and the Germans began instructing the councils not to select the deportees by name but rather to round them up from particular portions of a ghetto that were being cleared, these police did the footwork in most cases. They did so on the calculation that they and their families would remain alive as long as they were useful, and the Germans sometimes deceptively promised that they would survive even longer. The same motives account for the cooperation of the Jewish _Ordedienst_ from the Westerbork camp in rounding up Jews in Apeldoorn and Amsterdam in 1943 and in loading and sealing the deportation trains from Holland in 1942\u201344. And the _Ordedienst_ men shared the distancing social profile of their counterparts in the Polish ghettos: About half of them, including their commander, were not Dutch Jews but German or Austrian Jewish refugees in the Netherlands.\n\nA fourth impediment to resistance was the weakened condition of the ghetto inhabitants, which is something that cinematic depictions of the Holocaust generally cannot convey. Usually, as in Lodz and Kovno, the Germans sited the ghettos in the most miserable parts of a city, without sewers or much running water. Daily food intake for most ghetto inhabitants, aside from the privileged ones who worked in the administration or war production, hovered between 400 to 1,000 calories per day; in the largest ghettos, it usually averaged far less; in Warsaw in 1941, the daily allocation per person was between 180 and 220 calories. In Perechodnik's ghetto at Otwock, most of the 14,000 Jews barely subsisted in early 1941 on a weekly ration of 1.5 pounds of bread per person; there was no allotment of meat, eggs, or vegetables. Hunger, rampant disease, cold, filth, overcrowding, and enervation all took terrible tolls and undermined any desire to fight back. By July 1941, 5,550 people were dying in the Warsaw ghetto per month, almost 200 per day. One hundred thousand Jews died in the ghetto between its inception and the onset of the great deportations in mid-1942. The Germans designed the ghettos to confirm the picture of Jewish degradation, dirtiness, and disease that Nazi ideology posited; they were in this sense the fulfillment of an ideological prophecy, and cramming people together was part of the plan. In Warsaw, for instance, the ghetto inhabitants outnumbered the available rooms 7 to 1, and the population density worked out to 200,000 people per square kilometer in April 1941; in Kovno, 30,000 people lived where 7,000 had previously, in Vilna, 29,000 where 4,000 had. Under such conditions, people often lost the ability to think ahead, and those ghetto inhabitants who still could do so generally calculated that endurance was preferable to resistance or flight because of concern about family members and dependents who would be put at risk. Fleeing from the ghettos was also not an appealing prospect for most people because the topography of Poland was not conducive to hiding, and neither were the prevailing attitudes among the surrounding non-Jewish population.\n\nFifth and finally, the viciousness of the reprisals the Germans took was a powerful deterrent to resistance. These occurred not only in the form of individual beatings and shootings but also at the collective level. After all, putting aside the heroism of the people who launched the Warsaw Ghetto Uprising, the military balance sheet of trying to fight the Germans was catastrophic. In the course of suppressing the uprising, the Germans and their auxiliaries suffered somewhere between 110 casualties (seventeen dead and ninety-three wounded, according to the official figures) and three times that many (according to the resisters). Either way, the figure is tiny compared to the 56,065 people the Germans captured or killed. A few weeks later, the poorly prepared, more spontaneous resistance against the German drive to empty the Bialystok ghetto resulted in exactly nine German soldiers wounded, compared to the deaths of about 30,000 Jews either in the fighting or as a result of deportation to Auschwitz and Majdanek. Also in August 1943, the attempted breakout at Treblinka enabled only fifty to seventy inmates to survive the war. The camp uprising at Sobibor that October led to the deaths of only eleven or twelve SS men and two _Hiwis_ and the survival of only forty-seven inmates out of the 650 or so present when the fighting began. Moreover, the price of these events was Operation Harvest Festival in the fall of 1943, when Himmler ordered the liquidation of nearly all the remaining Polish work camps and ghettos in reprisal for these acts of Jewish resistance and as a sure method of preventing more of them. The shooting on November 3\u20134, 1943, of 42,000 Jews in the Lublin district, most of them at Majdanek and nearby Poniatowa, constitutes the largest single massacre of the Holocaust. At Poniatowa, one men's barracks tried to resist; the Germans locked the doors from outside and set it on fire, incinerating everyone inside. The only known survivors of those two days of killing were three women who had been left for dead in a mass grave. Only lightly wounded, they crawled away under cover of darkness, received succor from a Polish woman, and lived to see the end of the war.\n\nGiven all these circumstances, about the only effective form of resistance the Jews in ghettos could exercise in the short run was to defeat the Nazi effort to starve them to death. The principal way of doing this was through smuggling, and both the Warsaw ghetto administration and individual informal networks developed that into a fine art, which undoubtedly prolonged the lives of many people. Smuggling could not stop deportations once they began, though it sometimes became a means of helping individuals escape the trains. Otherwise, the only other form of resistance that offered a prospect of success was itself an expression of hopelessness. This was the attempt in almost all ghettos to leave a record of the Nazi crimes and a proof that the Jews had existed and struggled to survive. Both at Warsaw and Lodz, networks of people collected and hid extensive archival records and compiled a chronicle of the major events in the ghetto's history. Emanuel Ringelblum, a historian, and an organization called Oyneg Shabes, independent of the ghetto administration, did this work in Warsaw and buried the resulting documents under basements in the ghetto, where most of them were recovered after the war. At Lodz, the chronicle was the work of historians in an official ghetto archive that the Jewish Council established, and about two-thirds of these records were unearthed under various ghetto buildings after 1945. Along with a number of surviving individual diaries, these are our primary sources of information on the internal conditions of the ghettos during the Holocaust.\n\nPerhaps the most conclusive demonstration of Jews' limited ability to affect their own fates, whether they chose to resist or not, is that several Jewish ghetto administrations adopted different survival strategies, different mixes of compliance and resistance, but regardless of what they chose, they ultimately came to the same end. In Warsaw, Adam Czerniakow, the head of the Jewish Council, followed a strategy of placating the Germans until he realized that they intended to kill all the ghetto inhabitants, so he committed suicide in July 1942 rather than cooperate further. His act did nothing to head off the massacres of most of Warsaw's Jews that summer and of the last remnant in May and June of 1943. In Vilna, Jacob Gens, the head of the Jewish Council, tried to walk both sides of the street, providing the Germans labor and cooperation but also aiding the resistance in and around the city. The Nazis nevertheless liquidated the Vilna ghetto without interference from that resistance in September 1943. In Minsk, the two ghetto leaders Eliyahu Mushkin and Moshe Yaffe did not defy the Germans, but they were among the Jewish Council leaders who were most supportive of armed resistance, perhaps because some 10,000 Jews were actively fighting back in the nearby forests of Belarus. Still, that availed them little as the ghetto's population dropped from 100,000, in October 1941, to 12,000, in August 1942. By then both men were dead, too, and what was left of the ghetto was liquidated in October 1943. Finally, Chaim Rumkowski, the Jewish Council leader in Lodz, was the most persistent proponent of satisfying the Germans' every whim as the only way to survive. The strategy probably helped his ghetto endure longer than any other one, but it did not prevent the liquidation of its last 70,000 inhabitants in August 1944. In short, whatever the Jewish leaders did\u2014kill themselves, aid the resistance, appease the Nazis\u2014the outcome was the same. Historian David Silberklang's judgment, on the basis of studying hundreds of ghettos in the Lublin district of the General Government, holds throughout Eastern Europe and probably throughout the continent as a whole: \"No Jewish action caused any significant difference for large groups of people in terms of survival, though certain actions could make a difference for individuals.\"\n\nThe Jews had almost no control over their collective fate. Individuals could flee to the forests in some cases and try to survive, but whole communities could not. Neither could they devise a strategy that could accomplish anything more than to delay their deaths. It is unfair and inaccurate to hold the Jewish victims responsible for what happened to them. Whether they lived or died depended on two things alone: the actions of the Nazi regime and the progress of the Allied armies.\n\nTwo incidents\u2014one of resistance and one of compliance\u2014demonstrate this emphatically. The first, already discussed, is the Warsaw Ghetto Uprising of 1943, which failed utterly because it could not withstand the armed might the Nazis could bring to bear. The second illustration of the dependence of the Jews on the progress of the Allies is the fate of the Lodz ghetto. When its liquidation began, Soviet forces stood only seventy-five miles away to the east, where they had stopped their offensive at Warsaw in order to regroup and resupply their forces and to allow the Nazis to crush a rising that Polish nationalists launched in the city as the Red Army approached. Stalin planned to install a communist government in Poland after the war, and he thought that the suppression of this rising by the Germans would make that goal easier to achieve. Had he not made this cynical calculation and instead quickly resumed his military advance, the Germans probably would not have had time to liquidate the remaining Jewish population in Lodz, and Rumkowski's gamble of exchanging Jewish compliance with Nazi wishes for long-term survival might have paid off. Of course, the Nazis might have marched the survivors west, and many would have died in the process, which is what happened in July 1944 to the inhabitants of Kovno, the only other remaining ghetto of significant size. But the number of people to emerge from the Lodz ghetto alive at the end of the war probably would have been larger than turned out to be the case. Throughout the Holocaust, the Jews were at the mercy of the decisions of others.\n\nLeo Baeck, the rabbi and leader of the German Jews who ultimately survived the war in Theresienstadt, knew this, and his knowledge informed his most controversial decision. Even after he learned that most Jews were being gassed or shot, he refused to admit what he knew to the people around him and persisted in concealing their likely fates. Why? Because he believed that \"living in the expectation of death . . . would . . . be . . . harder\" than living with an illusion. His position may have been highly humane, but it was also debilitating. As the late dates of the ghetto and camp uprisings show, hope of surviving was the enemy of fighting back. So long as hope remained, people generally chose not to charge the German guns and urged their fellow Jews not to do so lest that provoke reprisals. Everywhere, Jews took arms only when they knew the alternative already was certain death.\n\nIn May and June of 1944, Hungary's Jewish leaders, principally Samu Stern, the head of the national Jewish Council that had come into existence when Germans occupied the country that March, similarly learned of what was happening at Auschwitz and chose to keep the information to themselves as the deportations from the Hungarian countryside began. Stern believed he was \"running a race against time,\" in which his job was to keep at least some Jews alive until the progress of Germany's enemies cut off the transports. For Jews to survive that long, he insisted they had to obey the authorities, and to make sure that Jews did, he withheld from them his knowledge of the fate that awaited those who boarded the trains. The result was the almost complete and almost completely unresisted annihilation of Hungarian Jewry, as the Nazis deported faster than the Russians advanced.\n\nIn assessing Jewish resistance to the Holocaust, some comparisons are instructive. Did any other persecuted group act more forcefully as the Holocaust proceeded? Consider the behavior of the 5.7 million captured Soviet prisoners of war, 3.3 million of whom died in German captivity, a mortality rate of 58 percent. Confined to prison camps or labor brigades, the survivors staged no important uprising until the very end of the war, even though they, unlike the Jews in the ghettos and occupied states, consisted almost entirely of young men with military training. Or consider the behavior of the occupied European peoples, among whom resistance movements generally became significant only after Stalingrad, by which time most of the European Jews already were dead. Even in 1943\u201344, according to the most authoritative estimate, only 2 percent of the French population consisted of active resisters. Finally, in assessing the conduct of the Jewish Councils, bear in mind that the Dutch civil servants who remained at the head of ministries in the Netherlands protested the deportations and threatened to resign if they continued but never could summon up the courage actually to do so. Instead, Dutch police, along with Dutch transport and railway workers, frequently helped the Germans carry out their plans.\n\nWhere resistance movements flourished, they generally had four advantages: favorable topography in mountainous and\/or heavily forested places like Yugoslavia and central France; sympathetic local populations; trained military veterans of the sort that the Germans usually killed upon arrival in the East; and equipment supplied by the Allies. The Jews of the ghettos, especially those in Poland and Ukraine, lacked all of these things.\n\nIn sum, why didn't more of them fight back more often? Because the odds were stacked against them, because they could not see or could not bear to see what was going to happen to them, because the slimmest chance that some might survive tempted them to avoid committing suicide by fighting back, and because they clung to life as best they could in ever more adverse circumstances. We have no right to expect or demand that they should have behaved more forcefully or heroically. They were, in the end, subjected to excruciating torture and confronted with \"choiceless choices\" in which all alternative courses of action seemed to present more danger than relief.\n\nLet me drive home this point about our obligation to withhold judgment with reference to a pair of iconic photographs that are reproduced in figure 6, the first of the little boy wearing a cloth cap and holding his hands up after being captured in the Warsaw ghetto, and the second of a group of Warsaw ghetto inhabitants being marched away by the Germans, with a young girl in the front row on the right. German photographers took both pictures, and they surfaced after the war in a few extant copies of an album made to commemorate the suppression of the uprising and later published under the title _The Stroop Report_ , using the last name of the German commander of that operation. Often overlooked because of the poignancy of these pictures is the most remarkable feature about them: that each shows the presence of a child under the age of ten as the ghetto was being liquidated. In fact, the first picture shows three or four more young children in the background. Yet the population of the ghetto had fallen from almost 460,000 at its peak in March 1941 to about 53,000 just before the Ghetto Uprising broke out in the spring of 1943; the corresponding figures for young children are from approximately 51,000 to fewer than 500, 255 boys and 243 girls. Moreover, the uprising occurred seven months after Rumkowski told the Jews of Lodz that they had to give up their children under the age of ten. The only children spared in Lodz were those of the Jewish policemen and firemen who helped round up all the others and those of the Jewish ghetto administrators. Almost certainly, the same was true in Warsaw, and the children you see in those two photographs are the offspring of people in or well connected to the Jewish Warsaw ghetto administration, people with enough clout there to shield their children from deportation, people who at the same time had benefited from the German exemptions and perhaps had helped organize the deportation of others, people who probably had argued against resistance so long as their positions gave them a chance of survival. We actually know who the girl was, unlike the boy in the first photo. Her last name was Neyer, and she is walking beside (from left to right) her mother, Yehudit, her paternal grandmother, and her father, Avraham, who was a member of the Bund Party and the only person in this family who survived the war. Now that you have the backstory of these children and what their parents may or may not have done, do you feel any less sympathy for any of them than you did when you first saw their images? I hope not.\n\nFIGURE 6: TWO PHOTOS FROM _T HE STROOP REPORT_\n\nCredit: United States Holocaust Memorial Museum\n\nImmediately after the Holocaust, its survivors had trouble understanding this point, not least because their pain was so fresh and their desire to imagine different outcomes so intense. Ad hoc Jewish Courts of Honor sprang up to unmask and punish alleged Jewish \"collaborators,\" especially former so-called _Kapos_ (who led work details) and members of Jewish councils or police forces. One such body in Italy convicted two former Jewish Council members in Lviv and Bedzin and banned them from \"any position in the public life of the Jews\"; a similar court in the American occupation zone of Germany handed down an identical judgment and penalty for a former Jewish Council member in Upper Silesia. In Amsterdam, another such court reached the same decision and imposed the same punishment in 1947 on the former co-chairs of the Jewish Council there, Abraham Asscher, who had survived Bergen-Belsen, and David Cohen, who outlived Theresienstadt. But a vote of the Permanent Committee of the Netherlands Israelite Church Organization vacated that decision three years later. Asscher died shortly thereafter, completely alienated from the Jewish community. Cohen continued defending his conduct until his demise in 1967, never abandoning the implausible claim that he first learned of the death camps after he got to Theresienstadt and thus did not know until then that the people on the deportation lists he compiled were almost certain to die.\n\nThe case of Rezso or Rudolf Kastner in postwar Israel was even more divisive, and its outcome more violent. A Zionist official in wartime Budapest who had helped Jews from elsewhere find refuge in Hungary, he knew by May 1944 that the Jews about to be deported from that country were likely to die, but he undertook no effort to warn them and instead began negotiating with Eichmann to let a limited number of them escape in return for cash payments. He thus managed to save 1,625 people, including several hundred from his hometown, his mother, wife, and siblings, and many dedicated Zionists. Because he was a parliamentary candidate of the governing Labor Party in Israel and the press spokesman for a government ministry, his conduct became an issue in Israeli partisan and identity politics. In 1952, an elderly journalist named Malchiel Gruenwald published a pamphlet attacking Kastner as a collaborator with the Nazis who had saved some of his family and friends in return for allowing the Hungarian Jews to cling to a false sense of security as they boarded the trains going northward. The Israeli attorney general insisted on suing Gruenwald for libel on Kastner's behalf, only to have the presiding judge conclude that Kastner had \"sold his soul to the devil . . . by deliberately avoiding his duty . . . to reveal to the Jews the fate awaiting them.\" The Israeli Supreme Court overruled that verdict by a vote of 4\u20131 in January 1958, on the grounds that Kastner's \"thoughts were directed to good and not to evil, to rescue and not to extermination.\" But the vindication was no help to Kastner, who had been assassinated ten months earlier.\n\nThe few surviving Jewish ghetto or council leaders who fell into the hands of the Soviet Union also faced summary justice. Moshe Kopelman, the Kovno ghetto Jewish police chief from 1941 to 1943, managed to escape as the ghetto was liquidated in July 1944. Captured two months later by the Red Army, he was tried for collaboration and sentenced to fifteen years of hard labor despite a plea for clemency from more than seventy other Kovno survivors. Almost exactly a year later, he died in a Siberian camp. The Soviets condemned Walter Lustig, the last leader of the remnant Reichsvereinigung in Berlin, as a collaborator and executed him in December 1945.\n\nAlthough such sentences came readily to Soviet judges, David Ben-Gurion, the first prime minister of Israel, struck a wiser note in two letters he wrote, one right after the final court verdict on Kastner, one almost five years later. He said, \"I would not take it upon myself to judge any Jew who was there. The Jews who lived in safety during the time of Hitler cannot judge their brothers who were burned and slaughtered or those who were saved. . . . The tragedy is deeper than the abyss, and the members of our generation who did not taste that hell would do best (in my modest opinion) to remain sorrowfully and humbly silent.\" As time passed, most Israelis came to accept Ben-Gurion's point. Although the Knesset, Israel's parliament, had enacted the Nazis and Nazi Collaborators (Punishment) Law in 1950, the last prosecution of a Jew for violating it occurred in 1964.\n\nTHE WORLD OF THE CAMPS\n\nOne cannot write about the Holocaust or about compliance and resistance without discussing the concentration camp system, but it is a confusing, dismal, and often inaccessible subject. It is probably also the aspect of the Holocaust about which people have the most misleading images in their heads, not least because most films dare not represent a reality that was so repellent, so the great majority are distortions. Probably the greatest offender of this sort is the Oscar winner _Life Is Beautiful_ , but even _Schindler's List_ misrepresented the Plaszow camp for artistically symbolic reasons (in reality, Commandant G\u00f6th's villa was somewhat below, not above, most of the camp site, and he aimed his rifle up, not down, at the prisoners).\n\nA great many types of camps existed, and a few, especially Auschwitz and Majdanek, combined all the different sorts. Indeed, the sheer number of camps is staggering. It used to be said that more than 1,000 of them dotted the German landscape by 1945. But if one includes all the sites identified by the United States Holocaust Memorial Museum, which is publishing a massive, multivolume encyclopedia of camps and ghettos, the number of camps established at one time or another in Germany and occupied Europe runs to about 40,000. They were, in short, neither rare nor invisible, but in fact constant, frequent presences across the continent and within the Reich. And they were not completely closed off from their surrounding areas but penetrable in many cases, and even sometimes visited and inspected by local dignitaries.\n\nAt the core of the system were camps established for political prisoners, people who were regarded as threatening or disloyal to the Nazi regime, at first in Germany (for example, Dachau, Buchenwald, Sachsenhausen, Gross-Rosen, Flossenb\u00fcrg, and Ravensbr\u00fcck) and then in the annexed and occupied regions (for example, Mauthausen in Austria, Westerbork in the Netherlands, Natzweiler in Alsace, Theresienstadt in Bohemia, Stutthof in northern Poland). Such installations and their satellites held fewer than 22,000 people when the war began in 1939 but then metastasized during the war until their population peaked at more than 714,000 in January 1945 (of this figure, 28 percent were women). Not including Jews, about 1.65 million people passed through the camp system between 1933 and 1945; about one million died. For Jews, the survival rate was far worse; at most, about 150,000 Jewish veterans of these core camps, probably fewer, emerged alive at the end of the war out of the nearly four million Jews sent there. From the camps dedicated solely to murder, the \"death factories,\" survival rates were infinitesimal: perhaps seven people sent to Chelmno and only two sent to Belzec\u2014all of them men\u2014were still alive when World War II ended.\n\nWithin the camps, a highly stratified system of indirect rule developed in which the Nazi officers were a feared but usually distant presence, and they delegated the management of the prisoners to privileged figures among them. These prisoner functionaries often occupy much more vivid\u2014and hated\u2014places in the memories of survivors than the SS personnel. _Kapos_ led work details, and a Block Senior or Elder ruled over each barracks. The SS usually selected these people from among the inmates incarcerated for political or criminal offenses. In fact, a hierarchy of prisoner categories developed in the camps, with each group clearly designated by the color of the triangles sewn onto their uniforms or clothing, next to each prisoner's identification number. Political prisoners wore a red triangle, criminals green, so-called asocials black, homosexuals pink, Jehovah's Witnesses purple, Sinti and Roma brown, and Jews yellow, sometimes by itself, sometimes in combination with a triangle of another color.\n\nIn the context of scarce food and grueling work, competition for favors was rife and corruption endemic. The reds, greens, and blacks fought a constant struggle to control the most important trustee assignments\u2014not only as _Kapos_ and block elders but also as clerical personnel in central offices, where a prisoner could gather important intelligence, and as workers in the kitchens, where an inmate could obtain extra food. Generally, when the reds were in charge, conditions improved, especially for fellow prisoners of the same political persuasion. Hermann Langbein, a political prisoner at Dachau, Auschwitz, and Neuengamme, has left a vivid account of the jockeying for position and its consequences in _People in Auschwitz_. But no matter who the trustees were, they were almost never Jews, who were at the bottom of the social pyramid, along with gays. Here, as in the ghettos, the lowest instincts of self-preservation were encouraged by the system of constant fear and deprivation, and survival seemed often to require sacrificing others.\n\nThis is probably where this book should address the matter of \"other victims\" of the Holocaust, even though doing so involves a partial digression from the central theme of this chapter. Up until now we have talked exclusively about Jews and the people with disabilities targeted by the T4 campaign as victims of the Holocaust, even though most museums and memorials in the United States also refer to the other groups that had their own camp triangle colors, especially the Jehovah's Witnesses (called by the Germans _Bibelforscher_ , Bible researchers), Sinti and Roma people (colloquially referred to as Gypsies), and gays. Although it is true that Nazism attacked these groups, it did not do so for the same reason it attacked Jews or with the same intensity or to the same extent. The Nazis did not consider any of these groups nearly as threatening to German power as Jews supposedly were and thus did not set out to kill every one of them. The Nazis also thought that the offenses of these groups were ones of behavior, not essence, so if they changed the offending behavior, they often were spared, whereas people of Jewish descent had no such option. Thus the Third Reich attacked Jehovah's Witnesses because they were pacifists; if they recanted and agreed to serve in the army, they were welcomed, though few, if any, took advantage of this opportunity.\n\nMost Sinti and Roma were racially impure in German eyes, but not all of them, so some were killed and some allowed to live. The Nazi regime even allowed some German Gypsies to remain in the German army into 1943; ultimately the Reich appears to have deported and killed about two-thirds of them and left one-third of them alone. In most of the occupied countries, the Gypsies rounded up were the itinerate ones; people with stable and continuous residences were not molested. Deportation rates of Sinti and Roma from Western Europe were thus not very high. Further east, inconsistency prevailed, but the proportion of the Gypsy population murdered was much lower than that of the Jewish population. Some 5,000\u20137,000 out of almost 12,000 Gypsies identified in the German-controlled Protectorate of Bohemia and Moravia by 1943 were put in camps and killed; in occupied and annexed Poland, the death rate appears to have been 8,000 out of 28,000; in occupied Serbia, 20,000 of 150,000; in Hungary, perhaps 30,000 out of 300,000. The most murderous place was the occupied Soviet Union, but even here policy varied by both time and place. Nearly all Gypsies died in the Crimea, but sedentary ones tended to survive further north, and Muslim Gypsies sometimes were treated differently than others, as was the case in Croatia. Two-thirds of Lithuania's Gypsies survived the German occupation, but virtually none of Latvia's or Estonia's did. As an indication of the arbitrary and capricious nature of Nazi policy toward Gypsies, consider the example of the six Roma deported from the border region between the Warthegau and the General Government in 1940 and sent to a labor camp at Belzec. Instead of being put to work and later gassed at the death camp that arose next door the following year, these Gypsies were released with a warning that they would be arrested again if ever found within Germany's borders without official permission. They lived not only to return to Germany after the war but also to petition a state government for restitution of lost property. Overall, then, the Nazis murdered Gypsies, including 20,000 of them sent to Auschwitz, but not systematically. Estimates of the death toll for all of Nazi Europe run from 200,000 to 500,000, but historians are not sure of the total population in 1939. The proportion that perished, however, was certainly well below the two-thirds figure for Europe's Jews, probably between one-fifth and one-quarter.\n\nThe treatment of gays was also far less harsh and sweeping as a rule than the treatment of Jews. In the first place, the Nazi regime cared almost exclusively about gay German men and their same-sex partners. The number of people prosecuted in occupied countries was tiny. In the Netherlands from 1940 to 1943, for example, only 138 court cases occurred, and those resulted in 90 convictions. The German legal prohibition on same-sex acts, Paragraph 175 of the Criminal Code, did not extend to women, so relatively few lesbians attracted the regime's notice and hostility. And, outside of Germany, the Nazis reacted positively when a client regime issued new regulations that criminalized gay male sex, as Vichy France did in 1942, but Germany did not pressure governments to do this; it did, of course, pressure them to deport Jews. Even inside Germany, persecution was uneven. The Nazi authorities estimated the number of gay males in Germany in 1933 at two million, or about 6.25 percent of the German male population of almost 32 million at the time. That population increased to almost 38 million by 1939, thanks largely to the annexations of Austria and what had been western Czechoslovakia, and the same percentage of that population works out to almost 2.4 million gay men. But the Third Reich arrested only 100,000 men under Paragraph 175 between 1933 and 1945, convicted only 50,000 of them, and sent only about 10,000 of them to camps, where 6,000 of them perished.\n\nThe gay men caught in this system suffered excruciating punishments, but they constituted a tiny portion of the target population. Why? Because the Nazis cared only about their behavior, not their nature. Himmler actually believed until at least 1943, when some documentary evidence suggests that he began to have his doubts, that most gay men were \"curable\" if given the right incentives. The goal was to eliminate their behavior among Germans through intimidation, punishment, and reeducation and, in so-called incorrigible cases of repeat offenders, castration or death. Put in contemporary phrasing, Himmler believed that most gay men could be \"scared straight.\" Killing them all was simply not necessary. It was even less necessary in the occupied countries, because the chief offense of a German gay man was non-procreation, but in the occupied countries, non-procreation of the native population was desirable. That is why the German authorities briefly toyed with the idea of decriminalizing sex among men in occupied Poland in 1939. A clear sense of what drove Nazi policy toward gay men comes across in the title of the Nazi organization founded in 1936 to conduct their persecution, the Reichszentrale zur Bek\u00e4mpfung der Homosexualit\u00e4t und Abtreibung, the Central Office for Combating Homosexuality and Abortion. Unlike the Jews, all gay men did not have to die because they were immutable enemies of the German _Volk_. Closeted gay German men could live; foreign gay men who stayed away from German civilians or military personnel were a matter of indifference to the Nazis.\n\nAll of this amounts to saying that Nazism targeted many groups, but it did not target them all in the same way. But if Jehovah's Witnesses, Gypsies, and gays did get caught up in the camp machinery, they had much in common with each other and with Jews. These groups were the most exploited, the ones treated consistently worst, and the ones with the fewest ways of bettering their situation.\n\nAnother group whose numbers in the camp system increased exponentially as time passed was Slavs, but they did not have a distinguishing color for their triangles, largely because they were usually considered \"political\" prisoners or \"asocial\" ones. Their presence has led some observers to lump them with other victims of the Holocaust, most famously in Simon Wiesenthal's formulation that the Holocaust had eleven million victims, six million Jews and five million others, mostly Slavs. But that number is fictional\u2014Soviet civilian casualties alone came to more than ten million people\u2014and not all Slavs were the same in German eyes. Nazi theory doomed some\u2014mostly Poles, Russians, and Serbs\u2014to ultimate extinction, but only over time, as German settlers multiplied and their need for native slaves in the conquered East declined to the vanishing point. Himmler's General Plan East foresaw the reduction of the Polish population by 85 percent, the Belarussian by 75 percent, the Ukrainian by 65 percent, and the Czech by 50 percent. But the Nazis considered other Slavs valuable \"racial\" allies, notably Bulgarians, Croats, Slovaks, and some Ukrainians. Hitler and Himmler even considered many Czechs and some Poles to be capable of \"Germanization\" ( _Germanisierung_ ), that is, of being turned into German speakers and racially assimilated.\n\nIn short, though the camps contained many different sorts of people, all of whom were subjected to terrible suffering, no other group was attacked as thoroughly and systematically as the Jews. And not even the population of Germany's mental institutions and sanatoria experienced a mortality rate comparable to that of Europe's Jews.\n\nIn discussing the camps, one must begin by remembering how people arrived at them: usually parched and starving, after train trips that lasted for days in stifling and overcrowded cars filled with often wailing, sometimes crazed people, many of them dying or already dead. The deportees from Polish ghettos endured all this after debilitating months of clinging to life under only slightly better conditions. Some of these people welcomed deportation as a relief, even when they feared the worst, and more or less embraced the German proverb \"better an end with horror than a horror without end.\" To put the matter bluntly, little fight was left in people who had been subjected to this sort of brutal treatment prior to and during deportation. To expect mass resistance on their part as they debarked at Auschwitz or Belzec or Treblinka is utterly to fail to imagine what they had been through.\n\nTo understand the behavior of people admitted to the camps, one needs to remember the fundamental observation by historian Michael Marrus that they were \"the most complete totalitarian structure to have been devised by man.\" Inmates were crushed beneath this structure, worn down by exhaustion, starvation, extreme heat and cold, and disease and wholly cut off from outside help. Any infraction of even the most trivial rules resulted in the application of the Nazi doctrine of collective responsibility\u2014vicious punishment of whole groups of inmates, not just those who had stepped out of line. The punishments included beatings and floggings, endless roll calls in all kinds of weather, group hangings, and two particularly gruesome acts: throwing people alive into the crematoria and in wintertime tying inmates to posts or to suspended ropes and spraying them with water, which turned to ice and froze the victims to death. Not for nothing did one survivor call Auschwitz \"a mixture of Hell and an insane asylum.\"\n\nThe inmates, like the inhabitants of the ghettos, were cowed and divided against themselves by the constant fear that any resistance to or even evasion of the Germans' mandates would provoke more suffering than was already prevalent. This has a lot to do with the hesitations that surrounded every underground organization in the camps and with their constant caution and changes of plan. For example, the inhabitants of the \"family camp\" for Czech Jews at Auschwitz, which lasted for several months, made elaborate preparations for launching an uprising at the moment when word came that gassing was imminent. But when it did come, the planners' will faltered because they feared harm to the children in a pitched battle. In the end, they went to the gas without incident.\n\nAll would-be resisters had to contend with the ubiquitous presence of spies, motivated by the prospect of extra bread or sleep or cigarettes or exemption from a selection in return for providing the German guards with information about plots. The prisoners also had to cope with their national and linguistic differences, which made coordination tense and communication difficult. And, as the Czech family camp example suggests, the Nazi guards were relatively few but vastly powerful, so highly intimidating. It is worth recalling that no camp rebellion ever really succeeded. Even at the very end of the war, on February 2, 1945, when 419 albeit much weakened Soviet POWs succeeded in breaking out of Mauthausen, the Nazi regime still hunted nearly all of them down. Only eleven were still alive when the war ended eight weeks later. We already have noted how few people survived the rebellions at Sobibor and Treblinka in 1943 and at Auschwitz in late 1944.\n\nThe only successful form of resistance in the camps was escape, although the odds were long. Only five people are known to have escaped Belzec, and the two of them who survived the war did not actually escape from the camp. Rudolf Reder got away when he was sent to a nearby town to collect building materials and left in the care of one sleepy guard while the rest went to dinner. Chaim Hirszman jumped from a train that was taking him from Belzec to Sobibor. Treblinka was more porous because its fencing was neither electric nor equipped with alarms, but only a handful of the dozens of people who got away survived for very long, either because they fled to ghettos that later were liquidated or because the Germans quickly recaptured them. The Germans surrounded Sobibor, on the other hand, with a minefield that made that camp particularly difficult to escape. At Auschwitz, the most extensively guarded of the death camps, prisoners made no fewer than 802 escape attempts, of which at least 144 succeeded. Jews, who made up half the camp's population in the second half of 1942 and a majority thereafter, accounted for only 115 of the tries (14 percent) and 4 of the known successes (3 percent). Those numbers tell a lot about the hierarchy, the gradations of treatment, and the limited role of Jews in resistance groups in the camps. At all of these sites, the reprisals for trying to escape were fierce, ranging from public beatings and hangings of recaptured prisoners or alleged planners of new attempts to the simple practice of killing ten inmates, or even every tenth remaining inmate, for each missing escapee. Such ratios might make the balance sheet of escape attempts seem problematic, except for one consideration: Escapees from the carbon monoxide death camps were virtually the only people remaining after World War II who could provide eyewitness testimony against the murderers and thus get some of them convicted and punished.\n\nWithin the camps, the Nazis could rely on three circumstances beyond firepower to retain complete control. The first was the way camp conditions were designed to strip people of their sense of dignity, indeed their sense of self, and to dehumanize them so that they became fatalistic and resigned. Everything from the insistence that inmates be addressed and identify themselves always by number, not by name, to the incessant verbal abuse by the _Kapos_ and guards, to the refusal to let people go to the latrines when in need, to the filthy and lice-ridden clothing and bedding\u2014all these things were intended to produce just such a degrading result. People so changed were called _Muselm\u00e4nner_ , which literally means Muslims, apparently because inmates who invented the term thought that Muslims were similarly accepting of all that happened to them. Once people lost the active will to live, they were useless to any potential resistance movement but also useless to the Nazis themselves, and thus destined for certain death. After the war, Hanna L\u00e9vy-Hass, who spent 1944\u201345 at Bergen-Belsen, recalled that camp life deadened people, even to their own memories. She wrote, \"We no longer even remember our own past. No matter how hard I strive to reconstruct the slightest element . . . not a single human memory comes back to me. . . . They've managed to kill in us not only our right to life in the present . . . but . . . all sense of a human life in our past. . . . I turn things over in my mind, I want to . . . and I remember absolutely nothing.\"\n\nThe second key weapon in the hands of the guards was their ability to drive inmates to exhaustion. That was the point of the long marches to and from work, the even longer hours at the labor sites, the assignments to ditch digging and industrial construction, the endless roll calls, the overcrowded bunks, and the compulsory calisthenics at the beginning or end of the workday, all coupled with malnutrition. Prisoners were made too exhausted to think, let alone to plan resistance efforts.\n\nA third instrument of the Nazi masters, some psychologists maintain, was inmates' awareness that they had been consigned to an arbitrary and negative universe through no fault of their own. This explains the powerful impact of the famous incident in which Primo Levi, a new arrival at Auschwitz, asks, \"Why?\" when faced with an act of unfathomable meanness and is told, \"Here there is no why.\" Though prisoners were right to think they did not deserve their fates, that knowledge often provoked self-pity and paralysis. Obsessing about the injustice of the situation and recognizing that the Nazis were impervious to persuasion led to despair and abandonment of the desire to survive.\n\nWho did survive, then? Broadly speaking, the late, the lucky, and the well connected. Those who entered the camps in, say, 1944 and were relatively (but not too) young had the best chance of emerging alive. So did those who drew fortunate labor assignments, such as the women sent to the Degussa subsidiary at Gleiwitz mentioned earlier in this book. And those who had allies in important trustee positions, which means that non-Jews survived more than Jews did. Non-Jews generally looked out for themselves and did little to aid Jews. Rudolf Vrba, who in April 1944 became one of the very few Jews who escaped from Auschwitz, recalled bluntly, \"the Resistance in the camp is not geared for an uprising but for the survival of the members of the Resistance.\" Even where a camp underground existed, it did little to impede the Holocaust. Auschwitz consumed 75,000 Poles, which is perhaps one-third of those sent there, but it took the lives of probably four-fifths of the Jews ever registered in the camp. If we include the unregistered Jews killed immediately upon arrival, then the mortality rate of Jews at Auschwitz was over 90 percent.\n\nOf course, we can never know the full reality of life in the camps or gauge accurately what it took to survive. In the first place, the evidence available is partial; it springs from the writings and testimony of people who did survive and thus may be skewed in some ways. What worked for them may not have worked for countless others, but we do not know how many tried the same methods and failed. In the second place, it is clear that survival was often arbitrary and purely fortuitous, a matter of having a skill the Germans desired at a certain moment, landing a particular work detail by some stroke of luck, or enjoying the favor of a key official in the camp or a pivotal _Kapo_ for some reason or as a result of a whim on that person's part. Zev Weiss survived Auschwitz, he says, because he sensed something fishy about a particular assembly call for his barracks, so he wriggled through a crack in the wall of that building, mingled with another barrack's population, and got himself registered there in place of a missing or dead prisoner, which actually was a not uncommon form of camp resistance activity. To this day, he cannot say what made him act as he did at that moment, but he is sure it saved his life, because the call to assemble led to the gassing of nearly all the population of the barracks he had fled. As G\u00f6ran Rosenberg, whose parents both survived Auschwitz, notes, \"There are no roads from Auschwitz but those of improbability.\"\n\nThe most persuasive insights we have on this subject are still those of Terrence Des Pres, in _The Survivor_ , published in 1976. Des Pres saw four key elements that determined who outlived the camps. The first was discovery of purpose\u2014bearing witness. Recording daily events helped inmates both to preserve senses of the future and of hope and to transcend the horror around them. Thinking ahead also was an act of resistance; the Nazis repeatedly mocked the inmates by saying that no one would ever know what had happened to them. Simply proceeding as if the Nazis could be proven wrong may have helped inmates maintain a will to live and a self-respect born of their defiance of anonymity.\n\nA second determinant of survival was the recognition that preserving appearances was essential. Central to this was appreciating that one purpose of the camps was to degrade people, to make them filthy and ashamed, and then to punish them for being those things. Facilities for washing were almost nonexistent, and latrines were both crude and withheld. Inmates were tortured by being denied the chance to relieve themselves except during two permitted times per day, but were fed and worked in a manner that made dysentery rampant. People either concealed their excrement in their own clothing or surreptitiously tried to deposit it in the only receptacles available, their eating dishes, and their thoughts became focused on controlling their bowels. Such an environment sapped self-respect and made daily urgencies loom so large that few people had the mental energy to contemplate overt resistance. Des Pres puts all of this under the heading of \"excremental assault,\" and he argues that those who saw through it had the best chance of living. They washed, even in filthy water. They kept their wretched wooden clogs tied securely and bound up their ragged clothes, not only to avoid selection by the SS but also to preserve a sense of self.\n\nA third key element in enduring the camp system was coping with the initial shock of arrival. Studies of prisoner mortality undertaken since Des Pres confirm his point: Those who made it through the first three months had an above-average chance of survival. If mourning or disgust did not produce a rejection of existence, a person might have time to pull together or, to put things another way, if fate saved a person long enough to recover from mourning and disgust, survival became possible. All of this was very difficult, since most people dumped into the unfamiliar environment of the camps were prone to deny its reality, to experience it as if it were a nightmare. This often proved fatal. Vigilance was the best protection; not giving in to shock became indispensable to existence. Those who managed this transition had a chance of developing the capacity to operate alertly and without illusion\u2014to take each day as it came. The difference between living and dying was sometimes between those who calculated the odds and despaired and those who thought that one chance of survival in one hundred or one thousand was good enough. Unsurprisingly, statistical and memoir-based evidence indicates that the chances of surviving the initial shock were better if one arrived in relatively favorable weather\u2014during the spring or the summer rather than in the depth of winter.\n\nDes Pres argues that a fourth determinant of surviving the camps was the discovery of what he calls a means of living simultaneously with and against the terms of existence: with them enough to avoid being snuffed out, against them enough to do the same. One or the other extreme\u2014complete abandonment to the rules or complete defiance\u2014meant death. One had to learn to operate at the margins, \"to organize,\" as camp jargon had it. One had to learn to use bribery, to smuggle, to carry out useful forms of barter, and all of these depended upon the ability to create or join little networks of prisoners who helped each other. In Auschwitz, survival networks generally involved some participant attached to the Canada detail. This was the group that sorted the goods of gassed deportees in giant warehouses along the edge of the Birkenau camp that the inmates called Canada because they imagined that land as overflowing with natural resources. Every day, these workers managed to pilfer food, clothing, and valuables despite at least three rounds of searches by the SS guards. Such thefts, along with corrupt deals with some of the guards, were the principal basis of the extensive black market within the camps, usually involving small possessions of value\u2014everything from needles and knives to tablets of sugar, saccharine, boullion, and the like.\n\nAnother key aspect of learning to live with and against the system was knowing when to lie in order to get the sort of administrative post or desirable job in a warehouse that could keep one alive. When the Germans asked arriving prisoners if they were chemists or tailors or carpenters or machinists, an inmate had to be ready to step forward whether she or he was or not\u2014virtually the only people to survive were those who eluded the hard physical work that either consumed prisoners, given the prevailing rations, or led to beatings or shootings at work sites. Still another form of with-and-against behavior was that of _Kapos_ who learned to appear vicious to prisoners in front of the SS personnel, thereby shielding them from the latter. Memoirs tell of a system of counteradministration in which prisoner trustees in offices and camp hospitals appeared to follow SS orders to the letter but found ways to conceal or change prisoners' identities or falsify diagnoses. Of course, not every prisoner in a key position helped his fellow inmates, but the system of solidarity was enforced by the knowledge that prisoners could exact revenge on toadies when the SS was not looking. A favorite tactic at Auschwitz was to push collaborators into the open latrines, where they would drown, apparently by accident. Within virtually all the camps, an intelligence system also sprang up, consisting of prisoners working as clerks in the SS offices and specialists among the prisoners who did repair work on the barracks. While seeming to serve the camp administration, they gathered information about the workings of the camp or events in the wider world and spread it around.\n\nFinally, Primo Levi and others stress that survival often depended on \"pairing\" with another inmate, looking out for each other, and simultaneously holding at bay the camp's multiple ways of crushing any sense of human solidarity.\n\nDes Pres and survivors who have given us memoirs to these effects may be right. But numerous accounts also come from survivors who say that they do not know how they got through the camps, cannot remember adopting a strategy for survival, and cannot say why they lived and others died. They recall instead a kind of endless numbness, a state of almost suspended mental animation that was broken only by liberation at the end of the war.\n\nIn short, the camp inmates developed a host of survival mechanisms, but the odds always were stacked against them, just as they were in the ghettos. In both settings, the likely outcome was death, sooner or later, unless the Allies arrived first. The most important explanation of why resistance never crystallized into a form that interrupted the killing machinery or threatened German control is that the system of divide and conquer functioned in the camps to the same diabolical effect that it operated in the ghettos. Inmates were not only outgunned but also atomized and generally resigned. The Germans exploited internal divisions and individuals' will to live right up until the dissolution of the camps. As Imre Kertesz, a Hungarian Jewish novelist and survivor of Auschwitz, writes, \"Provided that under the conditions of totalitarianism a person wants to remain alive, he will contribute with such an attitude to the preservation of totalitarianism: this is the simple trick of the organization.\"\nCHAPTER 6\n\n[HOMELANDS:  \nWhy Did Survival  \nRates Diverge?](contents.xhtml#ch_6)\n\nIF JEWS COULD do relatively little to deflect or break the force of the Holocaust, what of their non-Jewish fellow citizens in the countries affected? What did they try or fail to do, and why? Does the relative incidence of courage or lack thereof on the part of individuals explain why the survival rates of Jews diverged so widely by country?\n\nEveryone knows or should know that freedom is indivisible; when taken away from someone, it can be taken away from anyone. But few people dare act on that principle\u2014or think they need to do so\u2014even under the best of circumstances. The temptation in times of persecution is for those not immediately subject to it to try to ride it out until the horrors end, and in the meantime to look away or to take advantage. This was all the more true in German-occupied Europe, because the Nazi regime made sure people understood the risks of helping Jews. In Western Europe, these included being sent to a concentration camp. In Eastern Europe, concealing or hiding Jews could result in the execution of one's entire family. Such penalties lie behind one of the most uncomfortable truths of the Holocaust. For all our appropriate attention to the Righteous Among the Nations memorialized by Yad Vashem and the brave individuals who risked their lives to hide or otherwise save people, no more than 5\u201310 percent of the Jews who survived the Holocaust did so by virtue of someone's individual heroism.\n\nVARIETIES OF BEHAVIOR\n\nAlthough readiness to help Jews emerged within every country in Europe, the number of people willing to help, their proportion of the local population, and their attributes and motives varied greatly from place to place and over time. Germans may have hidden and saved 5,000\u201310,000 Jews during the war years, not counting those protected by marriages to non-Jews and other special provisions; Dutch people 7,000\u20138,000; and Poles anywhere from 20,000 to 65,000. But those totals represent much smaller shares of the native Jewish populations than those saved by Danes or Italians. Humanity was not the special property of any one or two nationalities nor altogether absent among any, but neither was it evenly distributed by place or over time. Especially in the first year and a half of the mass killing, when the carnage was at its peak and Jews most needed help, willingness to give aid was generally rare, including in areas where it later mounted.\n\nWhere such willingness did appear, it generally had its roots in one of three sorts of convictions: political, religious, and personal. Leftists tended to be more likely to help Jews than conservatives, in part because communist and socialist thought discouraged racist thinking, and in part because Communist Party discipline called for resisting all Nazi actions after the invasion of the Soviet Union. Minority religious status sometimes fostered identification with persecuted Jews. For example, Polish and Ukrainian Catholics living in western Ukraine were more likely to aid Jews there than were either Polish co-religionists in overwhelmingly Catholic Poland or the more numerous Orthodox Ukrainians who predominated further east. Similarly, Quakers and Baptists in Germany were much more active in smuggling Jews out of the country before 1939 and hiding them thereafter than their Catholic or Lutheran fellow Germans. And in Catholic France, the remote, predominantly Protestant village of Le Chambon-sur-Lignon and the surrounding region managed to save about 3,500 Jews, many of them children (along with 1,500 other people being pursued by the Gestapo), though one should note in this connection that some Catholics in the region also helped.\n\nMinority status was not always necessary to remind the pious to stand up for the persecuted. The Protestant bishops of Lutheran Norway protested collectively as deportations from that country were being prepared in November 1942. The Orthodox Primate of Bulgaria\u2014the head of the official church of that country\u2014played a central role in preventing deportations there. And although the Pope refused to speak out forcefully against the treatment of Jews and most Catholic cardinals and archbishops in majority Catholic countries remained silent, not all did. Cardinal Jozef-Ernest van Roey in Belgium and Cardinal Pierre Gerlier of Lyon, Archbishop Jules-G\u00e9rard Sali\u00e8ge of Toulouse, and Bishop Pierre Th\u00e9as of Montauban in France were among the Catholic prelates who openly denounced German racism.\n\nAs for the personal motives that led to attempts to protect Jews, certain character traits and behavioral records were better predictors of willingness to act than others. The sociologist Nechama Tec's _When Light Pierced the Darkness_ concluded, on the basis of a study of 754 Polish rescuers of Jews, that people with a strong sense of individualism and empathy and long records of helping the needy were more protective of Jews than people who took their behavioral standards from their environment and were more self-centered. That judgment is, perhaps unavoidably, rather circular. But another close examination of rescuers, Samuel and Pearl Oliner's _The Altruistic Personality_ , which rests on a similarly small sample but includes rescuers from across occupied Europe, reinforces Tec's conclusions in one important respect: People who rescued Jews tended to come from families that instilled strong moral and ethical values, empathy, and concern for the common good. Both these studies suggest that solidarity and courage were not spontaneous, as they often appeared to be, but rather the long-gestating products of a person's upbringing. Otto Jodmin, a German superintendent of an apartment building in Berlin who hid Jews in its cellars and vouched for others as bombing victims so they could obtain identity and ration cards, attributed his actions to the way he had been brought up, which made him think, \"I simply had to do it. . . . I just couldn't act in any other way.\" A Polish researcher named Teresa Prekerowa took issue with this line of analysis in the late 1990s on the basis of a much bigger sample of 3,300 people she considered \"typical\" of those who helped Jews. She concluded that helpers \"were ordinary people who differed greatly from each other, as ordinary people do, and I do not think it is possible to find any characteristics they shared in common.\" Perhaps, but a great deal of social psychology research reinforces the idea that altruism has to be ingrained and practiced or it atrophies. Think of it as a kind of muscle memory. When a person wonders, \"What would I have done?,\" the best clue to the answer may be his or her record of putting time and energy into helping people at risk.\n\nWe do not know enough about the youths of several diplomats who aided Jews in 1940\u201342 to say that they all fit this overall pattern, but some of them did. As the Nazis were sweeping over Europe, virtually the only effective rescue stemmed from the swift and unauthorized decisions of exceptional foreign diplomats to issue entry visas to their homelands to fleeing Jews. A notable example from mid-1940 was Aristides de Sousa Mendes, the Portuguese consul in Bordeaux, who, defying direct and repeated orders from his government, signed thousands of such documents as the German army bore down on that city. He was a _marrano_ , a Catholic whose ancestors had converted from Judaism under duress centuries earlier, and he was deeply devoted to the adopted faith. The combination of religious conviction and family sentiment may have accounted for his remarkable display of courage and empathy. A similar, almost simultaneous, and remarkable tag-team effort occurred just beyond the opposite end of the Nazi empire at the time. This was the joint action of the Dutch and Japanese consuls Jan Zwartendijk and Chiune Sugihara, in Kovno, Lithuania, which the Soviets recently had occupied, to provide partially specious documentation that enabled almost 2,000 Jews to escape across the USSR to Shanghai and other destinations. Another celebrated individual, quasi-official rescue effort was that of the American journalist Varian Fry, who went to France on behalf of the newly formed Emergency Rescue Committee and funded the escapes of some 2,000 people, most of them Jews and many of them famous artists and intellectuals, across the Pyrenees Mountains into Spain in 1940\u201341. A Swiss consular official in Austria named Ernest Prodolliet helped Jews gain admission to his homeland in 1938. Reprimanded and transferred to Amsterdam, he once more deftly evaded his orders by issuing a number of transit visas through Switzerland to Dutch Jews after Germany occupied the Netherlands. Just before his office was closed in 1942, he turned over the remaining available consular funds, worth about $180,000 in 2014 dollars, to Gertrude van Tijn, the head of the Dutch Jewish Council's still-functioning emigration department. In return, he sought only an unenforceable (but ultimately honored) promise of repayment by the representatives of the American Jewish Joint Distribution Committee in Switzerland.\n\nSad to say, not enough people in Europe possessed the same humanitarian reflexes as these individuals did, and there were not enough people like Oskar Schindler, either, the Sudeten German opportunist and would-be war profiteer who took over an enamelware factory in Cracow and gradually resolved to save the lives of some 1,300 Jews who worked for him. His heroism is inexplicable because it seems out of keeping with his self-indulgent and disorderly life both before and after. But he displayed great ingenuity and nerve in outwitting the SS. His story stands out not just because he tried to help Jews but also because he succeeded. He did so primarily because he owned his company and did not have to explain or justify his actions to any superiors who might have tipped the Nazis off to what he was up to. In contrast, Berthold Beitz, a German who managed a Karpathian Oil Corporation drilling site in Boryslaw in eastern Galicia, where he protected hundreds of Jews who worked for him for almost two years, did not work for himself. He could not arrange for the Jews' withdrawal to another factory when the Germans retreated in 1944, lest some superior denounce him to the Gestapo for that action. The most he could do was warn his employees just before the SS moved against them, enabling many of them to go into hiding. Alfred Rossner, a German who ran a number of uniform factories in Bedzin in eastern Upper Silesia, bribed and wheedled the local Nazi authorities successfully from May 1942 until August 1943 to keep his Jewish workers from the deportation trains, sometimes even hiding them in his shops. But in the end, not only were most rounded up and deported in the final clearing of the Upper Silesian ghettos, but also the Gestapo caught on to Rossner. Arrested in December 1943, he died in prison in 1944, hanged either by his warders or by his own hand.\n\nPerhaps the most remarkable story of an employer who tried and often succeeded in rescuing his Jewish workers comes from the very heart of the Third Reich, the capital city of Berlin, from a workshop on Rosenthaler Strasse in the middle of town. There Otto Weidt managed an operation that made brushes and brooms and employed at any one time about thirty deaf and mute Jews from a local home. Altogether during the war some fifty-six people from his workshop were slated for destruction by the Nazi state on grounds of both disability and heritage. He argued with the Gestapo each time one of his worker's names appeared on a deportation list, insisting that their work was vital to the war effort, and even bribed Nazi officials to get their names removed. In the end, half of his workers outlived the war, and so did he.\n\nIndividual heroism could achieve only so much in the face of the Nazi onslaught, yet about one-quarter of the European Jews in Nazi-occupied or -allied states and one-third of all the European Jews as of 1939 survived the Holocaust. How and why? We can begin to answer that question by looking at figure 7. It sorts Nazi-occupied or -allied countries in Europe according to two characteristics: whether more or less than the continent-wide average of two-thirds of the Jewish inhabitants were killed in each place, and whether each was ruled directly by the Germans or by a collaborating government.\n\nThe pattern that emerges is unmistakable, but not quite self-explanatory. That the most lethal parts of the continent were those directly occupied and administered by German officials does not mean that collaboration there was unimportant. In Serbia and Greece, veteran military leaders agreed to head puppet regimes that carried out German orders; similar arrangements arose in the Baltic states. In all of these areas, local police forces and\/or militias continued to function and often to participate in rounding up Jews, and residents eager to denounce Jews in hiding were numerous. A particularly notorious example was the Dutch staff of an organization called the Recherchegruppe (or Colonne) Henneicke, which tracked down and turned in 8,000\u20139,000 Jews who tried to hide in the Netherlands\u2014that is, more Jews than survived under cover in that country. Conversely, the generally lower death rates under indigenous collaborating governments do not imply that their personnel or citizens refrained from persecuting Jews. On the contrary, Vichy France under Philippe P\u00e9tain, Hungary under Regent Miklos Horthy, Romania under Marshal Ion Antonescu, and Bulgaria under Tsar Boris III independently enacted virulently antisemitic legislation, stripped many Jews of citizenship, and delivered certain groups of Jews to Germany and\/or engaged in killing them.\n\nFIGURE 7: GOVERNANCE AND HOLOCAUST MORTALITY RATES\n\n| DEATH RATE OVER 2\/3| DEATH RATE UNDER 2\/3  \n---|---|---  \nUnder  \nGerman  \nAdministration| Baltic states, Belarus, Holland, Germany, Greece, Belgium,Luxembourg, Czech Protectorate, Poland, Serbia, Ukraine| Belgium  \nUnder  \nCollaborating  \nGovernments| Slovakia, Croatia, Hungary in 1944| Bulgaria, Romania, Denmark, Finland, Norway, France, Italy, Hungary until 1944\n\nThe decisive variable that determined the mortality rate in any given country was usually time\u2014more specifically, whether the Nazi state attacked the resident Jews in 1941\u201342. Where Germans ruled directly, they almost always mobilized in pursuit of Jews promptly and thoroughly, unencumbered by an interest in preserving smooth working relations with local governments and populations. An exception was Belgium, and it was not really much of one. Though under German administration, authority over the police and so-called racial policy was in the hands of the German army, not the SS or the Nazi Party, until May 1942. And though a collaborating government did not actually rule Belgium, since the country's cabinet (but not its monarch) had fled to Britain, the indigenous civil service continued to function, and the Germans found working with it convenient and worth preserving. Still, Belgium did prove a great anomaly in one sense: More than 90 percent of the Jews there were foreigners, the sort of people usually deported first from most places, yet half of them survived. Another exception of a quite different sort was Greece, where a puppet government nominally existed after the country capitulated to Germany and Italy but where German control of the Nazi-occupied regions was very tight. Nonetheless, the Germans did not begin to deport Jews until March 1943; the somewhat smaller number in the Italian-occupied zone were not deported until 1944. Despite the delays, the death toll ultimately came to between 80 and 90 percent.\n\nWhere local administrations remained in place and were more autonomous, however, the Germans at first preferred to let native antisemitism run its course while they concentrated on the larger populations of Jews in the Reich's grasp elsewhere. By late 1942, when most of those other Jews were dead and Germany became insistent, the tide of war was turning and affiliated governments were growing wary of further persecution, since they might have to answer to the Allies if Hitler went down to defeat. Emblematic of the changing climate are the deportation statistics from two countries where the final death toll proved relatively low: The majority of the Jews ever deported from both France and Belgium departed in 1942, and then the pace from both places slowed. Equally telling was the behavior of Hitler's Balkan allies. Bulgaria, Hungary, and Romania each handed over to the Nazis some or all of the Jewish populations of regions taken in 1938\u201341 from neighboring states under German auspices but declined to turn over the Jewish inhabitants of their core territories in 1942\u201343. Even Slovakia, which in early 1942 eagerly agreed to deport most Jews\u2014in fact, actually paid Nazi Germany for taking them\u2014also had second thoughts toward the end of that year and suspended the deliveries, most of which had gone directly to Auschwitz.\n\nIn other words, the four chief determinants of the differing rates of Jews' rescue and mortality in Nazi Europe were: (1) how swiftly the Germans moved\u2014if they began massively killing in 1941\u201342, they got almost all the Jews in any given area; (2) how long the Germans remained\u2014their presence enabled the events in Hungary in May\u2013July 1944 and would have enabled the slaughter of the French Jews had D-Day not interfered with their general deportation, which the Germans finally mandated less than two months earlier; (3) whether the Germans had to deal with an indigenous and at least quasi-autonomous government interested in surviving the war; and (4) whether most Jews were still alive in an area by the time of the battles of El Alamein and Stalingrad 1942\u201343\u2014the interval that Winston Churchill called \"the hinge of fate\"\u2014and the onset of Germany's forced labor drafts. These are the moments when the likelihood that the Third Reich would win the war dwindled, and the Jews' interests and national interests began to coincide around resistance to Germany. If enough Jews were still alive, these developments began working to their benefit.\n\nThe importance of national and Jewish interests seeming congruent emerges clearly from the fate of Jews in an area where and at a time when the opposite was the case\u2014where national interests seemed to favor cooperation with the Nazis and the sacrifice of the Jews, notably the Baltic states and Ukraine in 1941\u201343. Ukrainian nationalists had seen their aspirations for independence crushed by the Bolshevik regime in 1919\u201321 and had endured a series of famines and purges in the 1930s that had deepened alienation from the Soviet state. Lithuanian, Latvian, and Estonian nationalists had lost their independence to occupation by the USSR in 1940. To them, the Germans came as potential liberators from Soviet enslavement, all the more so as Germany had allowed various national liberation groups to set up offices in Berlin and thus implied support for their goals. But because nearly all of these nationalist movements were historically antisemitic, Soviet rule in 1940\u201341 had an upside to the Jewish citizens of these states, some of whom found opportunities for advancement when the less discriminatory Soviet regime arrived, even though many other Jews suffered from the nationalization of their property by communism and from the deportations to Siberia that the Soviets conducted. As a result, Jews were overrepresented compared to their share of the Lithuanian population not only in the Communist Party and secret police there in 1940\u201341 but also among the people the communists sent to the Russian interior.\n\nThe consequence in most of the former Pale of Settlement was a situation in which Jewish and local nationalist interests seemed to conflict. To the Jews, the Soviet occupation of 1940 seemed the lesser of two possible evils; as one Jew from the region said at the time, the Soviet Union brought life in prison, but Nazi Germany brought the death sentence. But to Ukrainian and Baltic nationalists, even initially to the Catholic Metropolitan Archbishop Andrei Sheptytsky, who later tried to protect Jews, occupation by Germany appeared the lesser evil. These seekers of independence were only too ready to cooperate in removing a population that they disliked anyway in order to curry favor with the Germans. Well before the German invasion of Ukraine, both factions of the Organization of Ukrainian Nationalists (OUN), the Banderites and the Melnykites, had branded Jews as the allies of Bolshevism and endorsed killing Jewish males. On July 1, 1941, the day after the Germans occupied Lviv, the OUN issued a leaflet calling on Ukrainians to \"destroy\" Jewry, and a pogrom took place. Similarly, in March 1941, the Lithuanian Activist Front declared that Jews had \"betrayed\" the country and thus had no future there.\n\nAlthough the SS had some initial difficulty carrying out its orders to stimulate pogroms in Baltic cities captured by German troops, local militias soon recognized what the Germans wanted them to do to Jews and began bludgeoning and hacking them to death in Vilna, Kovno, and Riga, the largest cities of Lithuania and Latvia. Lithuanian militiamen probably killed more of the 180,000 Jews who died in that country by the end of 1941 than Germans did. Ukrainian police and militias played an active part in the massacres in their homeland during 1941, including at Babi Yar in September, even though by that time the Germans already had made their opposition to Ukrainian independence clear and even arrested Stepan Bandera, the leader of one wing of the OUN. So long as Germany remained on the offensive on the Eastern Front, it had no shortage of willing local volunteers for militias and security forces that hunted and killed Jews. In 1943, in fact, Himmler had about 300,000 mostly cooperative local policemen under his command in the occupied East, and Russian scholars have put the number of citizens of the occupied USSR who served in Wehrmacht and SS units during the war at 1.2 million. By the time the tide of the war turned, and the Baltic and Ukrainian nationalists finally recognized that a Nazi New Order in Europe was not going to restore their independence, nearly all of the Jews in Ukraine and the Baltic states were dead. Even then, many of the collaborators continued to fight for Hitler because they had become so complicit in his crimes that they had no alternative and, in the case of the Ukrainians, because they still aspired to eliminate Poles and Jews from their lands. These men and their families retreated with the German armies in 1944\u201345 and made up a significant proportion of the people in displaced persons camps there after the war ended.\n\nThis is not to say that national interests were the only driver of widespread popular participation in killing Jews in the occupied East. The availability of plunder also served as a strong inducement. A Pole who lived on the outskirts of Vilna and witnessed the massacres there observed, \"For the Germans 300 Jews are 300 enemies of humanity; for the Lithuanians they are 300 pairs of shoes, trousers, and the like.\" Nonetheless, the force that unleashed and claimed to legitimize covetous motives was perceived national interest.\n\nAnother sign of the decisive importance of national political considerations to the fate of Jews was the way that states officially or tacitly allied with Nazi Germany drew policy distinctions, albeit to varying degrees, between native-born Jewish citizens of their countries, especially veterans, and immigrant Jews of different nationalities. Vichy France, for example, was willing, even eager, to treat alien Jews as fit subjects for deportation but more resistant to giving up French citizens, though it did so on some occasions. Of the roughly 350,000 Jews in France in 1940, more than half had immigrated or fled illegally to the country since the beginning of the twentieth century. Drawing on mounting xenophobia during the 1930s and the convenient scapegoating of Jews for France's defeat in 1940, the collaborationist government headquartered in Vichy enacted antisemitic legislation voluntarily and in a form that was in some respects even more restrictive than Germany's. Vichy also accepted the arrests of foreign Jews in the occupied northern part of France beginning in October 1940; in fact, French police often carried out the roundups. French police also collected and handed over to the Germans 10,000 foreign Jews from unoccupied France during the summer of 1942. Deportations had begun in March of that year and resulted eventually in the transportation of approximately 76,000 Jews in France to concentration camps; only about 2,500 survived, and more than two-thirds of the deportees were foreigners. In the end, more Polish Jews who had sought refuge in France died at Nazi hands than did French Jews. The survival rate among foreign Jews in France ultimately came to about 50 percent, whereas for Jews who had French citizenship it came to a little less than 90 percent. But once more than half of the unfortunates left in 1942, the French government dragged its feet, partly as a matter of asserting its status as an independent, sovereign entity and partly as a matter of hedging its bets about the outcome of the war.\n\nSimilarly, the three German allies in southeastern Europe\u2014Romania, Bulgaria, and Hungary prior to 1944\u2014drew distinctions between Jews Germany could have and ones it could not and tailored national policies toward Jews to each country's political interests. The three states had leaders who held antisemitic views of varying intensity, and all three agreed to hand over Jews in lands acquired from neighboring countries in 1938\u201341 under German auspices. Thus in August 1941, Hungary pushed 17,000 Jews from the parts of Slovakia it had annexed in 1938\u201339 across its borders into German-occupied Poland and Ukraine, where the SS massacred 11,000 of them. Early in 1942, Hungary killed another 1,000 or so Jews in territory acquired during the dismemberment of Yugoslavia in April 1941. After Bulgaria received Thrace from Greece, Macedonia from Yugoslavia, and Dobrudja from Romania in 1940\u201341, it delivered 11,384 Jews from these regions to the Germans in early 1943. In all these instances, the principal and cynically self-interested motivation was demographic. Where killing Jews would reduce the size of the non-Hungarian and non-Bulgarian populations and speed the absorption of territory into their states, the acquiring countries were ready to cooperate.\n\nBoth Bulgaria and Hungary also enacted antisemitic laws designed to strip Jews of their property and exclude them from the civil services; Hungary's legislation went so far as to restrict the share of Jews in any profession to 6 percent and forbade sexual relations and new marriages between Jews and Magyars. But the countries' policies diverged even in 1941\u201342 regarding further deportations, with the Bulgarians promising to begin them in 1943 and the Hungarians steadfastly refusing, although they drafted adult Hungarian Jews for labor service on the Russian front, where about 42,000 of them died or were murdered. The Bulgarians bought the Germans off for a time by conscripting Bulgaria's Jews for work in the countryside but then reversed their position on deportations in March and April of 1943, partly because of intense and widespread domestic opposition and partly because of mounting concern that Germany might not win the war. Nearly all of the Bulgarian Jews ultimately survived because the Germans did not force the issue by occupying the country.\n\nIn Hungary, however, opposition to deportations crumbled after March 1944, when German troops poured into the nation, ostensibly to defend it from an impending Soviet invasion but really because Hungary was considering following Italy's example and finding a way out of the Axis alliance. Following an initial period of isolating and pillaging the Hungarian Jews, almost 60 percent of them, approximately 437,000 people, were deported in the space of only fifty-five days, between May 15 and July 9. At Auschwitz-Birkenau, about 25 percent of these people were selected for work and generally shipped onward to labor in Germany; perhaps half of them, about 55,000 people, survived the war. The rest of the deportees, more than 325,000 people, perished in the gas chambers upon arrival, making the total death toll from this round of Hungarian deportations roughly 380,000 and the total number of Hungarian Jews killed in the Holocaust, following another round in late 1944 and then a series of horrific death marches, between 500,000 and 565,000.\n\nEven though most of the victims died at the hands of Germans, not Hungarians, the thoroughness of this operation, which netted 97 percent of the Jews in the Hungarian countryside and annexed areas and left virtually the only survivors in the Hungarian capital of Budapest, was largely homegrown. Only 150\u2013200 German SS personnel were involved in the Hungarian roundups that the nation's own national and local police forces, supplemented by civil servants and volunteers, carried out under the direction of a Ministry of the Interior led and staffed by extreme right-wing Magyar antisemites. The concentration of Jews across the country into fifty-five short-lived ghettos proceeded according to a plan for the successive clearing of six different sections of the country. Finalized by Adolf Eichmann and several Hungarian policemen, that plan merely refined and made more specific a program that two nationalist Hungarian generals had devised in 1942, almost two years before the German occupation. In the apt summation of Peter Kenez, a historian of modern Hungary and himself a refugee from that country, \"The German role in the destruction of Hungarian Jewry is best understood as giving an opportunity to some determined [Hungarian] antisemites to carry out a policy that they had long desired and planned.\"\n\nHow can one explain the scale and speed of the carnage in Hungary, comparable only to the liquidation of most of the Warsaw ghetto in fifty-three days during the summer of 1942, and so fast that Commandant H\u00f6ss at Auschwitz repeatedly sought to slow the overwhelming pace? One part of the answer is that the RSHA could focus its efforts\u2014after all, most of the other Jews of Europe were dead or out of reach by May\u2013July 1944\u2014and the killing center at Birkenau was very close by and more swiftly murderous than ever, thanks to the recently completed rail spur that ran into the camp almost to the doors of two of the gas chambers. A second, somewhat technical, explanation is that the deportation had a war-related purpose, which helps to account for so many trains\u2014147 over the course of the operation, 3\u20136 per day\u2014being made available. Auschwitz was supposed to cull 100,000 able-bodied workers, 10\u201315 percent of the anticipated deportees, and send them on immediately to Germany to labor on the massive effort to put war-producing factories underground. But still a third important component of a response lies in the history of antisemitism in Hungary. As in Germany, prior to World War I Jews in Hungary enjoyed apparently ever-expanding acceptance, opportunities, and prosperity, only to experience rising hostility following defeat and territorial losses in 1918-19 and the bloody suppression of a communist revolution in which Jews played conspicuous parts. In interwar Hungary, as in Germany, nationalist forces harped continuously on a supposed link between Jews, disloyalty, and unrest and fanned resentment at the prominence of Jews in commerce, industry, law, and medicine. As a result of such agitation, the installation of an authoritarian government, the inauguration of antisemitic restrictions, and the rise of a mass antisemitic political movement, the Association of Awakening Hungarians (EME), all occurred more than a decade before Hitler came to power in Germany.\n\nWhen German diplomatic successes in 1938\u201341 led to the dismemberment of first Czechoslovakia and later Yugoslavia and meanwhile to the arbitration of Hungary's and Romania's competing claims to Transylvania, the Hungarian rulers were happy to express their gratitude for the pieces of territory that Hitler threw their way with the enactment of further restrictions on Jews' civil rights and economic activities. But the new territories nearly doubled the Hungarian Jewish population, from 401,000 to 725,000 (or from 491,000 to 825,000, counting converts of Jewish descent), making it larger than the entire Jewish population of Western Europe. That the additional Jews were much less likely to speak Magyar, and to resemble in dress and religious practices their co-religionists inside the previous borders, stoked the antisemitism that already prevailed in military and some government circles, including around the head of state, Admiral Horthy. When he finally capitulated in March 1944 to Nazi demands that he furnish 100,000\u2013300,000 \"Jewish workers for German war production purposes,\" the first two parts of the nation combed were the annexed regions to the northeast that happened to be closest to the advancing Russian troops; the last region scheduled for purging was the capital city, where the most assimilated and economically valuable Jews lived. In short, Hungarian desires, as well as Hungarian personnel, not only accelerated the deportations but also determined their course. Conversely, when Hungarian officials withdrew their cooperation with the Germans between July and October 1944, Eichmann and his aides could achieve almost nothing further except the deportation of 2,700 prisoners already interned in camps on Hungarian soil.\n\nBy far, the most contradictory and confusing policies toward Jews were those carried out in and by Romania in 1940\u201345, and to understand them, one needs to pay close attention to figure 8. Marshal Antonescu, the country's dictator, was an inveterate antisemite who blamed Jews for all of his country's weaknesses. In particular, he claimed that they had welcomed Romania's losses, in 1940, of the northern province of Bukovina, the northeastern province of Bessarabia (also then called eastern Moldova), and of northern Transylvania. The first two losses came as a result of a Soviet ultimatum and the third because of a German-Italian arbitration of border claims that gave this region to Hungary. Determined to regain all three territories, Antonescu joined in the invasion of the USSR in June 1941 and set out to murder the Jews of Bukovina and Bessarabia, both in punishment for their supposed pro-Soviet stance and as a means of speeding the Romanianization of the regions. He also hoped to use willingness to deport and kill Jews as leverage in persuading Hitler to give him back northern Transylvania. As a result, Romania acquired the dubious honor of becoming the German ally that killed the largest number of Jews, about 400,000 in Bukovina and Bessarabia and a territory the Romanians called Transnistria, the portion of Ukraine that Hitler awarded Antonescu in compensation for his loss of part of Transylvania.\n\nFIGURE 8: ROMANIA, 1941\u201344\n\nBut in 1942, when the Germans began requesting a schedule for the deportation of the Jews from the core provinces of Romania, an area called the Regat, Antonescu demurred. His generals on the Eastern Front already had begun warning him of impending disaster there, and he wanted to extort every last penny from the local Jews before he sent them off. So he played for time, deferring the first deportations scheduled for October 1942 until spring 1943, at which point he joined the Bulgarians in reneging on his earlier promises. He never gave up his crazed dream of ultimately sending the Romanian Jews to Transnistria and thus creating an ethnically pure Romanian heartland, but he did not hand over the Jews in the Regat to the Nazis. This engendered one of the greatest ironies of the Holocaust: The nation that next to Germany killed the largest number of Jews also was the nation that had the largest surviving Jewish population in Europe in 1945. Whereas 80 percent of the Jews in Bukovina, Bessarabia, and Transnistria died at Romanian hands, 80 percent of the Jews in the Regat remained alive at the end of the war. Their situation was wretched, as the Romanian regime had terrified and impoverished them, but they still lived.\n\nIn all these instances, cynical and practical politics played a greater role in deciding the fate of Jews than moral considerations. In fact, taking a strong moral stand in solidarity with Jews proved counterproductive when the timing was not right. Early mass resistance to Nazi discrimination could backfire, as it did in Holland. A general strike there in February 1941 in protest against the persecution process led to its acceleration, and the objection of Catholic bishops to the deportation of Jewish converts to Catholicism triggered expedited arrests of such people. Provoked by this opposition, the German administrators in the Netherlands, many of whom had acquired experience with persecuting Jews in Austria in 1938\u201339, now moved with a fury unmatched in any other occupied Western European country. Between July 1942 and September 1943, they rounded up and deported 110,000 Dutch Jews out of a total population of 140,000.\n\nFinally, as a demonstration of both the importance of politics to the fate of Jews and the difficulties of individual rescue efforts, consider what happened in the two countries where Jews enjoyed unusually high survival rates thanks largely to popular solidarity, namely Denmark and Italy. Denmark is, of course, famous for concealing almost all the nearly 8,000 resident Jews and ferrying them across the narrow strait between that country and Sweden, and Italy for resolutely refusing, even while Mussolini was enacting antisemitic laws, to let anyone be deported, not only out of Italy but also out of the parts of France, Yugoslavia, Albania, and Greece that Italy occupied and administered. In both countries, roundups of the Jews were delayed by special political circumstances. Until 1943, a Danish government continued to function and to cooperate with the German occupation, Mussolini's regime was an Axis ally, and the Germans thought preserving these arrangements more important than forcing these countries even to compile lists of Jews or make them wear identifying badges, let alone to begin deportations. Only when the political conditions changed in late 1943\u2014in Denmark when the cabinet resigned because the Germans imposed martial law in response to mounting popular resistance, in Italy when the Germans rushed to occupy the country because the king had dismissed the Duce and his successor had concluded an armistice with the Allies\u2014only then could and did the Germans strike against Jews. All this meant that the assaults occurred precisely at the moment when helping Jews became an act of national resistance against an oppressive foreigner.\n\nMany other pieces of good fortune were involved: the Danes had the virtual collusion of the leading German administrator in the country, Werner Best, and the opposition to the operation of both the military commander in Denmark, General Hermann von Hanneken, and the Gestapo chief there, Rudolf Mildner. Caught between Himmler's impatience to begin deportations and his own belief that they would complicate the job of managing the occupation, Best played a double game. He advocated action to the SS in Berlin in order to please Himmler, but he leaked news of the impending roundups to the Danish Jews via a German named Georg Duckwitz four days in advance in order to preserve a good working relationship with the Danish bureaucracy and police. This gave the Jews time to get away from their homes before the German police came to apprehend them on the evening of October 1, 1943. During the ensuing weeks, the Jewish Danes had two more priceless advantages in making their escape: an offer of asylum from the Swedish government for anyone who got to its shores, and only a narrow body of water to cross. Even so, most of them got away only because German navy patrol boats off the Danish coast made no attempt to interfere with the roughly 700 vessels\u2014mainly fishing boats\u2014that carried the exodus. Only 284 Danish Jews fell into Nazi hands in the roundup of October 1, and 22 more drowned while trying to escape. Ultimately, 7,742 reached Sweden, including 1,376 German Jewish refugees, along with 686 non-Jewish spouses. Perhaps even more amazing than these numbers is the fact that after the war, when these people returned to Denmark, they found their homes and property not only unmolested but also often carefully tended in their absence.\n\nIn Italy, Mussolini had just announced the imposition of forced labor on Italian Jews and was on the verge of commanding deportations when he was overthrown in July 1943, and the Jews in Italian-occupied Croatia already had been interned in a potential transit camp. But in the chaos that surrounded the influx of the German army, the remaining 2,600 Croatian Jews could escape, and most of the 32,000 Italian ones remaining in the northern two-thirds of the country had time to go underground. They then had the geographical advantages of rugged mountains\u2014 namely, the Apennines in the center of the country and the Alps in the north that provided ideal hiding places\u2014and proximity to the Allied front lines advancing up the Italian boot.\n\nNevertheless, the latest studies suggest that about one-quarter of those still vulnerable Jews were killed during the Holocaust, that many of those deported after the Germans occupied the country were apprehended by Italian collaborators, and that in regions where the German presence was greatest, for example around Trieste in the northeast, Italian attitudes hardly mattered and 90 percent of the Jewish community perished. One reason for the German thoroughness in that region is that the SS units from Operation Reinhard were transferred there when those camps in Poland closed. Local heroism was no match for German ruthlessness, as indicated by the fate of Giovanni Palatucci, a commissioner in the police headquarters in nearby Fiume. He used his office to impede roundups and help Jews escape by boat to southern Italy until the Gestapo arrested him in September 1944 and sent him to Dachau, where he died shortly before the liberation of that camp.\n\nTiming, geography, and small numbers were factors that favored relatively high rates of survival among Jews in Denmark and Italy. So did the fact that by the fall of 1943, the likelihood that Germany would lose the war became strong. But other circumstances played a role, and they were important in Bulgaria, too. In none of these countries were Jews notably prominent in commercial or cultural life or in communist politics and thus representable as profiteers or threats. Moreover, all three Jewish communities were highly acculturated. The members of all three routinely spoke the national language and dressed like the majority population. Unlike a majority of the Jews of Ukraine, Poland, Lithuania, Romania, and rural Hungary, Yiddish was not their lingua franca, and traditional Orthodox garb was rare. In Italy in 1938, more than one-third of all married Jews had non-Jewish spouses. Sometimes, the fate of Germany's and Hungary's urbanized Jews is invoked as a warning against acculturation, a proof that it does not protect Jews from the hostility of others. Certainly in those instances, it did not. But acculturation did not always fail as a safeguard. The different experiences of the highly integrated Jewish communities of Bulgaria, Denmark, and Italy, where much of the gentile population mobilized to shelter Jews, bear paying attention to as well.\n\nTHE CASE OF POLAND\n\nProbably no subset of issues related to the behavior of non-Jewish populations during the Holocaust is touchier than those surrounding what happened in Poland. The country was, after all, the epicenter of the Holocaust: the location of the death camps, the homeland before World War II of half the victims, and the graveyard of fully 90 percent of the Jews who lived there in 1939. Among the Jews who survived, the sense that Christian Poles had done little to help, indeed in many cases had favored and even encouraged the outcome, has been strong.\n\nThat perception drew strength from Claude Lanzmann's monumental, nine-hour-long documentary film of the 1980s, _Shoah_ , which showed some Polish peasants near Chelmno explaining that the Jews died because they had killed Christ centuries before and others near Auschwitz grinning as they recalled the arrival of deportation trains there. In 2001, the publication of Jan Gross's book _Neighbors_ brought renewed attention to the fraught nature of communal relations in Poland under the Nazis. Gross recounted a savage massacre of Jews by Christian Polish peasants in the village of Jedwabne, in the Soviet-annexed part of Poland, just after the Germans arrived in 1941. He overstated the numbers of both victims and perpetrators and minimized the instigating role of the Germans but established that local residents did the killing, often in bestial fashion. Works such as Lanzmann's and Gross's may have something to do with a curious feature of survivors' testimonies that Christopher Browning came across when he studied the Starachowice labor camp: Accounts of Poles' behavior given by Jews immediately after the war were generally far milder and less angry than those collected later. The sense of bitterness and betrayal grew more intense with the passage of time.\n\nAt the same time, aside from Belarus, Poland was the place where the German occupation was worst for everyone subjected to it. During the invasion, German troops repeatedly machine-gunned civilians and prisoners of war. In the parts of Poland seized by Germany, the death toll came to at least 50,000 people and perhaps more than 60,000 by December 1939 alone. Before the massacre of the Jews began, the Germans intentionally liquidated much of the Polish intelligentsia, killing one-third to two-thirds of the professors, journalists, lawyers, priests, leading politicians, and so on and thus greatly weakening the country that later emerged from World War II. The concentration camp at Auschwitz actually was established initially for these people, not for Jews. A few statistics give a sense of how complete the purge at some local levels was: In the Catholic diocese of Poznan (Posen in German), in the Warthegau, 77 percent of the priests were put in concentration camps, deported, or killed outright between 1939 and 1945. In the six dioceses that Nazi Germany annexed from Poland, the death rate for priests during the war varied from a low of 30 percent to a high of just over 50 percent. Moreover, Himmler established a program that essentially stole thousands of blond-haired, blue-eyed, racially German-looking children from their Polish parents and placed them in adoptive Nazi families within the Reich. His demographic engineering efforts in the Warthegau involved the displacement and impoverishment of 300,000 Poles, and the arbitrary nature of Nazi rule in the General Government assured that thousands more died at German hands. About two million more Poles were brought to the Reich for forced labor and exploited and mistreated there to varying degrees.\n\nThe lot of those left at home was not much better; hundreds at a time were shot and their farms or villages burned in reprisal actions against any resistance to German measures or harm to German troops. Secondary education for Poles was almost entirely banned, and all universities closed and plundered. Hans Frank, the Nazi master of the General Government, openly declared that he did not care whether Poles \"had anything to eat or not.\" As a result, in 1941 official rations provided Poles with only 29 percent of the daily calorie norms set by the League of Nations; in 1943, the figure was 17 percent. Most Poles survived by buying on the black market, but the search for food was time-consuming and exhausting, and the prices exorbitant. Martin Winstone, who has written the most thorough recent study of the GG, reports that \"bread prices\u2014the supreme barometer of the black market\u2014hovered at around 4,000 per cent of prewar levels\" from 1941 until the end of the German occupation. In just the first few months of German rule, the resources and machinery of the GG were stripped so clean that Frank described the region in March 1940 as \"economically speaking, an empty body. What there was. . . has, as far as possible, been taken out by the [German] Four Year Plan.\" Though the Nazis came to recognize a contradiction between keeping order in the country and impoverishing it, they never resolved the conflict, and living standards continued to plummet during the occupation.\n\nPolicy was one reason the annexed and occupied parts of Poland suffered grievously, but personnel was another. Germany generally staffed the GG with district leaders who were long-time, deeply committed National Socialists, usually of the most racist sort, and often the most incompetent, greedy, or scandal-ridden. Frank, the governor general, was prototypical in all these respects. Although this pattern made Nazi administrators occasionally susceptible to bribery that might ameliorate conditions, it also made the new overlords even more determined to extract everything they could, both for the Reich and for themselves, from the occupied region. Fritz Cuhorst, the first Nazi-appointed head of the city of Lublin, spoke for many of them in December 1939 when he remarked, \"[W]e have decided to behave as officials exactly the opposite of at home, that is, like bastards.\" As a result, according to the contemporary account of an anonymous Polish doctor, \"[I]t was like living in a country where all the thieves and gangsters had been let loose and the operation of the law entirely suspended.\"\n\nPerhaps one can get the best sense of the extent of the damage to Poland in World War II by comparing events there to two of the war's greatest conflagrations: the air wars against Germany and Japan. More Poles died in the bombing of Warsaw in 1939 than Germans in the firebombing of Dresden in 1945; in fact, more inhabitants of Warsaw alone, about 720,000 people, perished in the Second World War than did Germans in all Allied air raids. Even more shockingly, more Poles may have been killed in the suppression of the Warsaw Rising of 1944 than Japanese people were in the atomic bombing of Hiroshima and Nagasaki a year later. In the end, approximately two million non-Jewish Polish citizens perished during the Nazi occupation between 1939 and 1945, a staggering total, but not as many as the number of Polish Jews who were killed, and hardly comparable as a percentage of the prewar population. The oft-quoted statement that as many Christian as Jewish Polish citizens died under Nazi rule is false. Jakub Berman, a Polish communist leader who was Jewish, simply cooked up the number in December 1946 for political reasons, and it has been disproven by close statistical analysis. Even so, a great many non-Jews died in annexed and occupied Poland. Moreover, while this was happening, Polish gentiles also hid and saved tens of thousands of Jews. To put the matter in a superficially surprising form: The Jewish survival rate in Warsaw was equal to that in Amsterdam.\n\nSince 1945, competing claims to greater suffering and mutual indifference under the Nazis have perpetuated the sense of distance between the Jewish and non-Jewish Polish communities. To a regrettable degree, many Jews have talked as if the Poles were worse than the Germans during the Holocaust, and many non-Jewish Poles have treated every criticism of their behavior as a treasonous and ungrateful insult to a beleaguered nation. In April 2015, the Polish foreign minister went so far as to summon the American ambassador to complain that a reference to \"the murderers and accomplices of . . . Poland\" in a speech and newspaper column by FBI Director James Comey\u2014a remark that this chapter shows is entirely justified\u2014constituted an insult to the many heroic Poles who had resisted Nazi Germany. Of course, Poles exhibited both complicity and heroism during World War II; to cite one is not to deny the other. Moreover, as we will see, resistance to Nazism in Poland and implication in the Holocaust sometimes went hand in hand. But Comey decided to do the politic thing and apologize. Even in contemporary academic circles outside of Poland, these sensitivities have surfaced in the critical reaction to Timothy Snyder's important book _Bloodlands_ , which appeared in 2010. Snyder juxtaposed the suffering of Jews at Nazi hands with the suffering of Poles, Ukrainians, and other Eastern Europeans primarily at Soviet hands in the former Pale of Settlement between 1933 and 1945. In response, a number of prominent Jewish scholars, both here and in Israel, charged him with downplaying Polish antisemitism and generally presenting an excessively pro-Polish account of the carnage.\n\nHow can we sort through the mutual recrimination fairly and come to a measured assessment of what happened? I think such an effort has to keep seven essential and somewhat contradictory sets of facts in mind.\n\nFirst, antisemitism in Poland was considerable before 1939 and on the rise. To be sure, it was not universal. The popular Peasant Party and the elitist Democratic Party that emerged just before World War II advocated toleration and discouraged persecution. But the chief proponent of discrimination against Jews was Roman Dmowski. His National Party (known until 1928 as the National Democrats, or Endecja) gained influence from 1935 on, as the government that succeeded that of the deceased Marshal Jozef Pilsudski adopted a series of measures aimed at driving Jews out of the Polish economy and, indeed, the country. Recurrent small-scale pogroms flared up in the late 1930s, most of them in small towns in the center of Poland, resulting in the deaths of fourteen Jews and the wounding of 2,000 more. A government decree requiring businesses to post the full names of their owners facilitated boycotting Jewish enterprises, as did the division of municipal market halls into Jewish and non-Jewish sections. Discriminatory admissions policies drove down the share of Jews among university students in Poland by almost two-thirds (from 20.4 percent to 7.5 percent) between 1928 and 1938. Those who enrolled had to sit on specially designated benches in the lecture halls after 1937 and sometimes were subjected to violent attack. Between 1936 and 1939, the Polish parliament first limited, and then banned, kosher slaughtering. Meanwhile, virtually no Jews held positions in Polish governmental or municipal offices, the railway and postal systems, and the government monopoly industries, such as tobacco, alcohol, and lumber. Aside from two baptized generals of Jewish descent, the few Jews in the Polish army were almost all medical doctors. National legislation restricted Jewish actors to Yiddish theaters and Jewish journalists to Jewish-owned newspapers, and various professional associations, including those for electrical engineers and physicians, voted to exclude Jews henceforth. The political organization founded in 1936 to support the post-Pilsudski regime, the Camp of National Unity (OZON), also barred Jewish members.\n\nIn 1937, the Conservative Party leader, Prince Janusz Radziwill, endorsed the \"forcible emigration of the Jews,\" and the Polish government actually sent a delegation to Madagascar to explore the possibility of sending Jews there. The Polish foreign minister even discussed the idea with his French counterpart the following year and tried to lease roughly a million acres of land on the island to support the emigration of 30,000 Jewish families per year during the next five or six years, some 500,000 to 600,000 people all told. Shortly thereafter, the Polish ambassador in the United States opened talks with a group of wealthy and influential American Jews about their purchasing the Portuguese colony of Angola as a \"supplemental Jewish homeland.\" So eager was the Polish government to drive out Jews that it actually trained right-wing Zionist fighters in Poland in 1938\u201339 and then sent them off to Palestine. The hope was that they would perpetrate enough violence to persuade the British either to leave that territory or relax restrictions on immigration to it.\n\nThe depth and breadth of Polish antisemitism reflected the close link between Polish nationalism and Polish Catholicism. In the eyes of many Poles, one simply could not be Polish without being Catholic, and the nation's priests heartily concurred. As the most outspokenly antisemitic Catholic clergy in Europe, they usually threw their political weight behind Dmowski and his Nationalists. Church leaders and publications tied the Jews repeatedly to every alien and supposedly corrupting or polluting force in modern life and thus to every current of opinion or behavior that threatened the authority, power, and income of the Church. Poland's cardinals were particularly unabashed about blaming Jews for the nation's problems. The Church's official stance toward Jews remained unchanged since the Middle Ages: They were evil and seditious people who should be shunned, but not harmed physically.\n\nTypical of the entrenched animosity toward Jews among Catholic leaders in Poland was the pastoral letter entitled \"On Catholic Moral Principles\" that Cardinal August Hlond, the Primate of Poland, issued in February 1936. It read, in part, as follows:\n\nIt is a fact that the Jews . . . constitute the avant-garde of godlessness, the Bolshevik movement, and revolutionary activities. It is a fact that Jewish influence on morality is pernicious, and that their publishing houses spread pornography. It is true that the Jews permit fraud and usury. . . . But let us be fair. Not all Jews are like that. . . . One may love one's own nation more, but one may not hate anyone. In commercial matters it is good to prefer your own ahead of others, avoiding Jewish stores and Jewish booths at the market, but one may not plunder Jewish shops. . . . One must close oneself off to the harmful moral influences of Jewry . . . in particular boycott the Jewish press and corrupting Jewish publishing houses, but it is not permitted to attack the Jews, beat them, wound them, injure them, defame them.\n\nTwo years later, Father Jozef Kruszynski, the former rector of the Catholic University of Lublin and the chief intellectual propagator of the _Protocols of the Elders of Zion_ in interwar Poland, summarized the ambivalent teachings of the Church toward Jews. He described their persecution in Germany as barbaric but added, \"Hitler called the Jews the microbe of the world. The accusation is unusually harsh but we must admit that it is correct.\" In short, traditional religious antisemitism remained vivid and strong in Poland, and very few Catholic priests, especially at the parish level, spoke up in defense of the Jews or urged their parishioners to help them. On the contrary, the Church hierarchy repeatedly excused what it called the \"regrettable excesses\" of Polish antisemites by depicting them as understandable reactions to the Jews' disrespect \"for the faith and traditions of Christians.\"\n\nSecond, Jews and Poles tended to live as separate ethnic communities in much of prewar Poland, and there was little sense of solidarity between them. Only 12 percent of Polish Jews described Polish as their native language in a survey conducted before the war. The ambiguous phrasing of the questions asked suggests that this figure may be an understatement, and records of library borrowing indicate that Jews were reading more in Polish than in Yiddish. Nonetheless, most Jews spoke Yiddish primarily, and most who spoke Polish did so with an identifiable accent. Intermarriage and conversion were rare. Jews operated their own choirs, cooperatives, credit unions, cultural societies, hospitals, orchestras, orphanages, newspapers, publishing houses, sports clubs, and theater companies.\n\nIn much of the country, Jews and Poles were divided by residence and occupations. Although Jews came to 10 percent of the prewar national population, they made up 33 percent of the urban dwellers in western and central Poland and between 40 percent and 60 percent in different parts of the eastern half of the country, the area that fell to the Soviet Union in 1939. Although only 1 percent of the Jews were professionals, these Jews accounted for 63 percent of the people employed in commerce as of 1921, and 56 percent of the MDs ten years later, along with 43 percent of the teachers, 33.5 percent of the lawyers, and 22 percent of the journalists and publishers. On the eve of World War II, firms owned by Jews employed more than 40 percent of the Polish workforce, and Jews paid 35\u201340 percent of Poland's taxes. Class resentment and envy, in other words, along with ethnic distinctness and religious differences, created distance between the two communities. In Poland, the belief flourished that Jews had grown disproportionately wealthy by unfair collusion and thus that Poles were justified in repossessing what remained rightfully theirs. Yet much of the Jewish population remained poor, sometimes grindingly so, in part as a result of discriminatory employment and taxation policies enforced by the government. When World War II began, perhaps one-third of the Jews in Poland were dependent on relief aid, most of it coming from Jewish organizations in the United States.\n\nAll of this was less true in Warsaw than elsewhere: Jews in the nation's relatively cosmopolitan capital were more acculturated, more likely to speak Polish and interact with non-Jews, and less uniformly envied or resented. In fact, the relative frequency of contacts across communal lines largely accounts for the number of Jews concealed and saved in the city, which came to around 11,500, perhaps more. Gunnar S. Paulsson, the closest student of the rescue of Jews in Warsaw, has calculated that 70,000\u201390,000 non-Jews must have been involved in the effort. There were so many Jews successfully hiding in Warsaw in June 1943\u2014probably more than 25,000\u2014that the Nazis resorted to a trick. They claimed to have entry documents to various Latin American countries and to be willing to sell them to Jews who would then be exchanged with the Allies for German nationals abroad. The Germans even installed a number of Jews to live comfortably in the Hotel Polski, supposedly the collection point for the exchange. About 3,500 Jews emerged from hiding to fall into this trap and then die at Auschwitz.\n\nThird, politics divided Poles and Jews, too. As early as the Polish-Soviet War of 1919\u201320, the Polish army interned its Jewish troops in a detention camp as security risks. During the interwar period, a greater percentage of Jews than non-Jews stood on the political left in Poland, and in the 1930s, Jews composed more than half of the Polish Communist Party's local leaders and most of the members of its Central Committee, though most Jews did not belong to the Party. Most Poles believed that Jews were pro-communist in 1939\u201341, and, given the Germans' intentions toward Jews, the belief was not unfounded. Yehuda Bauer's book on the Soviet-annexed portion of Poland shows that Jews there did recognize that for them the Russians presented the lesser of two evils in Eastern Europe and generally behaved with corresponding cooperativeness when the Soviets arrived. Writing of 1939 in 1943, Calel Perechodnik described the \"immense happiness\" with which Jews greeted the Soviet occupation of eastern Poland and added, \"This is nothing to be surprised at. From one direction a German invaded, proclaiming slogans of merciless destruction and murder of all Jews. From the other direction, a Bolshevik invaded, proclaiming slogans that for him all people were equal under the law. There was nothing to compare here.\"\n\nGiven the depth of Polish hatred of Russia, born of both the long tsarist occupation in the nineteenth century and the Soviet deportation of some one-half million Poles from the annexed regions to Siberia in 1940\u201341, the general Jewish stance was bound to split the two communities even wider apart. In the case of Jedwabne, allegedly pro-Soviet behavior by local Jews in 1939\u201341 provided the pretext for the murders. And the massacre there was hardly an isolated occurrence: It was one of sixty-six nearly simultaneous such attacks in the province of Suwalki alone and some two hundred similar incidents in the Soviet-annexed eastern provinces. As Stefan Rowecki, a general in the Polish resistance, reported to the Polish government-in-exile in London on July 4, 1941, while the German armies were sweeping across the formerly Polish territory taken by the Soviets, many Poles were ready to offer \"administrative and economic cooperation with the Germans in these areas . . . [as] a knee-jerk reaction of gratitude to their liberators from the Bolshevist oppression in which the Jews had played a big part.\" Ironically, as Yehuda Bauer has argued, two forces\u2014the appeal of Soviet society to Jews in eastern Poland, especially to younger elements of the population, and the economic and antireligious measures that the communists adopted\u2014undermined the cohesion of the Jewish community there between 1939 and 1941. This sapped its capacity to resist the Germans when the invasion came, just as divisions over the Soviet occupation eroded solidarity between Jews and Poles in the region.\n\nJan Kozielewski, a valiant non-Jewish resister during the war who operated under the code name Jan Karski, wrote a report to the government-in-exile in London in February 1940 that made clear how deep this sort of division between Jewish and non-Jewish Poles already had become. He concluded that \" '[t]he solution of the Jewish question' by the Germans. . . . is creating something of a narrow bridge upon which the Germans and a large portion of Polish society are finding agreement.\" In consequence, almost everywhere outside of Warsaw, the principal resistance organization, the Armia Krajowa (AK), or Home Army, excluded Jews from its ranks on the assumption that they were security risks and potentially pro-Soviet. As the Russian armies pushed the Germans back toward Poland's borders, this attitude made some Home Army commanders, who were now fighting a two-front war against the Germans and the pro-Soviet Polish People's Army, even more hostile to Jews. As a result, no fewer than twenty-two of the Jewish inmates who escaped Sobibor during the uprising there in October 1943 died at Polish hands in subsequent days, at least eight of them killed by a unit of the Armia Krajowa. In August 1944, the Barwy Biale detachment of the Home Army, now part of the 2nd Legions Infantry Regiment, discovered three to four dozen Jewish escapees from the Skarzysko-Kamienna munitions factory hiding in a forest and slaughtered every one of them in cold blood.\n\nWhether for religious, social, personal, or political reasons, many peasants and even resistance units in rural areas also routinely killed or turned in hundreds of Jews who tried to hide from the Nazis. In fact, these Poles did this increasingly as time passed and right up until the end of the German occupation. Zygmunt Klukowski, a physician in a small town near Lublin, wrote in his diary on November 26, 1942:\n\nThe farmers are seizing the Jews hiding in the villages, out of fear of possible reprisals, and are taking them to the town, or sometimes simply killing them on the spot. In general, there has been a strange brutalization in relation to the Jews. A psychosis has seized hold of people, and, following the German example, they do not consider the Jews to be human, regarding them rather as an injurious pest that must be exterminated using all available means, like a dog sick with rabies or a rat.\n\nOn many occasions, the so-called Blue Police, the remaining Polish cops on the beat, and local units of voluntary firefighters were also involved in flushing out hidden Jews or picking them up after locals reported their locations. Whenever a successful hunt for Jews in hiding occurred, the local Polish leaders who led it got the right to distribute any property obtained, including the clothing of the victims. Meanwhile, the Germans offered rewards for each Jew delivered up, sometimes kilograms of sugar, sometimes money, and sometimes vodka, and threatened communities in which Germans found concealed Jews with collective punishment. Fear of such punishment had a lot to do with the collective psychosis that Klukowski noticed.\n\nThe evidence that is accumulating suggests that, at a conservative estimate, at least as many non-Jewish Poles turned Jews in as hid Jews from the Nazis. The vast majority of Polish Christians did neither of these things, but the minorities that helped or harmed Jews appear to have been unevenly balanced. Particularly in rural areas, the chances of being protected long enough to survive were slight. One study of what happened in Dabrowa Tarnowska County, about fifty miles east of Cracow, traced in the Polish and German archives and the records of postwar trials the destinies of some 337 Jews who tried to hide there after the liquidation of the ghettos. Fifty-one succeeded and emerged alive after the Soviet armies arrived, but 286 perished between 1942 and 1945. Among those killed, people who died at the hands of Polish civilians and police outnumbered those murdered by Germans 122 to 105. Tellingly, the underground press divided sharply in commenting on this sort of collaboration, with some resistance papers condemning it as shameful while others proclaimed, \"[W]e have to punish those who want to hide Jews and declare them [that is, the protectors] traitors.\" That divergence may account for something else apparent from those figures regarding Dabrowa Tarnowska: Most people who hid Jews there did so in return for money or other payments, yet very few of the Jews hidden on that basis\u2014only 9 percent\u2014actually managed to survive the war. This suggests that they were turned in when they ran out of valuables to exchange for protection.\n\nFourth, during the German occupation, the Polish resistance did rather little to help Poland's Jews, even though it was fully and quickly informed, first, about the conditions in the ghettos and, later, about the deportations and the death camps. The AK did pass its knowledge, including specific references to gassings, to the Polish government-in-exile in London, which publicized it, and did make sure that the underground press within the country disseminated the information. Official proclamations warned Poles against collaborating with the persecution of Jews or blackmailing those in hiding, and late in the war AK units carried out executions for such offenses. Moreover, that government sent Jan Karski to Britain in November 1942 and on to the United States in July 1943 to brief leaders on what was happening in Poland. But in keeping with the Home Army's strategy of hoarding strength until Nazi rule in Poland was on the verge of collapse, the AK made no effort to impede the transports from Warsaw or to blow up the rail lines to Belzec, Sobibor, and Treblinka. For the same reason, the AK provided only modest support for the Warsaw Ghetto Uprising in the spring of 1943: a total of fifty pistols, fifty hand grenades, about ten pounds of explosives, two unsuccessful attempts during the fighting to blow holes in the ghetto walls, and several sniper attacks on German guards. This level of assistance actually marked the high point of AK help to Poland's Jews. After Tadeusz Komorowski succeeded the captured General Rowecki as commander of the Home Army in July 1943, its willingness to aid Poland's few surviving Jews declined. Instead, the AK displayed greater eagerness to combat the so-called banditry of Jewish fugitives and partisan units that survived by requisitioning from peasants.\n\nPerhaps the most powerful demonstration of the halfhearted nature of the Polish resistance's support for Jews is the story of the organization that the government-in-exile formed for that very purpose. Zegota, the Committee to Aid the Jews, was supposed to do so by funding forged papers and hiding places. Not only did it come into existence rather late, in the autumn of 1942, after most Polish Jews had been killed, but its effectiveness was limited. Estimates of how many people the group actually saved vary widely but top out at several thousand, most of them children. Even the leaflet that called for public protests against the deportations and led to the formation of Zegota betrayed the ambivalence toward rescue that undermined such efforts. Zofia Kossak, the author, could not resist noting: \"Our feelings toward the Jews have not changed. We continue to deem them political, economic, and ideological enemies of Poland.\" The Catholic Church hierarchy provided no support and took little notice of the organization, and most of its funds\u2014certainly most of those that actually got to Poland\u2014came from Jewish sources abroad, not the London-based Polish government. One reason for this was that the faction of the National Party in the Polish government-in-exile refused to join or support Zegota and kept up a constant drumbeat of underground antisemitic propaganda.\n\nThe National Party's presence and actions undermined the government-in-exile's declarations that postwar Poland would be a state in which all citizens had equal rights. In fact, one of the most remarkable aspects of the Holocaust in Poland is how little impact the carnage had on the attitudes that had prevailed toward the nation's Jews before World War II. A survey of the leaders of thirteen political groups in the Polish resistance at the end of 1943 established that they favored liquidation or emigration of the Jews over integration and equality in a postwar state by a ratio of nine to four. Even among political prisoners in the concentration camps, according to Hermann Langbein, the persistent antisemitism of the Poles stood out.\n\nFifth, precisely because there were more Jews in Poland than anywhere else, more people stood to gain by their disappearance than anywhere else, and this, too, undercut any sense of solidarity. In fact, the Nazis consciously set out to buy the loyalty of non-Jews, especially in the regions conquered from the USSR in 1941, by swiftly giving away Jews' household possessions to the local populations and by turning schools, community houses, synagogues, and hospitals into service facilities for the local non-Jewish population. And even the death camps became sources of local enrichment, since the surrounding villages profited from the spending of guards and sometimes from the black market in goods taken from the people killed. Thanks to rumors that spread through the occupied country, currency and jewelry dealers set up shop around Treblinka in 1942\u201343, and prostitutes were drawn to the area. The extent to which many ordinary Polish citizens benefited from the murders is apparent even today in the Polish restitution laws, which stipulate that no one can reclaim property stolen from Jews unless the applicant is a resident of Poland. Given that most surviving Jews left after 1945 or were driven out by the late 1960s, this law effectively protects a massive degree of theft, and it was designed to do so precisely because the theft was so massive.\n\nSixth, antisemitism in Poland outlasted the Holocaust and continued afterward. Nechama Tec, who studied rescuers and who survived wartime Poland thanks to several of them, recalls in her memoir, _Dry Tears_ , that the first thing her protectors asked of her after the Russians liberated their town was not to tell anyone who had hidden her. Many other hidden children in Poland have reported the same thing, and when the Jewish Historical Commission in Cracow began to publish the names of rescuers in 1947, many of them requested that the organization omit them in the future. Polish rescuers often expected disdain from their neighbors for their kindness, not praise or respect, and often got what they expected. The only family to hide Jews from the massacre in Jedwabne in 1941 experienced so much disapproval after the war that most of the members emigrated to Chicago.\n\nMultiple pogroms broke out in Poland after the war; one of them took the life of Chaim Hirszman, one of only two survivors of Belzec. The Kielce pogrom of 1946 erupted when someone claimed that the Jews who had returned to live in the city's Jewish community center had kidnapped and killed a gentile child, just as the ancient blood libel alleged. Jan Gross, who has closely studied what happened in a book called _Fear_ , argues that the pogrom was not just an outbreak of endemic Jew hatred but also an attempt to remove witnesses to the extent of previous Polish complicity in the Holocaust. Indeed, a good deal of prosopographical evidence suggests that some of the most enthusiastic Polish antisemites in 1942 and 1946 tried to cover their tracks after the war by becoming some of the most enthusiastic Polish collaborators with communism. Meanwhile, other antisemites simply carried on the old tradition of depicting Jews as people ready to betray Poland to the Reds and spread stories\u2014once more exaggerated, but not completely unfounded\u2014of Jewish \"overrepresentation\" in the communist security services.\n\nAs a result of the pervasively antisemitic atmosphere, some 250,000 Jews, including many who had just returned to the country from their earlier refuge in the Soviet Union, fled westward from Poland in the first years after the war ended. In the late 1960s, the communist government of postwar Poland organized a so-called anti-Zionist campaign, largely in order to divert mounting popular unrest but also to disprove the regime's lingering reputation with the Polish public as a tool of Jews. After 1989 and the fall of communism in Poland, Lech Walesa, the hero of the Solidarity movement, showed how persistent antisemitism remained in parts of Polish society. He tried to discredit a competing candidate for the presidency of Poland by asserting that he was of Jewish descent and later dismissed Jan Gross's findings about Jedwabne as the work of \"a Jew who tries to make money.\"\n\nSeventh, more Poles are commemorated at Yad Vashem for saving Jews than any other nationality. In part, this simply follows from the fact that Jews were more numerous in Poland than anywhere else, so even a lower than average number of would-be rescuers would have saved more people or died trying than elsewhere. Still, Tec's studies and those of other scholars contain thousands of stories of Polish courage in defense of Jews in a place where this was especially dangerous. Emanuel Ringelblum, the creator of the Oyneg Shabes archive in the Warsaw ghetto, was hidden, along with his wife and son and thirty-four other Jews, in a hideout prepared and owned by a non-Jew named Mieczyslaw Wolski. He and his nephew were killed with those Jews when the Germans discovered the bunker in March 1944. Polish and German researchers have identified reliably almost 1,000 cases of Poles executed for helping Jews in hiding, nearly all of them not included in the Yad Vashem total.\n\nSo, to what conclusion do these seven points lead? Above all, to a call for understanding and for suspending the mutual blaming and competing claims to having suffered worst. The key point to remember is that the Nazis created a Hobbesian world in annexed and occupied Poland, where no indigenous government existed to exert restraint and different parts of the population were constantly pitted against each other in a desperate struggle to survive. This was not fertile ground for the growth of a sense of common interest. The environment was far more conducive to preoccupation with one's own interests and taking advantage of opportunities. That is why the fact that the Nazis victimized Poles in many ways did not immunize some Poles from several sorts of complicity in the Germans' crimes.\n\nAchieving this kind of balanced perspective has been and will continue to be much harder for people in Poland than it should be for those living elsewhere. This is because interpreting a nation's history is generally a high-stakes political game to its citizens; as William Faulkner famously observed, \"The past is never dead. It's not even past.\" Ever since 1945, descriptions of non-Jewish Poles' behavior toward Jewish ones during the Holocaust have provoked considerable controversy in Poland. People on the left, considering themselves increasingly secular and progressive and perhaps less embittered by the experience and memory of communism, have dwelled upon the hostility or indifference of the Catholic Church and the antipathy of the Home Army toward Jews. People on the right, closely identified with Catholicism and traditional values and still mistrusting the supposed Jewish-Bolshevik connection, have focused on every remotely demonstrable image of Christian charity and national generosity toward persecuted people in wartime Poland. Because these views of history function as sources of both identity and legitimacy in the present, Poles will continue to argue intensely over who did what to whom on their soil in the years 1939\u201345.\n\nBut the rest of us should have less difficulty acknowledging and empathizing with the suffering of nearly all parties, without asserting a false equivalence. The fate of the non-Jews who largely survived the war was not the same as that of the Jews who were, at least in Poland, virtually wiped out. Jews in occupied Poland were fifteen times more likely to be killed than non-Jews. And an ideological reason accounts for the difference: In the Nazi New Order, the Jews were destined for swift death, the Poles for enslavement and exploitation, but for extinction only when the time came that Germany no longer needed their labor.\nCHAPTER 7\n\n[ONLOOKERS:  \nWhy Such Limited  \nHelp from Outside?](contents.xhtml#ch_7)\n\nIF THE NAZIS meant what they said during the 1930s, namely that their goal was to \"remove\" Jews from German territory, then the best chance to save large numbers of Jews from what later became the Holocaust lay in their escape to other countries. As it happened, 60 percent of the Jews of Germany did get away in this fashion, along with 67 percent of the Jews of Austria, and about 25 percent of the Jews in Bohemia and Moravia. But very few Jews in Hitler's path toward living space could emigrate in the 1930s\u2014even fewer once the murders began. Instead, Jews discovered that no outside power would or later could offer them much beyond rhetorical support and promises of reprisal, and even this sort of backing was quite measured. Why couldn't more people get out of harm's way? Why did the Jews receive such limited help?\n\nThe short answer is that a combination of antisemitism and economic and political interests worked to restrict the admission of Jews to other countries throughout the Holocaust and to inhibit other action on their behalf. Sooner or later, every nation that might have helped decided that it had higher priorities than aiding or defending Jews. So did the League of Nations, headquartered in Geneva; most non-governmental organizations, such as the International Olympic Committee and the International Committee of the Red Cross; and almost every transnational religious institution, including the Catholic Church. The result was an erratic line of possibility for those persecuted within Germany's borders. Opportunities to get out of Nazi hands were widest in 1933\u201334 and again in 1938\u201339, but very narrow in the years in between or afterward. For the Jews of Eastern and southeastern Europe in the 1930s, the prospects were even worse.\n\nPREWAR EVASIONS\n\nThe initial opportunity for Germany's Jews stemmed from the hospitality of four democracies on the Reich's periphery: France, the Netherlands, Belgium, and Czechoslovakia. Revulsion at Nazi brutality arose in all four places, reinforced, in the case of the French, who took in 55,000 Jews between 1933 and 1939, by the same receptiveness to other immigrants that France had shown since the Great War depleted the nation's population. But in all four instances, sympathy declined over time, especially in France, where the late onset of the Depression compared to other countries meant that hostility to economic competition from refugees peaked just as the need for asylum did. By the mid-1930s, France enacted various rules that made immigration less appealing, restricting the practice of medicine to citizens and placing quotas on foreign artisans who could enter the country, for example.\n\nAfter 1936, four other arguments arose and gradually narrowed the passage through France's gates. First, the popularity of the policy of appeasing Nazi Germany\u2014that is, allowing changes to some of the terms of the Versailles Treaty in order to avoid war\u2014made the presence of Jewish refugees politically inconvenient. Second, the election in 1936 of L\u00e9on Blum, a Jew, as prime minister of a leftist government called the Popular Front mobilized antisemitic feeling among French conservatives. Third, opponents of immigration stoked suspicion that escapees from Nazi Germany would include spies who would undermine French security. And fourth, critics pointed out that letting in German refugees would lead to admitting far more numerous Jews seeking to escape from Poland. The influential journalist Emmanuel Berl, himself a Jew, argued in November 1938 that such people were \"taken as a whole not very desirable.\" Opening the borders to them, he said, would be an act of \"crazy generosity.\" Even the French Jewish Committee split over the advisability of increasing Jewish immigration and failed to make a strong case for it. After _Kristallnacht_ , France actually made getting into and staying in that country more, not less, difficult for refugees, imposed prison sentences on illegal residents, and even sentenced the aunt and uncle of Herschel Grynszpan to six months in prison for having let him live in their home as an unauthorized immigrant.\n\nThe trend of events in the Netherlands, Belgium, and Czechoslovakia was similar, though not for exactly the same reasons. In Holland, the general policy was to take in any refugees who crossed the border but to make sure that the local Jewish community, through its Jewish Refugee Committee, formed in 1933, paid for their upkeep, and then to hasten them on their way. Thus the Dutch government progressively narrowed work opportunities for Jews in Holland during the 1930s. The 22,000 German Jews who were in or had passed through the Netherlands by the end of 1937 depended almost completely on charity, much of it obtained from the American Jewish Joint Distribution Committee, usually referred to as \"the Joint.\" The name reflected the organization's origins as an alliance of philanthropic groups associated with differing strains of political and religious opinion within the American Jewish community. Following the German pogrom of November 1938, the Dutch government decided to intern all new immigrants in camps for which the Refugee Committee would have to provide a million guilders ($550,000 at the time) in construction and maintenance funds. Though Holland generally did not enforce its threat to turn away all refugees at its borders beginning in December 1938, construction of a central internment camp at Westerbork began for the estimated 23,000 to 30,000 German Jewish refugees in the country as of early 1939. Of that number, 7,000\u20138,000 got away before the Germans invaded in May 1940. Belgium also took in about 30,000 German Jews between 1933 and 1939, about half before and half after the pogrom, but also made entering the country and staying progressively more difficult. Statistics from Czechoslovakia highlight its hardening policies: 60,000 Austrian Jews applied for residence following the pogrom of November 1938, but only about 6,000 got in, most of them illegally. In short, the chances of finding refuge in Western Europe declined as desperation to escape Nazi Germany rose.\n\nSwitzerland provided the most glaring illustration of this tendency to close the escape hatches precisely when they were most needed. Never very receptive to Jewish refugees during the 1930s, thanks largely to the efforts of an antisemite named Heinrich Rothmund, who headed the Swiss Federal Police for Foreigners, the country actually sealed its borders on August 19, 1938, and deployed troops to catch and repatriate anyone trying to enter from Nazi-occupied Austria without the appropriate visa. Paul Gr\u00fcninger, a courageous police captain in the frontier canton of St. Gallen, was one of the rare officials who refused to comply with these instructions. As a result, about 1,000 Jewish refugees slipped into Switzerland via his jurisdiction before his conduct cost him his job early in 1939. Meanwhile, in order to preserve normal tourist traffic with Nazi Germany while keeping Jews from there out, the Swiss persuaded the Germans to stamp the passports of German Jews with a large _J_ and began categorically refusing them admission. One month later, in October 1938, the Swedes adopted the same practice.\n\nThroughout the 1930s, the USSR declined to offer a haven to all but a handful of ranking Jewish communists. The Soviet Union declared that Jewish refugees were unsuited to life in an unfamiliar socialist society and, in any case, not the USSR's responsibility, since their persecution was a product of capitalist quarreling. From September 1935 on, Jews entering the socialist motherland had to satisfy several discouraging and, at least in part, mutually contradictory preconditions: proletarian ancestry, possession of substantial amounts of money, and willingness to become Soviet citizens and perform manual labor on construction sites in northern or eastern parts of the USSR.\n\nBritain saw its role in the crisis of German Jewry as that of a \"transit nation,\" one that might allow refugees to land on the \"tight little island\" but not to stay very long. Given the reluctance of the Dominions, such as Canada, Australia, New Zealand, and South Africa, to provide destinations\u2014South Africa, for example, accepted only 6,000\u20137,000 Jewish refugees during the 1930s and Canada fewer than 5,000 in the entire period of 1933\u201345, including a grand total of only 23 from Germany and Austria during 1938, the year of the _Kristallnacht_ pogrom\u2014this self-image meant that Britain was not a frequent refuge for Jews seeking to get out of Germany. The country took in only about 70,000 European Jews during the 1930s, only 10,000 of them up until the end of 1937, and fully 50,000 of them just in the short time from January to September 1939, including some 10,000 young people on the famous _Kindertransport_ , the Children's Transport.\n\nMoreover, Britain pursued similarly restrictive policies in Palestine, the territory in the Middle East from which the Romans had driven most Jews in ancient times and to which Zionists wanted to return, but which for the present was subject to British rule under a mandate from the League of Nations. To be sure, in the Balfour Declaration of 1917, the British government had declared its rhetorical support for a future \"national home for the Jewish people\" in the region, largely and cynically for two reasons. First, Britain wanted to bolster its claims to the territory after the war. Second, the British cabinet hoped the declaration would prompt allegedly influential Jews in the United States and elsewhere to support the countries then at war with Germany and Austria. Ironically, Edwin Montagu, the only Jewish member of the cabinet at the time, voted against the declaration, in part because he was appalled by the antisemitic overtones of this fantasy of Jewish power, in part because he rejected Zionism as likely to bring strife and misery to Palestine. Partly in consequence of the declaration, the Jewish population in the region rose to around 400,000 by the mid-1930s. This growth set off the violent backlash that Montagu had predicted in the form of the Arab Revolt (1936\u201339). Henceforth, the British thought that their control, not only of Palestine but also of the Suez Canal, the jugular vein of the British Empire, depended on placating Arab opinion, so they reduced the already low permissible annual quota of Jewish immigrants. Whereas 149,076 Jews from all countries got into Palestine from 1933 to 1935, only 54,899 did in 1936\u201338. The annual intake rose again in 1939, but only to 31,195, and a government white paper of May 1939, issued just after the revolt finally was suppressed, set the quota for the ensuing five years at 15,000 per annum for a total of only 75,000 more places, after which Jewish immigration to the region would cease altogether. The British explicitly stated that their goal was to confine the Jewish proportion of the population in Palestine to one-third.\n\nIn Britain, as virtually everywhere else, the people who made these restrictive policies claimed to be haunted by the specter of what might happen if they were more generous. They feared that more open borders would prompt Eastern European governments, especially those in Poland, Hungary, Romania, and Lithuania, to enact even more antisemitic measures than they already had and thus to set off an exodus of almost five million Jews, which is to say 5.5 times the combined Jewish population of Germany, Austria, and western Czechoslovakia in 1933. Such concerns were not imaginary. At the meeting of the Council of the League of Nations in May 1938, Poland and Romania explicitly expressed the desire to reduce the size of their Jewish populations and requested aid in doing so. The following October, Poland's ambassador in London tried to blackmail Britain into allowing 100,000 Polish Jews into its colonies per year by stating that otherwise his government would be \"inevitably forced to adopt the same kind of policy as the German government.\"\n\nThe fate of these Eastern European Jews also haunted the Jewish Agency in Palestine, to which the British occupation authority delegated the distribution of the annual allotment of legal entry permits, and that fact further narrowed the access of German Jews to the region. Because the Jews of Poland and Romania seemed equally in danger but were historically more pro-Zionist and currently had fewer avenues of escape than the Jews of Germany, the agency restricted the latter population's share of the permits awarded annually from 1933 to 1938 to an average of only 22 percent. The proportion exceeded one-third in only the last of those years, when it topped 40 percent. In short, Nazi racism set off a vicious circle in which partial success in driving Jews out of Germany encouraged imitation by bigots in countries to the east that, in turn, pressured potentially hospitable places into scaling back possible exit opportunities for German Jews.\n\nFear of a refugee flood also prevailed in the United States, along with other obstacles to generosity toward refugees from Nazi persecution. The problem was not at the top of the American government; President Franklin D. Roosevelt was no antisemite\u2014indeed, he appointed more Jews to senior positions in government than any president before him. He was anti-German, an attitude born of both bad experiences with a German governess in his youth and his service as secretary of the navy while the United States fought Germany in 1917\u201318. But existing American law and public opinion hamstrung him from doing much to help Jewish refugees during the 1930s, and he avoided taking political risks for the sake of Jews abroad.\n\nThe legal obstacles stemmed from the quota system of immigration that the United States introduced during the 1920s. It set a maximum total of 150,000 legal entrants to the country annually and apportioned that figure almost entirely among European nations according to the share of the American population that traced its descent to each of them in the census of 1890. The year was not an accidental or arbitrary choice but an intentional and eugenicist one. Congress selected 1890 because it antedated a great influx of immigration from Italy, the Balkans, and Russia around the turn of the century. America's legislators wanted to give preference to predominantly White Anglo-Saxon Protestants over all others. Ironically, this resulted in a relatively large permissible number of arrivals from Germany per year, 25,957 people\u2014relatively large as a share of the number of entrants allowed annually (more than one-sixth) but, of course, tiny in relation to the need in the 1930s, since Germany had 560,000 inhabitants whom the Nazis considered Jews when Hitler came to power and later added some 300,000 Jews in Austria, the Sudetenland, and Bohemia-Moravia. At almost 26,000 German Jewish immigrants a year, admitting everyone in this population would have required thirty-three years; admitting even the almost 310,000 German, Austrian, and Czech Jews who actually applied for entrance by 1939 would have required almost twelve years.\n\nBut the United States had no intention of admitting the full quota of German immigrants annually, let alone of allowing Jews to fill the full allotment. In fact, from 1933 to 1939, when the quota permitted the admission of up to 156,000 people, the United States let in only 77,000, including about 65,000 Jews. From all of Europe in this interval, the United States took in only 92,000 Jews. If one extends the time frame to 1933\u201344, the immigration total for America is probably about 225,000 Jews from all of Europe, including 120,000 Jews from Germany and Austria, and the number of unused German quota slots rises to 190,000.\n\nThese admission figures are paltry compared to the European Jewish population of nine million in 1939 or the six million Jews killed in the Holocaust. But 225,000 is three times the number of people Great Britain took in and almost fifty times the number that Canada accepted; 120,000 Jews is more than any other country admitted from the German Reich; the number the United States took rose annually from 1933 to 1940; and the total admitted from 1937 to 1941 was more than four times the total of the preceding four years. In 1938, President Franklin Roosevelt combined the immigration quotas for Germany and Austria to raise the permissible number of entrants to 27,370 and thus improve the odds of Jews getting out, and in 1939, he issued an executive order indefinitely extending the visitors' visas of all Jews then in the United States, thereby saving another 15,000 Jews from repatriation and death. The most authoritative study of FDR and the Jews concludes that between 1937 and 1941, \"FDR's second-term policies likely helped save the lives of well over 100,000 Jews.\" In other words, America performed terribly in the face of the crisis of European Jewry, except in comparison to every other country. Moreover, at least until World War II broke out, American receptivity gradually increased, precisely as refuge in Europe was growing generally harder to find.\n\nWhy didn't the United States do better? The short answer is that both powerful individuals and public opinion opposed doing better, with the results that no serious move to change the immigration quotas arose, and strict enforcement of immigration rules held down the numbers admitted until very late during the 1930s. American policy was not as harsh as British, which assured that that country admitted more than five-sevenths of its total refugees at the last minute before World War II began. Still, in the United States, the comparable figure was one-half in the short interval between _Kristallnacht_ and mid-1939.\n\nOpposition to immigration fed on three primary causes: fear of economic competition, popular nativism and isolationism, and elite antisemitism. The fear of economic competition was expressed in many quarters. For example, the dentists of Westchester County lobbied FDR's political advisor Samuel Rosenman to prevent the admission of any more refugee dentists into the country, and the national conventions of the Veterans of Foreign Wars and the American Legion passed resolutions against further immigration so long as unemployment persisted in the United States. Such resistance resulted in strict enforcement of the Likely to Become a Public Charge, or LPC, rule, which denied immigration to people considered so lacking in funds that they would become dependent on welfare. U.S. consular officials abroad, who received applications to immigrate, required extensive data on each person's likely financial resources after arrival and generally set, as their superiors in Washington required, a high standard for economic security before granting a visa. Frances Perkins, the secretary of labor, argued vehemently for a relaxation of these standards, but the State Department argued equally forcefully in their favor. FDR sided with State except in two brief intervals, one during late 1936 and the second in 1938\u201339 after the _Anschluss_ and _Kristallnacht_.\n\nThe rationale behind FDR's stance was straightforward: The American public opposed letting more people in. Throughout the 1930s, every national public opinion poll on the question showed that two-thirds to three-quarters or more of Americans rejected the relaxation of the quotas and the admission of more refugees. As a result, early in 1939, Congress defeated the Wagner-Rogers Bill, which would have admitted 20,000 Jewish children under the age of fourteen to the United States. Not only was the general public hard-hearted, but student opinion followed: the _Daily Northwestern_ of December 13, 1938, reported that 68 percent of American students were against more admissions for fear of \"imperiling U.S. living conditions.\" The sad truth is that virtually no politician outside of a few urban centers on the East Coast could get elected in the United States during the 1930s on a platform of offering asylum to the Jews of Europe. FDR was a politician who had to win across the nation, not just in these pockets of empathy.\n\nNativism and isolationism were revved up by the radio broadcasts of a Detroit-area priest named Father Charles Coughlin, who peddled the same charge against Jews that others had leveled at his Irish forebears decades earlier, namely that they could not fit into American life. He had an audience of three million fans listening weekly and cited (and republished) the infamous _Protocols of the Elders of Zion_ to make his point. The Catholic hierarchy did not muzzle him until 1942. Meanwhile, far more mainstream figures played on American antisemitism, including those leaders of the Republican Party who declared that, thanks to FDR's appointment of many Jews to office, he was offering the public, not the New Deal but the Jew Deal. Given such attitudes, perhaps one should not be surprised that a poll in 1938 found that 58 percent of Americans considered Jews in Europe at least \"partly\" at fault for their own persecution. Another survey in July 1939 showed that 32 percent of Americans believed Jews had too much influence in business, while another 10 percent favored deporting Jews. The prevalence of these views caused even the proponents of helping Jewish refugees to sanitize their vocabulary and to speak of \"persecutees\" who needed help, not of Jews.\n\nA telling illustration of the forms antisemitism could take comes from the history of the university where I taught for thirty-six years, which had restrictions on the number of Jews admitted annually until the 1960s. In January 1939, the _Daily Northwestern_ ran an article about a class in the Medill School of Journalism that had compiled a list of the ten greatest news stories of 1938. The group considered worthy of inclusion such by now long forgotten events as the wrong-way flight of Douglas Corrigan\u2014he ostensibly set out to fly to California from New York but went to Ireland instead\u2014and the Lima Conference of Pan-American states, but not the _Kristallnacht_ pogrom, even though the burning of the synagogues in Germany in November 1938 had made the front page of the _Chicago Tribune_. On the almost universally white and predominantly Protestant students of Medill, the attack on Jews in Germany seems hardly to have registered.\n\nAttitudes at Northwestern testified to the power of antisemitism among American elites in the 1930s. Especially important as a representative of this current was an assistant secretary of state with the sonorously white Anglo-Saxon Protestant name of Breckenridge Long. A former ambassador to Italy and a fervent admirer of Mussolini, he fought hard to keep down the number of Jews admitted to the United States annually. His most convenient and effective argument was the possibility that relatives remaining in Germany could be used to blackmail refugee Jews into becoming spies for the Reich. Every train or boat carrying Jews out of Nazi Europe, he said, \"is a perfect opening to Germany to load the United States with agents.\" As a result, early in June 1941, the U.S. State Department instructed its consuls worldwide to deny visas to foreigners who had close relatives in Germany or the countries it controlled.\n\nAgainst these impediments to accepting more refugees, no political force arose that was strong enough to prevail. FDR chose at key moments to offer modest help, but he did not want to incur political costs. Immediately after the _Anschluss_ , he asked his cabinet whether Congress would support an expansion of the German immigration quota but backed off when the members answered in the negative. He became even more cautious after the Republicans, including many isolationists, gained eighty-one seats in the House and eight in the Senate the following November, a few days before _Kristallnacht_. In 1939, he encouraged several Latin American states, notably Bolivia, Brazil, the Dominican Republic, and Paraguay, to admit more Jewish refugees. But he also refused to issue a special order to let the refugee ship _St. Louis_ land in the United States or even in the U.S. Virgin Islands, as offered by that territory's governor and legislative assembly and advocated by two members of FDR's cabinet. He also declined to endorse the Wagner-Rogers Bill. Taking the long view, he decided that such actions would undermine his effort to get Congress to repeal America's Neutrality Acts and thus would prevent him from helping countries to resist Hitler's aggression later. Shortly thereafter, he backed away from the idea of using Alaska as a refuge for Jews once he learned that he would then have to set up new restrictions on travel between there and the continental United States. At a press conference in June 1940, he even repeated Long's claim that the German government was threatening to shoot the relatives still in the Reich of refugees who declined to work as spies for Germany. Finally, in March 1941, FDR did nothing to reverse the U.S. Maritime Commission's denial of permission for an ocean liner, the _S.S. Washington_ , with a capacity of 1,700 passengers, to add a direct route to New York from Lisbon, almost the last escape hatch from Europe.\n\nInterestingly enough, German intelligence offices in occupied Holland did concoct a scheme for smuggling agents into the Americas under the cover of releasing Jews, and some 486 of them got permission to leave the Netherlands for Spain, the Caribbean, and South America between May 1941 and January 1942. But in view of the time frame, this project clearly was an outgrowth of Long's often publicly expressed fears as much as a vindication of them.\n\nThe American Jewish community proved on its own incapable of rallying popular solidarity with Europe's Jews. Though Jews then constituted a slightly larger percentage of the U.S. population than they do now, they were divided by heritage between the American Jewish Committee, whose members traced their lineage back to Germany for the most part, and the American Jewish Congress, headed by Stephen Wise, whose members hailed primarily from Eastern Europe. The former group feared that too much agitation for Jewish immigration would stoke antisemitism and preferred behind the scenes, high-level efforts to exert influence. The latter group favored public rallies and boycotts of German goods to put pressure on the Nazi regime. Neither organization had much effect on U.S. policy toward refugees. The two groups also differed in their attitudes toward the creation of a Jewish state: the committee's leaders were non-Zionist or sometimes anti-Zionist, whereas the congress favored settlement and eventually a Jewish state in Palestine. That stance on the part of the congress meant that it had conflicting priorities: Escape to the United States was not escape to the prospective Jewish homeland, so it was both desirable and not. Even David Ben-Gurion, the principal Jewish leader in Palestine, feared that too much receptivity to Jewish refugees elsewhere would endanger the Zionist project. Conversely, the American Jewish Joint Distribution Committee, dominated by the American Jewish Committee, preferred to concentrate its resources on supporting the increasingly impoverished German and Eastern European Jewish communities and on sustaining refugees in Europe and the Western Hemisphere rather than on aiding immigration to Palestine.\n\nThe difficulties of getting out of Germany gave rise to an improbable escape route in late 1938, one of the few that remained available in the early years of World War II. Perhaps 17,000\u201320,000 European Jews found refuge in Shanghai, on China's east coast, more specifically in the part of the city called the International Settlement, which a consortium of eleven countries ruled until December 1941, when Japanese troops marched in. People who reached the International Settlement needed no visa to enter, just transit visas through any countries en route, which were usually the USSR plus the Japanese puppet state of Manchukuo, in northern China, and both were happy to collect the fees. The Japanese occupiers confined the Jews to a slum neighborhood called Hongkew, where most of them survived the war through complicated transfers of aid from the Joint Distribution Committee.\n\nThe futile Evian Conference of 1938 reflected a widespread tendency of nations to pass the buck when it came to offering a haven to Jews. The outcome confirmed the observation two years earlier by Chaim Weizmann, the president of the World Zionist Organization, that Jews confronted a globe \"divided into places where they cannot live and places they cannot enter.\" During the late 1930s, as historian Bernard Wasserstein writes, \"Dutch Guiana, Angola, Cyprus, the Philippines, the Belgian Congo, the Dominican Republic, Mexico, Haiti, Ethiopia\u2014each was broached, researched, and hailed as a potential haven. In each case obstacles were discovered and globes twirled again, until eyes fixed anew on the latest, ever more improbable land of redemption.\" In view of all this, the remarkable thing is how many people got out, not how few. The fate of the passengers on the refugee ship _St. Louis_ was prototypical, in this sense. Of the 937 Jews on board, 28 got off in Cuba, and one committed suicide. Of the 908 remaining, 620 were admitted to France, Belgium, and Holland, where 365 survived the war. Britain admitted 288, all of whom were similarly fortunate. In short, about three-quarters of the once apparently doomed passengers in fact found secure refuge from the Germans, and about half eventually found their way to the United States. But these were German Jews, and the large share of them who got out mirrored the relatively high overall escape rate of their fellows. Farther east, the chances were far worse. In the year 1937, for example, only 9,000 Jews managed to emigrate legally from Poland to any new homeland, and the annual U.S. immigration quota for that country came to only about 6,000 people.\n\nA similar sense of ambiguity surrounds the actions of another international player that might have done more to help the Jews in the 1930s, namely the Roman Catholic Church, especially its spiritual head in the Vatican. The Church's record has both up and down sides, but in the end, like most of the countries discussed thus far, it looked out for itself first and did not do nearly as much not only as it could have done but also as its leaders at one time or another actually thought of doing.\n\nFrom the start, the Church's leaders in Rome recognized that Nazism represented a barbaric force. They had to be talked into signing the Concordat with Hitler in July 1933 by Germany's Catholic cardinals, a majority of whom favored the agreement as the only way to limit Nazi incursions on Church activities. Almost immediately after Hitler came to power, a group of Jesuits began drafting a condemnation of Nazism for the pope to issue. Four years later, this document became the encyclical entitled _Mit brennender Sorge_ ( _With Burning Sorrow_ is the official translation, but _Sorge_ actually means \"concern\" or \"anxiety\"). Despite that dramatic label, the wording was considerably watered-down from what the Jesuits had prepared. Though it denounced the glorification of race and nation as \"idolatrous,\" the text did not mention Nazism by name and was far less critical of Germany's ruling regime than another encyclical condemning communism issued only a few days earlier. The juxtaposition was telling: However much the Church's leaders in Rome despised Nazism, they always hated and feared communism more, and this fact consistently caused the Vatican to pull its punches in dealing with Hitler's regime. When the Nuremberg Laws appeared in 1935, the Church said nothing. It was likewise silent in 1938, when Nazi mobs burned synagogues, smashed homes and shops, and arrested and beat Jews.\n\nChurch authorities hardly could mount a full-throated defense of Jewry from persecution because they had so long advocated and indeed enforced forms of it. As Mussolini pointed out when he inaugurated Italy's first antisemitic laws in 1938\u2014which excluded Jews from the Fascist Party, the military, and public education, ejected them from honorary societies, revoked grants of citizenship to them since 1919, and limited the size of businesses or estates they could own\u2014these restrictions were not as severe as the ones the popes had imposed in the lands they ruled until 1870, including the city of Rome. Moreover, the limits on Jewish activity were quite similar to those that major Catholic publications, including _La Civilt\u00e0 Cattolica_ , the biweekly Jesuit publication whose contents had to be cleared by the Vatican before printing, had been advocating for more than fifty years. Behind that advocacy stood the Church's traditional conviction that contact with Jews could corrupt the faith of believers, now reinforced by the view that Jews, Freemasons, and Bolsheviks constituted an unholy modern and conspiratorial alliance against all that the Holy Mother Church stood for. Shortly before the publication of _Mit brennender Sorge_ , _La Civilt\u00e0 Cattolica_ published \"The Jewish Question,\" an article that denounced the Jews' supposed \"domination over money and their preponderance in socialism and communism\" and concluded by suggesting that the only way to contain their influence was to strip them of citizenship in Christian nations. In May 1937, another article began with this sentence, \"It is an evident fact that the Jews are a disruptive element due to their spirit of domination and their preponderance in revolutionary movements,\" and went on to advocate segregating Jews from Christians. And, in mid-July 1938, the journal wrote of the Jews' \"messianic craving for world domination\" before endorsing the recent enactment of laws in Hungary designed to restrict Jews' professional opportunities.\n\nNonetheless, Pope Pius XI, who reigned until February 1939 and grew increasingly appalled at Nazi violations of the terms of the Concordat and glorification of the Aryan race, contemplated speaking out. In September 1938, he told a group of Belgians visiting the Vatican, \"antisemitism is inadmissible. Spiritually, we are all Semites,\" and just before Christmas that year, he referred to the Nazi swastika, for which the German word is _Hakenkreuz_ (hooked cross), as \"a cross that is the enemy of the Cross of Christ.\" But these remarks remained known only to the few who heard them and passed them on. Temporizers and outright antisemites in the Vatican not only made sure of that but also undercut an initiative the pope had taken the previous June, when he asked an American Jesuit named John LaFarge to draft an encyclical tentatively titled \"The Unity of the Human Race.\" Wlodzimierz Ledochowski, the vehemently antisemitic head of the Jesuit order, first assigned two more traditionalist clergymen to assist LaFarge and then held up the completed text for months before reluctantly passing it on in January 1939, less than a month before the pope died. The document went no further than his bedside table. The text has survived, however, and it suggests that neither the Church nor the reigning pope could break free of the policy of caution toward Nazism or the doctrinal inheritance of certain forms of antisemitism. The text contained an ambivalent argument that on the one hand condemned racism as heretical and called for an end to the persecution of the Jews, but on the other, repeatedly referred to the supposed moral failings of Jews and the danger to the faithful of paying attention to or coming into close contact with them.\n\nEven that was too much criticism of Nazi racism for Pius XI's successor, the former Vatican secretary of state Cardinal Eugenio Pacelli, who took the papal name of Pius XII. In 1936, Pacelli had opposed issuing _Mit brennender Sorge_ as an encyclical to be read in German churches and suggested a mere pastoral letter to just the German bishops. Not without reason was he the candidate the Nazi envoys in Rome hoped would prevail in the conclave that chose the new pope. After his election on the third ballot, in March 1939, he destroyed not only all the copies of his predecessor's draft encyclical that his aides could find, but also the very plates on which a speech Pius XI had been planning on the subject had been printed. A Roman aristocrat by descent and a diplomat by training, Pius XII was a deeply cautious and conservative man with regard to both politics and theology. As the papal nuncio in Germany prior to Hitler's accession, he had grown fond of the country and critical of the Catholic Center Party for its participation in democratic politics, which he disliked, and for its longtime opposition to becoming part of a coalition government with the Nazis, which he advocated. Though not happy with the form the Concordat took and disappointed that it contained no protection for Jewish converts to Catholicism, he negotiated the agreement and then clung to it in subsequent years as the best hope for the Church's survival in the Third Reich. Above all, he abhorred \"godless communism\" and sought to coexist with any political regime that combated it.\n\nPius XII considered his chief duty to be to the Church and to Catholics, not to suffering people in general, and some critics have reproached him therefore for practicing parochial rather than pastoral politics. Not all of these critics have spoken in hindsight or from outside the Church. Some of the leading German clerics, notably Bishop Konrad von Preysing in Berlin, advised him to display greater firmness in dealing with the Nazi regime and to express greater solidarity with German Jews, but others overrode such arguments. The dominant voice was that of Cardinal Adolf Bertram in Breslau, who feared provoking a renewed persecution of the Catholic Church in Germany along the lines of Chancellor Otto von Bismarck's _Kulturkampf_ during the 1880s. Thus, although Preysing, for example, organized various efforts to help Jews in Berlin, especially ones who had converted to Christianity, the Vatican encouraged neither these actions nor their imitation by other dioceses.\n\nTo appreciate the constraints that Church leaders felt in the 1930s and 1940s, one has to grasp the importance of the sacraments in Catholic religious teaching. Broadly speaking, the Church's doctrine was \"no salvation without the sacraments\"; that is, one cannot go to heaven without having had access to baptism, communion, confirmation, confession, marriage, holy orders, and extreme unction or the last rites (now called the anointing of the sick). Moreover, one cannot have the sacraments without the clergy who administer them: no salvation without priests. Graham Greene's novel _The Power and the Glory_ (1940) provides an excellent testimony to the importance of the sacraments to Catholic doctrine. The flawed, alcoholic, and unchaste \"whisky priest\" at the heart of the plot goes underground in a corner of Mexico during the 1930s, when that country's government was trying to suppress the Church. In the story, his determination to risk his life to keep the means of salvation available to the faithful overrides his personal flaws and transforms a sinner into a holy man. The deliverer is essential; the power of the sacraments outweighs and cancels both his sins and those of his flock.\n\nThis indispensability of the sacraments is a doctrine that can disarm the Church in the face of ruthless and violent political movements. The threat to remove priests and suppress the Church is, given Catholic doctrine, a threat to deprive all Catholics in the areas affected of any hope of salvation. Fear of this threat propelled both the Church's anticommunism, since communists appeared intent on suppressing the Church, and its caution in challenging Nazism, lest it resort to suppression. And the Nazi regime proved adroit at exploiting these fears. It displayed animosity toward the Church on occasion, especially when it tried to remove crucifixes from school classrooms and engaged in show trials of supposed immorality among monks in the 1930s. But it always stopped just short in Germany of wholesale persecution. Like many other Germans and German institutions, as we have seen, Catholic leaders therefore tried to steer as clear as possible of challenging the regime \"in order to avoid worse.\" But worse for whom or what? Generally for them and their Church.\n\nWARTIME PRIORITIES\n\nAs German policymakers inched toward the decision to murder the European Jews, the worldwide failure to rally to their defense largely continued. To be sure, the Nazis permitted emigration from the continent until October 1941, and approximately 72,000 Jews got out of Greater Germany between the outbreak of the war and that date. But that was a relatively small number compared to the need. And after the slaughter began, the countries allied against Nazi Germany, the papacy, neutral countries, and Jews abroad did little to contain the carnage. Why?\n\nAllied passivity was not the result of ignorance of what was happening in Nazi-occupied Europe. Diplomats and journalists from neutral countries, a category that included the United States until December 1941, could read about ghettos in the German press, and businessmen from these nations, such as Swiss factory owners in Poland, witnessed the condition of Jews there and reported on the matter to their head offices. Once the killing began, the Allies learned of it almost immediately. British intelligence intercepted the reports of mass shootings in Russia by the Order Police as they began and passed summaries on to Winston Churchill every morning during the summer of 1941. Both he and the code breakers concluded on September 12 that continuing to do so was superfluous because he could do nothing in response. He could not even reveal the gruesome information for fear of tipping off the Germans to the deciphering of their messages. In October of that year, apostolic delegate Giuseppe Burzio, the Vatican's ambassador in Slovakia, reported the killings to the pope. By March of 1942, a representative of the Joint Distribution Committee in Budapest described the mass murders in Russia at a press conference in New York City, and many American newspapers picked up and publicized the information. That same month marked the beginnings of large-scale deportations to the first death camps, and the papal nuncio in Bern, Switzerland, gathered enough information about what was happening to report to the Vatican that deportation was tantamount to execution. The first published report of murders by gas appeared in the _Times_ of London on March 10, 1942, very shortly after they began on a large scale.\n\nBy May 1942, the flow of information was thickening. Father Pirro Scavizzi, a military chaplain with the Italian troops that participated in the invasion of the Soviet Union, came home on leave, secured an audience with the pope, and told him of the mass shootings. Meanwhile, the Jewish Bund Party in Poland smuggled out to the Polish government-in-exile in London an account of the gassings at Chelmno in particular and the massacre of the Polish Jews in general, which was then publicized by the British government and picked up by the American press. By June and July of 1942, the BBC and American newspapers were carrying fairly frequent reports of mass murder, though knowledge of gassing was not yet widespread, and Auschwitz had not been identified publicly by name.\n\nBut the information ran into considerable emotional and psychological resistance, and even among Jewish leaders disbelief prevailed for a long time. Mass annihilation seemed inconceivable, and those who did not want to accept its occurrence recalled the exaggerated stories that had been told in 1914\u201318, about the brutality of the German occupation of Belgium, as an example of how inflated tales circulate in wartime. As late as December 1944, a majority of the British public did not believe in the so-called atrocity reports coming out of occupied Europe. Incredulity persisted, even though all grounds for it fell away in the period between August and November 1942. In August, Gerhart Riegner, the representative of the World Jewish Congress in Switzerland, told the American vice consul there and Jewish leaders in London that he had received a reliable report that the Nazis planned to \"exterminate\" all the Jews in the East in one swift operation using prussic acid gas, which is the generic name for Zyklon. His source for this broadly but not completely accurate information, not revealed until long after the war, was Eduard Schulte, the chief executive of a German steel and mining firm headquartered in Upper Silesia, not far from Auschwitz, whose talkative second-in-command was a close friend of the region's Gauleiter. Schulte was an unlikely person to pass information to foreigners, an old-fashioned German nationalist whose sons were fighting on the Eastern Front. But he had grown so disgusted by the conduct of the Nazi regime that he decided to use his periodic business trips to Switzerland to begin transmitting intelligence to his country's enemies, not only about mass murder but later also about troop movements and the like.\n\nIn November 1942, confirmation of the revelations about gassing in the East came from three unimpeachable sources: The first was Carl Burckhardt, then the vice chairman and later the chairman of the International Committee of the Red Cross in Geneva, who relayed his knowledge to the U.S. State Department, and the second was a series of leaks from the officially secretive Vatican. The third source swept away the last doubts among Jewish leaders; it consisted of a group of Palestinian Jews whom the Germans had interned in Europe and then exchanged for Germans captured by the Allies. These repatriated Jews recounted what they had seen with their own eyes in ghettos and camps. The result was the United Nations declaration of December 17, 1942, in which the Allies acknowledged and denounced the massacre, thus informing every neutral or Nazi-allied government in Europe of what was happening and of the Allies' intention to exact postwar punishment. This was followed by a radio broadcast in German on the BBC by Thomas Mann, the exiled Nobel Prize\u2013winning novelist, that notified anyone listening of what the Nazi regime was doing to Jews.\n\nEven so, Allied operatives had trouble grasping the reality. This is most strikingly apparent with regard to a message intercepted by British intelligence on January 11, 1943. It contained a tally by H\u00f6fle, the Eichmann of the General Government, of the total number of Jews killed at the Operation Reinhard camps to date: a figure of 1,274,166. That's a stunning number, considering that it refers to the deaths at only Belzec, Sobibor, and Treblinka, none of which had been in operation for even ten months. But the code breakers did not know the names of the camps or recognize the initials that identified them in the document, so the information remained unpublicized and classified for the duration of the war.\n\nGrasping was not the only problem; deciding what to do with the information was also difficult. The principal Allies worried that making too much of Jewish suffering would play into the claims of Nazi propaganda that Churchill, Roosevelt, and Stalin were fighting for the Jews, indeed were their agents. Thus the Allies were reluctant to see, let alone to stress, the special nature of the Nazi attack on Jews, preferring to talk always\u2014and this continued even after the war\u2014about the suffering of \"citizens\" in the occupied states. Given the speed of the German onslaught and its geographical concentration out of the reach of Allied aircraft, there is little the Allies could have done to impede the process except to spread the word, mobilize neutral states to help, and encourage resistance to what the Germans were doing, but worries about seeming too pro-Jewish inhibited such actions.\n\nNor was that the only constraint on Allied rhetoric. The USSR continued to refuse to recognize ethnic distinctions among the victims of Nazism. Stalin spoke only once during the entire Second World War about the fate of the Jews\u2014in a speech on November 7, 1941, accusing the Germans of having carried out pogroms. Neither he nor any other Soviet military leader encouraged partisan units to aid Jews or to interfere with attacks on them. The USSR never considered the idea of bombing railroads to the camps or launching offensives aimed in their direction. The Russians first learned of Auschwitz by name in November 1943, about eight months before the Western Allies acknowledged its existence. By August 1944, when Soviet troops were only 160 kilometers (about 100 miles) away, the leaders of the NKVD, the Soviet secret police, were well versed in the camp's operations and tasks. Yet that information did not flow down the chain of command, and capturing the camp did not become a military objective. In 1944, various Jewish representatives lobbied Soviet diplomats to encourage a raid on the site. At the time on the Eastern Front, the USSR's planes outnumbered the Germans' by seven to one, and Auschwitz was within range of all Soviet light bombers, including the Pe-2 dive-bombers that were ideally suited to hitting narrow targets like the camp's crematoria. But nothing happened, and the principal reason appears to be that Stalin did not want to highlight the situation of the Jews. The Soviets' attitude was summed up by their behavior after they liberated Auschwitz in January 1945\u2014they maintained complete silence about the camp until May, when they issued a report and broadcast a description that did not even mention the word \"Jew.\"\n\nMeanwhile, the top ranks of Great Britain's government exhibited sympathy for the plight of the Jews but remained constrained by worries about holding the loyalty of Arabs. Churchill, who had opposed the white paper of May 1939 that limited Jewish immigration to Palestine, was the most vocal in urging British action to impede the Holocaust. The United Nations' declaration of December 1942 that condemned the murders occurred largely at Britain's instigation, and Churchill insisted that the British seriously consider how to attack Auschwitz in 1944. But he got equivocal support from his own foreign secretary Anthony Eden, who was personally antisemitic and very pro-Arab, and almost no backing from lower down in the British bureaucracy, where Air Secretary Sir Archibald Sinclair blocked the bombing plans and other officials stymied assorted relief efforts. In 1943, one British official called the possible \"release\" of 70,000 Jews from Romania a \"frightful prospect\" because they might go to Palestine and upset the delicate political balance there. The same worry made the British strong opponents of various plans toward the end of the war to ransom Jews still in the Nazi grip. Only 37,451 Jews succeeded in legally immigrating to Palestine between the outbreak of World War II and the end of 1944, and more than a third of them got in only in that last year. Most remarkably, the British reluctance to seem to be defending Jews accounts for the fact that both the United States and the UK purposefully ignored for more than a year after April 1943 consistent reports from Polish intelligence identifying Auschwitz as a site of mass murder.\n\nOne of the reasons the British and other Allies hesitated to emphasize Jewish suffering and the need for Jews to escape Europe was a man named Hajj Muhammad Amin al-Husseini, the Grand Mufti or highest authority on Islamic law in Jerusalem since 1921. One of the leaders of the Arab revolt in Palestine from 1936 to 1939, he had been driven by the British first out of Palestine, then Iraq, and finally Iran. In November 1941 he found asylum, along with several other Arab nationalists, in Berlin. His propaganda writings and broadcasts depicting America, Britain, communism, and the Jews as the common enemies of Arabs and the Axis powers had little practical effect, except possibly in provoking a spike in desertions by Palestinians from British army units in the run-up to the Battle of El Alamein in the fall of 1942. Whether exiled or not, Arab leaders were so internally divided and contentious during World War II that none of them, including the Mufti, could speak for very large segments of the public in the Middle East. But the British especially feared that demonstrative support for Jews and their interests might change the situation, provoking anything from increased sabotage of Allied military units and operations in the region to an uprising that would divert precious troops and resources from the war effort.\n\nLike the Eastern European nationalists who imagined that allying with the Nazis would increase their chances for future independence, and the several hundred thousand Muslims of the southern Soviet Union who joined the Wehrmacht and the SS in order to shake off Stalin's yoke, the Mufti had his hopes for affiliation with the Axis disappointed. Hitler put off giving him anything more than oral support for an end to colonial rule in the Middle East, not least because the Reich's Italian ally intended not only to retain Libya and Ethiopia after the war but also to expand its holdings in the region. The Germans also steadily refused to sanction an Arab-led army to fight with them. Instead, they confined their support to the raising of a few Muslim Bosnian and Albanian SS units (with German officers) and a tiny German-Arab Battalion that by August 1942 had attracted a mere 243 volunteers. These forces proved ineffective. Transferred in 1943 to North Africa and swollen, through local recruitment efforts, to about 2,000 men, the German-Arab Battalion fought so badly that the officers broke it up into labor units. By the fall of 1944, rampant desertion led the Germans to disband the Bosnian and Albanian forces, which the Mufti had encouraged and helped to organize. The desperate Third Reich finally announced its \"recognition of the independence of the Arab countries\" in November 1944, but the moment for rallying Arab or Muslim support to the Nazi cause long since had passed. All told, far more Arabs fought for the Allies in World War II than for the Axis, and probably more Muslims did, too.\n\nIn the meantime, the Mufti scored a few victories, notably in late 1942, when he used his influence with Himmler to block an exchange of Jewish children from Slovakia, Poland, and Hungary for German civilians in Palestine under the auspices of the Red Cross. Husseini also in the following months successfully discouraged the German allies Romania and Bulgaria from accepting monetary payments in return for permitting thousands of Jews to emigrate to Palestine. He even suggested to the Bulgarian foreign minister that the children should go to Poland instead, even though the Mufti had learned directly from Himmler what happened to Jews transported there. But these were limited, short-term triumphs, and the Mufti's association with the Axis ultimately had larger, long-term, and disastrous consequences for his goal of a Palestinian state, let alone one over which he would rule, as he hoped to do after the war. Although he managed to escape to Cairo after Germany's defeat and thus live on, his wartime linkage of Arab and Nazi interests helped move the United Nations toward the partition of Palestine in 1947 and the United States and UK toward siding with the Jews in the civil war there in 1948. Husseini's active political career came to an end due to his adamant refusal to accept partition, his disastrous leadership during the fighting that year, and his unacceptability to the former allies against Nazi Germany. King Abdullah of Jordan replaced him as Grand Mufti in December 1948.\n\nIf the British were more worried about their position in Palestine and the Middle East than the fate of the Jews, Pope Pius XII was more worried about protecting the city of Rome, finding a way to mediate an end to the war before the atheistic Soviets penetrated to the heart of Europe, and preserving his standing as the \"Common Father\" of Catholics everywhere, even those perpetrating atrocities. He therefore carefully maintained public silence about the killing of the Jews, on which he was thoroughly informed. He also did not speak publicly about the arrests of Catholic priests in various parts of occupied Europe or the murders of the Sinti and Roma and of the Soviet prisoners of war. He was only slightly more overt in opposing the German euthanasia campaign, even though some of the victims were Catholics and Bishop von Galen condemned it from within the Reich. His only public utterance on the subject of the Jews came in his Christmas message of 1942, which made oblique and brief reference (twenty-seven words in a document of twenty-six pages) to the tragedy of hundreds of thousands of innocent people dying on account of their race. Quietly and behind the scenes, however, he tried to exert some influence against German persecution. He had his ambassador to Vichy France, for instance, tell Marshal Philippe P\u00e9tain in July 1942 that the pope did not approve of deportations, and a few months later, P\u00e9tain agreed to limit them to foreign Jews in the German-occupied parts of the country. But the achievement evaporated when the Germans extended their occupation to all of France in November 1942. In August 1943, following an audience with a remarkable French monk and rescuer named Father Marie-Ben\u00f4it, Pius XII used Vatican diplomatic channels to persuade Spain to grant entry visas to and repatriate all Spanish Jews in occupied France, even those who had fought against the ruling regime in the Spanish Civil War a few years earlier.\n\nBut for the most part, the pope left decisions about whether and how to aid Jews to individual bishops, abbots, prioresses, and nuncios throughout the Catholic world, while he at the same time withheld from them the information he was accumulating about the murders. Even more strikingly, he declined to intervene with the Germans when they began deporting Jews from Rome in 1943, although he did get the Nazi representatives to promise to respect sanctuary in many Roman churches. Pius also put off pressing the Catholic ruler of Hungary, Admiral Horthy, to stop the deportations from that country in 1944 until after the Allies liberated Rome. By the time the pope finally appealed to Horthy on June 25\u2014three full weeks after U.S. troops entered Vatican City\u2014115 trains carrying more than 340,000 Hungarian Jews already had arrived at the selection ramp of Birkenau. When the deportations resumed after Horthy's overthrow that fall, Pius refused to send another protest.\n\nTimid, prudent, and hoping to play the role of intermediary who could broker a peace that would end the fighting, Pius XII behaved more like a politician\u2014and a rather petulant one at that\u2014than a prelate, more like the keeper to the keys to Rome's sumptuous churches than the keeper of the keys to the Kingdom of Heaven, and thus more like a provincial Roman than a prince of the universal church. Whether one endorses or condemns his conduct depends to a large degree on what one considers his primary responsibilities or obligations. He thought they were to Catholics and the accumulated patrimony of St. Peter. How one judges him also depends on whether one agrees with the Polish president-in-exile, Wladislaw Raczkiewicz, who contradicted Pius XII's refusal to denounce Nazi atrocities by asserting that \"divine law knows no compromise.\" Does it? Perhaps it does not to a religious figure who sees himself as the Vicar of Christ on earth, but surely it does to someone who sees himself as the CEO of a morally and materially valuable institution. Pius XII's actions suggest that he saw himself more as the latter than the former. The historian Michael Bess has summed up the pope's conduct: \"Push never came to shove because the Nazis pushed, but the Vatican did not shove back.\"\n\nThe upside of Pius's generally hands-off policy regarding the persecution of the Jews is that his conduct opened the way for some of the clerics to whom he left the matter to behave better than he did. As we have seen, several French and Dutch bishops spoke out against the mistreatment and murder of Jews. These brave souls came to nowhere near a majority of the bishops in either country, most of whom remained silent, but they demonstrated that at least some prelates' priorities differed from the pope's. We also already have encountered Metropolitan Sheptytsky in Lviv, who tried to impede Ukrainian collaboration in the murders in two extraordinary ways. First, he wrote to Himmler in February 1942 to request that Ukrainian Catholic police not be used in actions against Jews. Second, he issued a pastoral letter the following month that deprived parish priests of the power to absolve parishioners of murder after confession. Reserving that power to himself alone, Sheptytsky directed the faithful to treat Catholics involved in killing with \"the disgust and disgrace they deserve.\"\n\nArchbishop Aloysius Stepinac of Zagreb in Croatia also spoke out, complaining to that country's leader in November 1941 about the \"inhuman and cruel treatment of non-Aryans\" and delivering sermons in subsequent years that forbade participation in killing Roma and Jews and condemned racism. Going beyond words, Stepinac also provided baptismal certificates and work permits to Jews and hid many of them in Catholic buildings. In France, the first roundups and deportations in mid-1942 triggered a protest on the part of the Assembly of French Catholic bishops, in the form of a letter from Cardinal Emmanuel C\u00e9lestin Suhard, the head of the assembly, to Marshal P\u00e9tain. It read, in part, \"Deeply moved by the information reaching us about the massive arrests of Israelites that took place last week and by the harsh treatment inflicted upon them . . . our voice is raised to protest in favor of the inalienable rights of human beings. It is also an anguished call for pity for . . . mothers and children.\" But the letter asked for nothing more specific, and the papal nuncio in Vichy, Monsignor Valerio Valeri, dismissed the document as \"platonic.\" The church hierarchy in Slovakia was even slower to perceive its Christian duty. A pastoral letter distributed by the bishops of that country in 1942 defended only Jews who had converted to Catholicism and otherwise invoked antisemitic arguments to justify deportations. But the authors reversed themselves less than a year later. In March 1943, they issued a new letter that denounced the shipments as an unwarranted application of collective guilt that violated the Golden Rule. The deportations from Slovakia already had stopped, but the clerics' intervention tied the hands of the Slovak president, Jozef Tiso, an antisemitic Catholic priest who periodically toyed with resuming the deliveries, and no more occurred until the death rattle of Tiso's regime in the latter part of 1944.\n\nThe further down the Catholic Church hierarchy one looks, the more brave and principled behavior one finds. In Poland, for example, about two-thirds of the convents offered refuge to Jewish children and adults. The nuns saved, according to the best estimate, no fewer than 1,500 people in this fashion. In Lithuania during the carnage of 1941, several parish priests berated their flocks for having brutalized and stolen from Jews, even though their bishops took at first an equivocal stance and did not begin to condemn the persecution and organize rescue efforts until 1943. In Belgium, a network led by two Catholic laymen, Albert van den Berg and Georges Fonsny, and supported by Capuchin and Franciscan friars and the Sisters of St. Vincent de Paul, placed about 400 children in various Catholic institutions and thus rescued them. It was one of at least six such primarily Catholic groups that worked to conceal Jews in Belgium during the war. And in Rome, perhaps 4,000 Jews found refuge in monasteries, convents, and churches in 1943\u201344. But much more could have been achieved had the pope made rescue the Church's official policy, enjoined the faithful to carry it out, and used some of the Holy See's convertible currency to aid operations aimed at saving Jews, all of which the Vatican steadfastly declined to do.\n\nWhen pressed by foreign diplomats as to why he did not do more, Pius XII always emphasized the dangers that might flow from speaking out. Perhaps it would only enrage the Germans and provoke even more violence, like\u2014although the pope never explicitly drew this comparison\u2014the Dutch bishops' protest against the deportation of Jewish converts to Catholicism that resulted in an acceleration of the practice. Yet neither the Dutch prime minister nor the queen of the Netherlands was cowed into silence. Only days after the deportation trains began to roll east from Holland in July 1942, the prime minister condemned the practice, and a follow-up broadcast on Radio Orange, the voice of the Dutch government in exile, spoke of gas chambers; in October, Queen Wilhelmina told her people over the same sender that she felt \"personally affected [by] the systematic extermination\" of Dutch Jewry. Still, these leaders spoke from the safety of exile, and events in Germany highlighted the risks of reprisal. Although the Gestapo left Bishop von Galen alone after he spoke out against the euthanasia campaign, police arrested thirty-seven clerics in his diocese and sent them to camps, where six of them died.\n\nAlternatively, the pope sometimes claimed that an open protest might cause patriotic Germans to desert their faith, either during the war or in anger after a German defeat, for which they might blame him. That is what some of the German bishops and cardinals feared, and, like them, Pius XII opted to avoid confrontation \"in order to avoid worse.\" Once again, the sacraments functioned as an inhibition: The pope felt responsible not only to keep them available to the faithful but also to keep the faithful open to them and thus to salvation. But such fears did not stop Bernhard Lichtenberg, the provost of the Catholic cathedral in Berlin, St. Hedwig's, from praying publicly for the Jews being deported and from drafting a denunciation of a pamphlet written by Goebbels that condemned any expression of sympathy for Jews. For these offenses, the Gestapo arrested Lichtenberg in October 1941, jailed him for two years, then put him in a work camp, and finally shipped him to Dachau. Incarceration and mistreatment had shattered his health, and he died in transit on November 5, 1943. To Lichtenberg, unlike the pope, the prospect of mass apostasy could not outweigh the commandment to love one's neighbor here and now. Far better than Pius XII himself, Lichtenberg lived up to the ringing words of the new pope's first encyclical, \" _Summi Pontificatus_ : On the Unity of Human Society\" (October 1939): \"In the fulfillment of this, Our duty, we shall not let Ourselves be influenced by earthly considerations nor be held back by mistrust or opposition . . . nor yet by fear of misconceptions or misinterpretations. . . . The Ecclesiastical Hierarchy . . . in union with the Successor of Peter . . . [is] firm when, even at the cost of torments or martyrdom, it has to say: _Non licet_ ; it is not allowed!\"\n\nWhen all other arguments for inaction failed, the pope played his final card in fending off Allied calls for greater forthrightness: the assertion that if he criticized Nazi crimes, he would have to criticize Soviet ones, and the Allies could not want that while the fighting still raged. But of course he never relented in his vocal opposition to communism, so Allied representatives found this a particularly infuriating pretext.\n\nThe best hope for outside help for Jews caught up in the Holocaust was probably the United States, but it responded to the crisis hesitantly, partly for reasons already apparent before the war, partly for new ones. First, the incidence of antisemitism in the American population actually increased during the conflict. A Gallup poll in July 1942 found that 44 percent of the respondents thought that Jews had too much power and influence; two years later, another such survey reported that the same proportion\u201444 percent\u2014considered Jews \"a threat\" to the United States. Second, Breckenridge Long remained in office until 1944 and in opposition to anything that would increase the flow of Jews into the United States, and FDR, who had known Long since their common service in the Department of the Navy in World War I, remained deferential toward him, especially toward his argument that refugees presented security risks. As a result, in 1940\u201341, the two years before America entered World War II, only about 30,000 German Jews got into the country, along with perhaps an equal number from elsewhere in Europe. Third, military planners, in particular, took the line that the only way to help Jews was to win the war as quickly as possible, and then used this argument to rule out small actions that might have helped at the margins. For example, suggestions to transport more immigrants to the United States were rejected repeatedly from 1941 to 1944 because of an alleged shortage of shipping. But 400,000 German POWs were brought across the Atlantic to the United States, and many munitions ships returned empty from Europe.\n\nWashington's attitude softened in late 1943 as a result of several developments. Jan Karski, the Polish resister who earlier had reported to his government-in-exile about rising antisemitism in occupied Poland, also briefly had managed to smuggle himself into the Izbica ghetto, near Lublin, to see what was happening. When he met with FDR personally and told him of what he had witnessed in 1943, the president did not display particular interest in the subject, but the meeting lasted twice as long as planned, and after the conversation FDR seemed aroused as never before by the killings. At the same time, the turn of the tide of war in the Allies' favor indicated that action was becoming possible: Pressure from Congress began to mount, prompted partly by the activism of the outspoken representative of right-wing Zionism in the United States, Peter Bergson; and Treasury Secretary Henry Morgenthau and others persuaded FDR that Long had to go after he gave clearly misleading testimony to a congressional committee. In January 1944, a War Refugee Board came into existence, equipped with large amounts of money, almost all of it provided by the Joint Distribution Committee and other American Jewish organizations. The funds aided Jews through means that ran from bribing Nazi officials to financing the creation of protective identities for individuals, lobbying foreign and neutral governments to help Jews, and supporting escape efforts. Although the board could not stop the Hungarian deportations in the first half of 1944, it did underwrite the efforts of Raoul Wallenberg, the Swedish businessman-turned-diplomat who went to Budapest later that year and organized efforts to issue thousands of Swedish and Swiss protective documents to Jews in that city. In early 1945, the food that the board paid for and stockpiled in Swedish ports saved thousands of lives when Himmler briefly tried to open a negotiating channel to the Western Allies by allowing the International Red Cross to provision prisoners at Ravensbr\u00fcck and other camps in northern Germany. In retrospect, it seems clear that the board was created relatively late, but perhaps as early as it could make any difference to people's fates.\n\nEven the War Refugee Board's growing influence in Washington could not suffice, however, to persuade the War Department to order the bombing of Auschwitz and the train lines to the camp. The United States first recognized its function and location only in March 1944, despite earlier Polish underground attempts to alert Americans to the camp's operations. This was at about the same time that the refitting of captured air bases in Italy first permitted aircraft to get from American or British lines to the camp and back without running out of fuel. The first bombing proposals by Jewish groups in the United States reached the State Department and the Department of the Army between May 16 and June 2, 1944, and John Pehle, the director of the War Refugee Board, forwarded other such requests to U.S. Assistant Secretary of War John McCloy in late June. A few weeks later, on July 7, British Foreign Secretary Anthony Eden asked British Air Secretary Sinclair whether bombing runs could stop the murder of Hungary's Jews. It was, in fact, already nearly over, since the last deportation trains from Hungary departed on July 9. In early August, the chief of the U.S. Air Staff requested reconnaissance photos of the Auschwitz-Birkenau area, which had been taken on April 4, May 31, June 26, and July 8 but not yet developed. A formal request to bomb Auschwitz, again to McCloy, came from the World Jewish Congress in New York on August 9, but John Pehle undermined the request on August 11 for fear that large numbers of inmates would die in any air raid. Three days later, McCloy turned down the proposal, saying that it was \"impracticable,\" even though low-flying bombers that could have hit the crematoria were at Italian bases at the time. McCloy also maintained that the idea represented an unwarranted diversion of military assets to a nonmilitary target.\n\nThe military argument actually had some force, especially as things looked at the time. One needs to remember that Allied airpower had three principal preoccupations in the months just prior to September 1944: smashing development and launching sites for the German V-1 and V-2 rockets that were terrorizing England; aiding the Allied advance up the Italian boot, which had been very slow; and breaking German resistance in Normandy, which finally occurred on August 12, more than two months after D-Day and just as McCloy was considering the WJC's proposal. Thereafter, while the Allies were hurtling toward the German borders on the west and east, and when Pehle first on October 1 transmitted a Polish request that Auschwitz be targeted and then on November 8 added his own such plea, most American bombers were fixed on smashing Germany's fuel production in order to bring the Reich's armies to a halt. That was, in fact, the mission of American bombers that flew directly over and took pictures of the Auschwitz camp on August 20 and September 13 on their way to hitting the nearby IG Farben factory at Monowitz, only three to four miles east of the gas chambers.\n\nIn the end, bombing the camp might not have saved many lives. By the time those planes appeared, about 90 percent of Auschwitz's victims already were dead. The SS transferred more than half of the population of the camp complex\u2014and of the core sites at Auschwitz-Birkenau in particular\u2014to camps further inside Germany between July 1944 and the end of the year. Though transports of Jews continued to arrive and to provide, along with inmates, victims for the gas chambers, the Germans could have murdered the numbers involved (30,000 in October, for example) by other means without difficulty. And the gassings were almost over, in any case: Himmler terminated them at Auschwitz on November 2. Had Allied warplanes attacked the camp, collateral damage would have occurred, as it did when U.S. aircraft bombed a V-2 guidance factory adjacent to Buchenwald on August 24, 1944, and 315 prisoners died, and in early 1945, when planes hit suspected atomic energy facilities near Sachsenhausen and killed some 250 prisoners. The fortified perimeter of Auschwitz was so wide that few people could have broken out while the crematoria were being hit.\n\nBut planners did not know all this at the time, so the question remains, why did they not try? The answer with regard to the military authorities, as with regard to the governments herein described and the papacy, is simple: Trying just was not important enough to them; other needs or goals always took precedence. Even with regard to the one thing that the Allies and the pope might have done in 1942 that would have worked\u2014publicizing Nazi crimes against Jews more\u2014political and theological inhibitions prevailed.\n\nShould we include the behavior of American or Palestinian Jewry among the reasons for the insufficiency of the world's response? It is true that the American Jewish community was divided and did not concentrate its lobbying effort. Stephen Wise of the American Jewish Congress held FDR in awe and refused to pressure him. Similarly, Yehuda Bauer, the author of a multivolume history of the Joint Distribution Committee, describes the people who worked at its headquarters in New York as \"constitutionally incapable of serious questioning, let alone serious criticism, of an administration that stood between the Jewish community and antisemitism or worse.\" But Jews came to only 3.6 percent of an increasingly antisemitic American population during the war. They plainly lacked the power antisemites constantly ascribed to them. Something similar must be said about the Jews of the _Yishuv_ , who also largely failed to rise to the challenge. They, too, were a relatively small population, around 400,000 people in 1940, more than 85 percent of them living in only three urban areas: Haifa, Tel Aviv, and Jerusalem. Also in an exposed and vulnerable position, Jewish leaders in Palestine recognized that they had few material resources to bring to bear in rescue attempts and achieved little success with these until 1944. All told, their clandestine program of _Aliyah Bet_ , or illegal immigration to Palestine, managed to smuggle no more than 19,000 Jews into the territory between 1939 and 1945. One problem was fragmentation: The _Yishuv_ was as deeply politically divided as the Jews in the ghettos, in part along the same lines, so coordination around a coherent strategy was lacking. A second problem was mounting fatalism. The advocates of a future Jewish state understood by 1943 the depressing implications for them of what the Nazis already had accomplished, namely that the population the Zionists had counted on to provide the overwhelming majority of future settlers had been largely eradicated. Henceforth, the demographic future of a Jewish homeland seemed to them to lie with the then 800,000 Jews of North African and Arab lands and to depend, even more than before, on not alienating the Allies by protesting against their perceived inaction in bringing the Nazi killings to a stop.\n\nThe tragedy of 1939\u201345 is that the fate of the Jews of Europe was always a matter of secondary importance to everyone but themselves and the regime that wished to kill them. This was especially true of Switzerland, almost the last remaining potential refuge for Jews left in a Nazi-dominated Europe. The Alpine confederation's official policy during World War II read, \"Refugees who have fled purely on racial grounds, e.g., Jews, cannot be considered political refugees.\" But enforcement was inconsistent. About 2,000 Jews got into the country legally between 1939 and 1945. Almost 20,000 more were admitted and held in internment camps, while approximately 24,500 were turned back at the borders, even though the Swiss government possessed ample information about their likely fate thereafter.\n\nA similarly uncaring attitude initially prevailed in the one country that ultimately rose to the challenge: Sweden. Until late 1942 and the Nazi roundup of Norway's Jews, Sweden and its diplomats were distinctly indifferent to the Jewish catastrophe and intent on not jeopardizing their country's neutrality during the war and its lucrative sales of such items as iron ore and ball bearings to Nazi Germany. But thereafter the Swedish government began successively extending its protection to ever-widening groups of Jews. Its first move in this direction came in December 1942, when the Swedish cabinet informed the German government that Sweden would open its borders to all remaining Jews in Norway, regardless of their country of citizenship, and offer asylum. Almost exactly eleven months later, in early October 1943, Sweden announced the same policy regarding all Jews in Denmark, which opened the way for their mass flight across the Baltic Sea. The Swedes even tried unsuccessfully to persuade the German government to divert its ship carrying some of the few arrested Danish Jews to a Swedish port.\n\nAs the exodus from Denmark began, the Swedish embassy in Copenhagen commenced issuing provisional passports to Jews who could establish some connection with Sweden, and these documents sometimes sufficed to prevent Germans from detaining the bearers. That precedent proved highly important in March 1944, when Germany occupied Hungary and fearful Jews began besieging the Swedish embassy. But provisional passports required some commercial or residential basis and approval in Stockholm; they could not be issued to just anyone, and thus were inadequate to the need. Ambassador Carl Ivar Danielsson and his chief aide, Per Anger, now improvised a hierarchy of protective documents modeled on ones called _Schutzp\u00e4sse_ , which the Swiss vice consul in Budapest, Carl Lutz, had been issuing since 1942. These were simply official-looking pieces of paper with the Swedish coat of arms in color and assorted stamps, all designed to impress upon Hungarian police that the bearer was exempt from deportation by virtue of not being a Hungarian citizen. But the Hungarian deportations started in the outer provinces, far away from the Swedish embassy, so this sort of protection initially was not of much help; neither was the Swedish decision, in mid-June, to allow the embassy to issue provisional passports and entry visas without prior approval from Stockholm.\n\nMore efficacious was a letter from King Gustav V of Sweden to Miklos Horthy, delivered on July 3, urging him to put a stop to the deportations. Along with messages from the pope and the U.S. government, this document helped to push Horthy, on July 7, into ordering the suspension of the deportations, thus providing breathing room for the not yet arrested Jews of Budapest. Two days later Raoul Wallenberg arrived in the Hungarian capital, and his continuation of the practices that Swedish diplomats had developed proved instrumental in saving thousands of Jews after Horthy's overthrow on October 15, 1944. These heroic efforts were the culmination of a two-year-long process of recognizing Sweden's responsibility to act that was virtually unparalleled by any other nation.\n\nThat is not to say that the Swedes were the only diplomats who tried to impede the Holocaust in Hungary. From Switzerland, an equally extraordinary effort was led by George Mantello, a Romanian Jewish refugee serving as the first secretary in the Salvadoran consulate in Geneva. In 1943, backed by his superiors, he began issuing at no cost Salvadoran citizenship papers to between 20,000 and 30,000 mostly Jewish applicants in Hungary and Romania, thus obstructing their deportation. Then, in the late spring of 1944, he sent an emissary to Budapest who obtained copies of two eyewitness reports on the functioning of Auschwitz and the extent of the Hungarian deportations. He immediately released these to Swiss newspapers and with the help of four prominent Swiss theologians whipped up a press campaign exposing and denouncing the murders. To claim that he thus became \"the man who stopped the trains to Auschwitz,\" as the title of a recent study of his actions asserts, goes too far, but the outcry surely played a part in persuading Admiral Horthy to suspend the deportations in July. After they resumed the following fall, the papers Mantello had issued became significant again, not because of further action on his part but because Carl Lutz of the Swiss consulate took over representing Salvadoran interests in Hungary and persuaded the new Arrow Cross regime to honor the documents. They were then supplemented by thousands of comparable papers being issued by the Portuguese and Vatican representatives in Budapest and by a remarkable Italian, Giorgio Perlasca, who had obtained political asylum in the Spanish embassy in Hungary's capital. From November 1944 to January 1945, he posed as a Spanish diplomat, and in that capacity he issued thousands of safe conduct documents, supposedly on the basis of a Spanish law that extended citizenship to Jews descended from those expelled from Spain in the fifteenth century. Of the 140,000\u2013150,000 Jews who survived the Holocaust in Budapest, roughly 120,000 owed their lives, at least in large part, to the protective papers that Salvadoran, Spanish, Swedish, and Swiss diplomats provided.\nCHAPTER 8\n\n[AFTERMATH:  \nWhat Legacies,  \nWhat Lessons?](contents.xhtml#ch_8)\n\nTHE TRAGEDY OF THE Holocaust did not end with Germany's surrender in May 1945. Conditions on the death marches from abandoned camps and in the camps that continued to operate until the Allies arrived were so atrocious that tens of thousands of Jews died even afterward. The toll at Belsen was prototypical: 35,000 inmates expired in the final few weeks of the war, including Anne Frank, and more than 14,000 died after liberation, sometimes from disease but mostly because their bodies could no longer absorb the food that now was available to them. As a result, by mid-1945, only about 200,000 Jews had survived the camps, roughly 100,000 of whom had been at Auschwitz at one time or another.\n\nRETURN, RESETTLEMENT, RETRIBUTION, AND RESTITUTION\n\nEven this number was too much for the unprepared Allies to cope with. They had set up the United Nations Relief and Rehabilitation Administration (UNRRA) in 1943, but neither this organization nor the military units that liberated the camps in 1945 were ready for what they found. Indeed, the shock to the U.S. troops that liberated Dachau at the end of April 1945 was so profound that some of them went on a rampage, murdering between 40 and 122 of the guards discovered on the site. Two weeks earlier, when British units had reached Bergen-Belsen, they used bayonets and rifle butts to make the remaining German guards collect and bury the bodies strewn around the camp. Of the treatment meted out, an accompanying journalist wrote, \"The punishment they got was in the best Nazi tradition, and few of them survived it; but it made one pensive to see British soldiers beating and kicking men and women, even under such provocation.\"\n\nBut the object of Allied revulsion soon changed from the perpetrators to the victims, since many of the camp inmates had been demoralized, in both senses of the word, by what they had experienced and now behaved in ways that aroused more antipathy than sympathy on the part of those who had freed them. Such behavior prompted General George Patton, the commander of U.S. troops in southern Germany, to call \"the Jewish type of Displaced Person . . . a sub-human species without any of the cultural or social refinements of our time.\" But Patton was a notorious loudmouth and bigot who was looking for such opportunities. He later called the Nuremberg trials of Nazi war criminals a \"semitic\" event, accused the American press of being under \"semitic influence,\" and stated that the purpose of that influence was to \"implement Communism.\"\n\nPatton's antisemitism was more overt than most, but prejudice played a part in shaping the initial American and British incomprehension of the differences among the two million displaced persons (DPs) in Germany at the end of 1945. Many of them were survivors of Nazi labor camps, but many others were refugees who had fled Eastern Europe with the German armies, including 600,000 people from the Baltic states alone, among whom were numerous former collaborators with the Germans. Once more, Jews were treated as just one persecuted group among many. At some 2,500 UNRRA installations, a lot of them identical to places where the Nazis had caged people, all DPs were initially thrown in together, without regard to whether they had been victims or servants of the Nazis. The tensions that arose were particularly high between Jews and the far more numerous Christian refugees from Eastern Europe who feared to return to their now Soviet-occupied homelands.\n\nSo bad were the conditions in the refugee camps at the middle of 1945 that Earl Harrison, President Harry S. Truman's inspector, issued a scathing report that included a passage that, in retrospect, is astounding: \"As matters now stand, we appear to be treating the Jews as the Nazis treated them except that we do not exterminate them. They are in concentration camps in large numbers under our military guard instead of SS troops. One is led to wonder whether the German people, seeing this, are not supposing that we are following or at least condoning Nazi policy.\" Truman instructed General Eisenhower, the overall commander of American forces in Europe, to improve the situation of Jewish DPs. Some progress was made, including the establishment of thirteen separate camps for Jews, no fewer than twelve of them in the American occupation zone, but U.S. policy remained constrained by its chief goals: (1) to keep the residents confined so that the German populace, who feared them, would not be alienated; and (2) to keep conditions uncomfortable enough to encourage DPs to return to their lands of origin.\n\nReturn proved short-lived for many Jews because of events like the pogrom at Kielce in Poland in July 1946 and because of the hardships that accompanied the tightening Soviet grip on Eastern Europe. As a result, the problem of Jewish refugees actually increased after 1945. Whereas only 18,000 Jewish survivors were in UNRRA camps in Germany and Austria in December 1945, that number swelled to over 97,000 a year later and to more than 167,000 at the end of 1947. Many of these people were Polish Jews who had escaped the Nazis by retreating with Soviet forces in 1941, returned to Poland in 1945\u201346, and then decided to flee westward. Others were Hungarian and Romanian Jews who had survived homegrown persecution and now took the first chance to get away. Still others were Jews from Ukraine who had fled with the Red Army in 1941, returned with it in 1944, and encountered the same sort of reluctance to vacate their former residences that the new occupants showed virtually everywhere else. The large numbers were increasingly expensive to support\u2014UNRRA spent almost $4 billion in the late 1940s, a staggering sum at the time, most of it from the United States. Yet the refugees seemed to have nowhere else to go. Because the United States continued to enforce its quota system of immigration, only 15,000 Jewish DPs were admitted between May 1945 and June 1947. Meanwhile, Britain and the Dominions proved more hospitable to non-Jewish refugees from Eastern Europe than to Jewish ones, though Australia was a partial exception, and the British continued to enforce the white paper limit of 15,000 Jewish immigrants to Palestine per year.\n\nThe United States, to which Britain was heavily indebted at the end of World War II, tried to persuade Prime Minister Clement Attlee to allow 100,000 Jewish refugees into Palestine, but he set two preconditions: that the United States pay to transport and support them, and that the Jewish fighters then seeking to drive Britain out of Palestine lay down their arms. Neither party cooperated, so no deal occurred. But the point became moot when the British decided in early 1947 to turn the question of Palestine over to the fledgling United Nations. It voted nine months later to partition the region between Jews and Arabs. Between 1945 and 1951, by a combination of legal and illegal means, somewhere between 133,000 and 200,000 European Jewish refugees got to the territory that became the State of Israel in 1948. They were often received somewhat insensitively\u2014either suspected of having collaborated with the Nazis in order to survive, or pitied as the remnant of a weak and failed diaspora. Either way, they were regarded as living proof of the need for Zionism and an independent and self-reliant Jewish state.\n\nMeanwhile, resistance to the immigration of DPs to the United States softened somewhat as a result of growing public sympathy with their plight and an increased perception among American officials that their continued presence on German soil was politically inconvenient and embarrassing. Even so, the price of greater openness was readiness to turn a blind eye to earlier collaboration with Nazism on the part of many of the tens of thousands of non-Jewish Latvian, Lithuanian, Ukrainian, and _Volksdeutsche_ residents of German DP camps, who were also allowed into the United States under the terms of the Displaced Persons Act of 1948 and the amendments passed in 1950. Now admired as refugees from communism, these people actually outnumbered the Jews who gained entrance to America under the new legislation. Altogether, the United States admitted between 80,000 and 137,000 Jewish Displaced Persons by 1953, a not inconsiderable total but about the same share of the total number of Jews who found refuge worldwide as in the 1930s. Think about that for a minute: The United States actually was, in relative terms, no more open to Jewish immigrants from 1945 to 1953 than from 1933 to 1939. Of course, most of them were no longer in mortal danger after World War II, so one might argue that their need had become less acute, but they were often homeless and destitute.\n\nThose who got here faced incomprehension of their experience akin to the attitudes exhibited earlier by the U.S. military commanders in Germany. Most Americans simply could not imagine what survivors had been through. The sense of isolation that many of them felt was compounded by two policies on the part of well-meaning Jewish social service agencies. The first was a conscious decision to disperse survivors among disparate Jewish communities that volunteered as sponsors. Many Jewish survivors thus found themselves in places, such as Columbia, South Carolina, and Denver, Colorado, that were worlds apart from their places of origin. Once there, they ran up against another conscious policy that the agencies encouraged sponsors to adopt: an emphasis on persuading survivors to \"move on\" and not dwell on or talk about the past and its losses. A great deal of emotional and psychological pain remained unresolved in the process of rebuilding lives.\n\nIt is, of course, not true that the Holocaust was forgotten in the 1950s and 1960s. By the time I graduated from high school in 1964, the subject was already a conspicuous topic in American popular culture. I first learned about it in junior high in the late 1950s from reading Leon Uris's novel _Exodus_ , the biggest bestseller in the United States since _Gone with the Wind_. This highly fictionalized account of the voyage of a real illegal refugee ship to Palestine became a film starring Paul Newman. I saw it, as I did _The Diary of Anne Frank_ (1959). When I was in high school, _Judgment at Nuremberg_ with Spencer Tracy was a box-office success, and so was _The Pawnbroker_ , with Rod Steiger, during my first year in college. But it is true that the Holocaust did not yet stand out sharply from the enormous cataclysm of World War II. This is an example of what I call the optic of history. Most Americans thought, after 1945, that the real story of World War II was the story they had been part of\u2014namely, the war in the Pacific and the invasions of Europe, not what had occurred in Poland and Ukraine. According to family lore, my father ended World War II on the island of Tinian, having been trained in New Mexico in 1944\u201345 to drop an atomic bomb on Japan. Fortunately, he did not in the end do so because there were only two bombs for five trained crews, but I grew up hearing a lot more about defeating Japan than fighting Nazis, even though almost twice as many Americans died in the war against Germany than in the Pacific theater. Besides, the cold war put a damper on paying attention to the Holocaust, since most Germans were now America's allies, and political convenience argued for not raking up the past. Decades had to pass before survivors felt that they had an audience for their recollections.\n\nPostwar politics also worked against extensive retribution to perpetrators and demands for restitution to the victims, but in both instances, as with the myth of silence about the Holocaust following the war, more happened than people tend now to remember. It is simply untrue that many major perpetrators of the Holocaust escaped punishment afterwards, just as it is untrue that Germans, especially those in the eastern half of their country, paid little or no price for what their nation had done. Both legends are the opposite of reality. Germany was a badly damaged country in 1945, and it remained that way for many years after, despite the economic revival of the 1950s. When I first visited, in 1968\u201369, I saw numerous empty, bombed-out lots in D\u00fcsseldorf, as well as trees growing from the roofs of the Frankfurt Opera House and the twin churches on the Gendarmenmarkt in Berlin. Those edifices were ruins twenty-four years after World War II ended.\n\nSo tenacious is the legend of perpetrators escaping punishment that it seems to blind the people who retell it to even their own evidence. A case in point is Donald McKale's _Nazis after Hitler: How Perpetrators of the Holocaust Cheated Justice and Truth_ , an extended philippic about Nazis who supposedly avoided punishment after World War II and advanced self-justifications that aided the cause of Holocaust denial. Yet of the thirty-one individuals on whom the author focuses to make his case, his own text shows that twelve were executed for their deeds, two committed suicide, four died in captivity, two died as they were about to be arrested and prosecuted, one died on the run, and four went to jail. Only six went unpunished. The mortality rate came to two-thirds by the time Adolf Eichmann was executed in Jerusalem in 1962.\n\nIn fact, in the early postwar years, the reckoning was pretty intense. Altogether, European courts condemned and sentenced approximately 100,000 Germans and Austrians for wartime criminality of one sort of another. The four victorious Allies convicted another 8,812 Germans and Austrians in proceedings held in occupied Germany. American prosecutions of 1,030 camp officials and guards on atrocity charges in 1945\u201347 produced 885 convictions; 261 of the 432 defendants condemned to death for these offenses or for harming American military personnel ultimately died on the gallows. The hanging at Dachau on May 27\u201328, 1947, of forty-eight German personnel from Mauthausen constitutes the largest mass execution in American history. Among those also executed by the United States were Paul Blobel, who had commanded _Sonderkommando_ 1005, the unit charged with exhuming the bodies of camp victims, burning them, and destroying all traces of Belzec, Sobibor, and Treblinka; Otto Moll, among other things the commandant of several gassing installations and of the slave labor camps at IG Farben's murderous mines near Auschwitz; and Oswald Pohl, the head of the SS Economics and Administration Main Office and, as such, the architect of the SS camp labor system. The British tried 989 people on war crimes charges and hanged eleven members of the camp administration at Belsen. The executees included Franz H\u00f6ssler, who had commanded the first gas chambers at Auschwitz and later supervised the exhumation and burning of 100,000 bodies there, as well as two businessmen who sold Zyklon to the SS. The Soviets hanged Friedrich Jeckeln, the SS man who presided over the murders at Babi Yar, on the site of the Riga ghetto in 1946. They also executed six of the former _Hiwis_ at Sobibor even before the war ended and ten more of them after a trial in 1962. Altogether, Soviet courts convicted almost 26,000 Germans and Austrians and about 11,000 local collaborators.\n\nThe Poles tried 5,358 German nationals between 1945 and 1957. Among the people executed were Rudolf H\u00f6ss, the longest-serving commandant of Auschwitz; J\u00fcrgen Stroop, the SS commander who put down the Warsaw Ghetto Uprising; Hans Biebow, the German administrator of the Lodz ghetto; Amon G\u00f6th, the sadistic commandant of the Plaszow concentration camp made famous in _Schindler's List_ ; Arthur Greiser, the Nazi governor of the Warthegau; the two top-ranking officials of the General Government; the four senior German figures in occupied Warsaw; Heinrich Josten, the commander of the SS guard force at Auschwitz; Erwin von Helmersen, an SS doctor at Birkenau; Werner H\u00e4ndler, the man in charge of food for the inmates of both those camps; and Maximilian Grabner, the head of the Political Section of the Auschwitz-Birkenau camp administration from 1940 to 1943, which was the subunit responsible for torture and executions. Poland also sentenced two of the men who poured Zyklon into the gas chambers to long prison terms; one of them died in his cell in 1955, and the other was released in 1958.\n\nArthur Seyss-Inquart, the German administrator of the occupied Netherlands, was condemned to death at the Nuremberg trials and executed. The Dutch followed up by putting to death forty Nazi officials and collaborators, including Hanns Rauter, the SS chief in Amsterdam. The death sentences of Ferdinand aus der F\u00fcnten, who directed the deportations from Holland, and of Willy Lages, the chief of the SS Security Service there, were commuted in 1951 to life in prison. Lages served fifteen years, then died five years later. Aus der F\u00fcnten served thirty-nine years until the Dutch released him on grounds of ill health two months before he died. Albert Gemmeker, the commandant of the camp at Westerbork from which most Dutch Jews were sent to their deaths, got off more lightly with a ten-year prison term, of which he spent six behind bars before his release in 1955.\n\nIn general, the chances of high-ranking perpetrators being punished were quite high. Consider the fates of the sixteen people who at one time or another had independent command of a death camp: thirteen were killed one way or another during the 1940s, one received a death sentence in 1954 and promptly died of a heart attack, and two escaped justice for a time, only to be caught ultimately and given life sentences. The figures for the fourteen people who commanded an _Einsatzgruppe_ are similar: Seven perished during the war, two committed suicide in custody, and three were executed, for a total of twelve fatalities. The remaining two were sentenced to prison, albeit for what turned out to be only brief terms. In both categories, no one got off scot-free. Of the forty-two individuals who ever commanded one of the thirteen most notorious concentration camps\u2014Bergen-Belsen, Buchenwald, Dachau, Dora-Mittelbau, Flossenb\u00fcrg, Gross-Rosen, Mauthausen, Natzweiler, Neuengamme, Ravensbr\u00fcck, Sachsenhausen, Stutthof, and Theresienstadt\u2014fourteen died before 1945, eighteen were executed or committed suicide, four served prison terms, and only six (14 percent) went unpunished or unaccounted for after the war. Nikolaus Wachsmann, the author of a definitive history of the Nazi concentration camps published in 2015, says that only seven of the former wartime commandants of the twenty-seven main SS concentration camps were still alive in 1950. Though not a perfect record, this is hardly a terrible one.\n\nWith regard to euthanasia killings and slave labor, the attrition among order-givers was also extensive. The three chief figures in T4, Philipp Bouhler, Viktor Brack, and Karl Brandt, died shortly after the war, Bouhler by suicide after his capture by the United States in 1945 and Brack and Brandt by hanging in 1948 after their condemnation by an American court. Both Albrecht Schmelt, who devised the SS's sliding charges for different categories of Jews leased out as slave laborers, and Hans Kammler, the SS man in charge of the enslaved workforce at Dora-Mittelbau and the other Fighter Staff Program factories, perished as the war was ending.\n\nIn addition, courts in their homelands condemned to death the Vichy prime minister Pierre Laval and the Romanian dictator Ion Antonescu, both of whom had delivered Jews to the Nazis and then thought better of it. Vichy's chief of state Philippe P\u00e9tain escaped the same fate only because Charles de Gaulle commuted his sentence to life in prison, where he died. Norway's collaborationist leader Vidkun Quisling was shot by a firing squad; Slovakia's Jozef Tiso was hanged; and so was Hungary's Ferenc Szalasi, who took over its government and resumed the deportation of Jews in late 1944, along with the three chief figures of the Hungarian Interior Ministry who organized the mass deportations earlier that year. In the meantime, every one of the German envoys to Croatia, Slovakia, Hungary, Bulgaria, and Romania who lobbied those governments to kill or deport Jews during the war had been killed either upon capture or following a trial in 1945\u201347.\n\nFinally, the Germans themselves accounted for a considerable number of prosecutions. West Germany sent 6,479 people to prison between 1945 and 1986, and the East Germans convicted 12,861 individuals between 1945 and 1976. Still, there were notable omissions and lapses, especially during the 1950s. Only about 10 percent of the Germans who ever worked at Auschwitz went on trial anywhere after the war, and the mid- to low-ranking personnel at most concentration camps were largely ignored later or given light sentences\u2014at least by American standards\u2014when tried. Of the 50,000 members of the Police Battalions that killed about half a million people in occupied Eastern Europe, only 64 men were ever charged and 41 ever sentenced. And most of the SS officers who were imprisoned shortly after the war were out by 1958. But exceptions occurred: Hermann Krumey, a key figure in the deportations from Hungary, got a life sentence in the late 1960s and served it. Hans H\u00f6fle, Globocnik's chief of staff during Operation Reinhard and the man who drew up the infamous statistical tally of the killings during 1942, evaded justice until his arrest in 1961 but killed himself the following year. In 1969, East Germany executed Josef Bl\u00f6sche, the SS man pointing a machine gun toward the boy with a cloth cap (see chapter 5, figure 6) during the suppression of the Warsaw Ghetto Uprising. Though most of the district-level Nazi administrators who presided over deportations in the General Government went unpunished, two who were investigated in the 1960s also committed suicide. Only a few of the high-ranking figures at Auschwitz got away, notably Josef Mengele, the doctor who conducted selections at the arrival ramp and vicious experiments on inmates and who hid out in South America until he drowned in 1979. Wilhelm Boger, the infamous interrogation officer in the Political Section of the Auschwitz camp, was not quite as lucky. After he escaped from American custody in 1947, he managed to remain at large until 1965, when the German authorities caught up with him. Sentenced to life in prison, he died there twelve years later.\n\nThe record also is mixed, but not negligible, regarding the 121 men from T4 who staffed the Operation Reinhard camps. Forty-two (that is, more than a third) of them died during the war, in Soviet captivity, or immediately after 1945, mostly by their own hands. Twenty-two were sentenced after the war, nine to life in prison, twelve to terms of three to twelve years, and one, who committed suicide, to death. One other former T4 man killed himself during the preliminaries to his trial in 1965. Among those caught and punished was Hermann Bauer, who called himself the \"gas master\" of Sobibor. Condemned to death in 1950 but saved by the abolition of capital punishment in West Germany, he served out a life sentence, dying in West Berlin's Tegel prison in 1980. Still, about fifty-seven (47 percent) of these participants in murder escaped punishment. According to Michael Bryant, the most recent and careful student of their prosecutions, German courts would have convicted as many as twenty-one more of them as accomplices to murder in the three successive trials of Reinhard camp guards in 1963\u201366 and another of Majdanek personnel in 1966\u201371 if more eyewitness testimony, to which those courts generally were deferential, had been available. Where relevant survivors who could implicate individual guards in cruelty or killing were in short supply, however, the courts had no alternative under West German law than to give defendants the benefit of the doubt regarding their claims to have \"inwardly opposed\" Nazi actions and been uninvolved in the gassings.\n\nOf course, a number of infamous figures did escape punishment, many of them through the efforts of an entity that also had been less than consistently helpful to Jews during the Holocaust: the Roman Catholic Church. Driven by the view that any ally against communism was worth assisting, Catholics developed several escape routes, known colloquially as ratlines, for Nazis and their European allies. All of these itineraries ran out of Germany through South Tyrol, the German-speaking area in northeastern Italy, and then either directly to the port city of Genoa or first to Rome and then to that port. From there, the escape routes went either to Franco's Spain via Barcelona and sometimes then on to Juan Peron's Argentina or directly to Buenos Aires. Along the way, the International Red Cross and the Vatican Relief Commission, the latter run by Monsignor Giovanni Montini, the future Pope Paul VI, provided new identities and travel documents, and Giuseppi Siri, the Archbishop of Genoa, furnished food and shelter there. Most of the money for the operation, about $5 million at the time, came from unwitting donations on the part of the National Catholic Welfare Committee in the United States, spurred on by Cardinal Francis Spellman of New York City.\n\nSome of that American funding also went to a Nazi sympathizer in Rome, an Austrian bishop named Alois Hudal, the rector of a seminary for German-speaking priests. Among the notorious criminals that Hudal helped get away were Josef Mengele and Adolf Eichmann; Gerhard Bohne, one of the principal organizers of the T4 program, who ultimately returned to Germany and escaped punishment; and Eduard Roschmann, the vicious commandant of the Riga ghetto, who lived in Argentina from 1948 to July 1977. The prospect of extradition drove Roschmann to Paraguay, where he died within about a month of his arrival. Another beneficiary of Hudal's aid was Erich Priebke, who led a massacre of 335 Italians during the German retreat from Rome and then spent fifty years in Argentina before finally being extradited to Italy in 1995, tried, and sentenced to life imprisonment under house arrest, which is where he died, in 2013, at the age of 100. Hudal also hid Franz Stangl, the former commander of the Sobibor and Treblinka death camps, at the seminary until he could make his escape to Syria and later to Brazil. He finally was arrested there in 1967, extradited to West Germany, and sentenced to life imprisonment in 1970. Stangl's escape, as well as that of one of his deputies at Sobibor, Gustav Wagner, was the work of another old Nazi who worked out of Hudal's seminary, Walter Rauff, the inventor of the motor-fed gas van. They, too, initially went to Syria, but, unlike Stangl, both Wagner and Rauff lived out their lives in safety, the former in Brazil, where he died in 1980, the latter in Chile until he succumbed to lung cancer in May 1984.\n\nA similar ratline emanated from a pontifical college for Croatian priests in Rome, where Father Krunoslav Draganovic funneled both the remaining funds of the brutal Ustasha state to the Vatican Bank and thousands of Ustasha veterans and a few Nazis to safety abroad. Two of his more infamous successes were Klaus Barbie, known as \"the butcher of Lyon\" for his role as a wartime torturer for the SS in that city, and Ante Pavelic, the former ruler of Croatia, who had presided over the slaughter of thousands of Jews, Sinti and Roma, and Serbs. Justice did not catch up to Barbie until 1983, partly because he was protected by both American and West German intelligence agencies and a succession of military rulers in Bolivia. When that country returned to democracy that year, the new government arrested and extradited Barbie to France, where he was sentenced to life in prison four years later. He died there of multiple cancers in 1991. Meanwhile, Pavelic had escaped retribution far more briefly, despite the fact that he, too, had additional help from a Western intelligence agency, in his case Britain's. After an assassin sent by the Yugoslavian secret police nearly killed Pavelic in Argentina in 1957, he fled to Chile and then Spain and died of his wounds two years later.\n\nEven more Nazis and their allies would have escaped if Catholic leaders had gotten their way. Pius XII pleaded repeatedly for clemency for condemned war criminals, both in general and in specific instances. He thus held to the theory of pastoral responsibility that he had followed throughout World War II, a theory that historian Jacques Kornberg has shown assigned less importance to condemning sin that to keeping open possibilities of forgiveness and redemption. Most German bishops, including Clemens von Galen, the man who had criticized the euthanasia program, went even further by denouncing the war crimes trials themselves as unjust. So did Bishop (later Cardinal) Aloisius Muench, the antisemitic, German-speaking son of Bavarian immigrants to the United States who served both as liaison between the American occupation administration and the German Catholic Church and as the papal representative in occupied Germany. He wrote a pastoral letter that contrasted \"Christ's law of love\" with the \"Mosaic idea of an eye for an eye.\" But when the pope and German Catholic leaders pressured John McCloy, the U.S. High Commissioner for Germany from 1949 to 1952, to commute the sentence of Otto Ohlendorf, who had commanded an _Einsatzgruppe_ and a section of the RSHA, their advocacy was too much for even Muench. Quietly but firmly, he advised the German prelates and the Vatican to back off, lest their stance become public and embarrass the Church.\n\nOne other famous group long supposed to have enabled escapes by war criminals, the _Organisation der ehemaligen SS-Angeh\u00f6rigen_ (Organization of Former Members of the SS), known by the acronym ODESSA, appears to have been largely mythical. That did not prevent the famous \"Nazi hunter\" Simon Wiesenthal from believing it was real and from encouraging the novelist Frederick Forsyth to place it and the aforementioned Eduard Roschmann at the center of a gripping bestseller called _The Odessa File_. In 1974, it became a hit movie of the same name starring Jon Voight. Although grist for a vivid story, ODESSA was the sort of fantasy that fevered postwar imaginations conjured up, and its nonexistence helps explain why, in the end, few major Nazi war criminals got away. An independent historians' commission entrusted in the late 1990s with an exhaustive examination of Nazi activities in Argentina combed the archival record there and in Europe and reached the conclusion that only 180 likely war criminals or collaborators had gained entry to that South American country, of whom about 100 were French and Belgian, about 50 Croat, and only 23 German or Austrian. That assessment gains credibility from a recent detailed study of the case of Aribert Heim, an SS doctor who killed prisoners at Mauthausen and got away to live out his years in Cairo until 1992. The authors, two investigative journalists, argued that the success of people like Heim in eluding capture owed much more to the efforts of their friends and families than to any organization's support. A peculiarity that helped make this so was the provision in postwar German law that barred charging close relatives of suspects with aiding and abetting their escape. In consequence, immediate families could refuse to cooperate with investigators without fear of punishment.\n\nThat the Western powers did not hold more people responsible was partly a matter of cold war politics. To combat the Soviet Union, the United States wanted to exploit the expertise of some compromised individuals, not only people like Barbie and Pavelic but also scientists such as Wernher von Braun of Germany's V-2 rocket program. Braun's connection to the use of slave labor at Dora-Mittelbau seemed less important to America after 1945 than his ability to design ballistic missiles and, ultimately, the spacecraft that took John Glenn into orbit around the earth. More generally, the United States sought to embed West Germany in the West and the NATO alliance and considered continuing prosecutions counterproductive to that purpose. But leniency also reflected a domestic German democracy-building strategy. Konrad Adenauer, West Germany's first postwar leader and a man with impeccable anti-Nazi credentials, believed that integrating former Nazis into the new political order was the best way of reconciling them to a democratic system and alliance with the West. He wished to prevent the rise of a sense of victimization comparable to the one Germans had nursed after World War I. Thus he accepted prosecution of only the most obviously criminal actors, but argued for forbearance otherwise and for a kind of collective amnesia about the degree to which Germans had supported the Nazi F\u00fchrer and shared his hatreds. Adenauer saw to it that former perpetrators and their widows received state pensions and that some even returned to positions in the West German government. His own right-hand man in the 1950s was Hans Globke, who had written the manual for implementing the Nuremberg Laws.\n\nAdenauer's strategy largely succeeded in political terms but only temporarily in historical ones. Beginning in the late 1950s and accelerating thereafter, pressure to confront the details of the past and in some cases the perpetrators themselves rose dramatically in West Germany, as East German propagandists exposed the questionable pasts of many officials and people born after the war reached maturity and began posing painful questions. By the time they did this, the country's democratic institutions were strong enough to withstand the call for honesty about the past. Since the 1970s, openness about what Germans did and about the reality of the Holocaust has been part of what Germans call their \"constitutional patriotism,\" and memorials reminding Germans of the worst of which they were capable now dot the nation's capital, as well as most of its large cities.\n\nGerman restitution policy toward victims of the Holocaust followed a similarly halting course toward a similarly accepting endpoint. From 1945 on, the Germans conceded that they had to pay something in the form of restitution or compensation for all the misery that they had caused, but they sought consistently to keep the bill as low as possible. As a result, every concession came in response to outside pressure and was confined to relieving it, but the pressure never really stopped, and the ultimate bill came to a staggering sum. Since 1945, total payments to survivors, their heirs, and the state of Israel have come to more than $100 billion, not counting the value of returned objects, such as art works. Yet certain categories of victims benefited disproportionately, some received nothing at all because they died before compensation was extended to them, and even $100 billion falls well short of the worth of the damages the Germans inflicted.\n\nThe survivors who came off best were Jewish Germans who managed to flee the country before the Holocaust or who survived it somehow on German soil. Under Allied occupation rules as well as laws passed by the fledgling German state in the early 1950s, such people were entitled to the return of their old property, such as homes, businesses, furniture, jewelry, and other assets, or a cash payment equal to its worth. The total payout for identifiable and lost property came to 7.5 billion deutsche mark by the mid-1960s, which was just shy of two billion U.S. dollars at the time. German Jews whose careers had suffered by virtue of being driven out of the country were entitled to a lump-sum payment of 10,000 deutsche mark for \"damage to education,\" and those expelled from the practice of law or university faculties were granted the lifelong pension of someone who had reached the senior ranks of the judiciary or the professoriate. Hannah Arendt lived comfortably in New York City in part off of such income. In the first years of this century, 100,000 people worldwide were still receiving such payments.\n\nOther categories of victims came away with much less, if anything. Jewish refugee organizations got 120 million marks worth of German foreign assets to use in the immediate postwar years to aid resettlement of Jewish survivors, along with the proceeds of refining and selling the gold that had been shipped to Berlin from the death camps in Poland but not smelted by the end of the war. Israel received three billion marks to support survivors as a result of the Luxembourg Agreement of 1952, and the Jewish Claims Conference another 450 million marks for the same purpose. Between 1958 and 1961, in accordance with the usual rule in international law that only countries, not individuals, can get compensation from other countries, West Germany signed treaties with sixteen non-communist European states that provided them with 2.5 billion marks to distribute to Holocaust survivors within their borders.\n\nSubstantial as these amounts were, they excluded large groups of survivors, primarily those in Eastern Europe. The West Germans insisted until unification in 1990 that they were responsible only for survivors who met two criteria: (1) they had lived within Germany, defined by its borders in 1937, at some time between 1933 and 1945 or moved to the Western occupation zones or West Berlin between 1945 and 1952; and (2) they currently resided in West Germany or in a country that had diplomatic relations with West Germany. The second rule disqualified most Eastern European survivors until the 1970s, since most of their countries had diplomatic ties only with communist East Germany until then. The first rule excluded many survivors in Eastern Europe altogether.\n\nA second major category of survivors who were left out of the German compensation schemes comprised people who had been slave laborers for German private industry. For many years, German courts refused to hold German firms liable to pay such people, contending that the companies had been acting on government orders and that the state, not the firms, was the proper address for claims. Largely in order to limit damage to their reputations in foreign markets, a few companies made token postwar payments to former slave laborers as a gesture, not an admission of obligation or guilt. The legal remnant of IG Farben, along with the Krupp, Siemens, AEG, and Rheinstahl companies gave the Jewish Claims Conference 51.5 million marks between 1957 and 1962 to aid approximately 15,000 Jews who had toiled for these enterprises during World War II, but the average payout converted to a rather paltry $850 at the time. Two decades later, Daimler-Benz and Volkswagen did something similar.\n\nBoth gaps in the German compensation system were filled in the 1990s. The German government first extended payments to survivors who had fled Eastern Europe after 1965 and to severely injured survivors still in the region. Then, in 1999, Germany worked out a deal with the United States that traded the suspension of class-action suits in American courts\u2014legal efforts to seize German assets in the United States to pay survivors\u2014in return for the establishment of a fund to pay their claims. The fund would contain ten billion marks, half from the German government and half from private German corporations. Some of that money collected for this German Foundation Initiative went to non-Jewish Eastern European forced laborers, but three billion marks, or about 1.5 billion U.S. dollars at the time, went to Jewish survivors in compensation for both former slave labor and confiscated monetary assets, notably insurance policies.\n\nIn short, the history of recompense by Germany for the crimes of the Holocaust is an ambiguous one. On the one hand, buoyed by the extraordinary postwar revival of its economy and motivated by an initially self-interested desire for integration into NATO and the new Europe, Germany consented to pay an overall indemnity for the Holocaust that no one would have thought possible in 1945. On the other hand, the German record is clouded by the highly variable support provided to individuals, along with the halting and grudging way in which compensation expanded, which meant that hundreds of thousands of victims died before they became eligible.\n\nSomething similar happened in other European countries. Throughout Eastern Europe, of course, the record was far worse, as communist governments nationalized property rather than returned it, and most of them quickly drove out their surviving Jewish populations. Ninety percent of Bulgaria's remaining Jews had emigrated by 1949, nearly all of Romania's and Poland's by the 1960s. After the fall of communism, most of these countries then established residency and citizenship requirements for restitution of confiscated possessions, mostly real estate, which conveniently meant that they would not have to give anything back, since few Jews wished to return and many had lost their citizenship automatically upon emigrating.\n\nIn Western Europe, an initial flurry of attention to restoring homes and physical assets soon gave way to insensitivity and indifference that lasted into the 1990s. Backed by the Vatican, Catholic religious institutions and orphanages in Holland and France often declined to relinquish the Jewish children consigned to them by parents who had perished to other relatives or Jewish community institutions. So-called heirless assets\u2014ones whose owners never came back\u2014notably thousands of art works, remained in the hands of whatever person or institution held them when the war ended. Only in the 1990s were the postwar deficiencies made up. For example, the Dutch state provided compensation for the stocks and bonds that had been seized from Jews in Holland in the 1940s and sold to Dutch citizens, and the French government endowed a new Foundation for the Memory of the Shoah with 2.5 billion francs, a sum thought to be the value of property formerly owned by Jews in France that had remained unclaimed after the war.\n\nSwitzerland presented a particularly awkward case of restitution because it had been formally neutral during World War II but had purchased considerable quantities of plundered gold from the Third Reich and had served as the salesroom for much of the art, furs, jewelry, and commercial paper that the Nazis stole from Jews. Moreover, Switzerland's banks were suspected of having pocketed the contents of numerous \"dormant\" accounts opened by Jews who later were killed in the Holocaust. These issues were largely swept under the rug in the immediate postwar years. The United States acceded to the Washington Agreement of 1946, by which the Swiss promised to liquidate frozen German assets in their country, transfer half their value to a fund for stateless Nazi victims, and hand over one-sixth of the gold acquired from Nazi Germany in return for rehabilitation as an acceptable trading partner. Although the Swiss government passed a law in 1946 that ordered restitution of stolen art even if the purchase had been made in good faith, the legislation allowed only a short interval for making claims and applied only to works bought after 1939 in occupied areas, not in Germany proper.\n\nDuring the 1990s, the World Jewish Congress succeeded in turning a spotlight on Switzerland's involvement with the Nazi regime, especially the issues of stolen gold, dormant bank accounts, production of war materials, and hostility to refugees. A series of commissions of inquiry were named, notably one under Paul Volcker on the conduct of Swiss banks and another led by Jean-Fran\u00e7ois Bergier on the broad subject of Swiss policy and actions during World War II. The associated research teams demonstrated that the number of bank accounts opened by Jews during the Nazi era, unclaimed after the war, and then drained by the banks through fees probably was lower than Switzerland's critics had claimed, but that Swiss banks had conspired to frustrate postwar inquiries about them. The Bergier Commission also found that the Swiss National Bank knowingly had accepted plundered gold from the Nazi regime and afterward repeatedly mischaracterized\u2014that is, lied about\u2014its policies and conduct.\n\nAs these findings emerged, they played a significant role in setting the terms of the settlement of a U.S. court case against the Union Bank of Switzerland in 1999 by which the bank agreed to pay $1.25 billion into a fund administered by the Jewish Claims Conference: $800 million for restitution of dormant bank accounts; $100 million for compensation for looted assets; and $325 million for payments to former slave laborers at Swiss-owned companies in occupied Europe or at German firms that had put their revenue in Swiss banks and for refugees mistreated by the Swiss. By January 2005, the Claims Conference had disbursed $690 million, mostly in the latter two categories.\n\nIn retrospect, the recurrent pursuit of recompense for the victims of the Holocaust has proven both impossible and necessary\u2014impossible because so much of what was lost was intangible and irremediable, necessary because so little of what could be given back or paid for was treated as such in the early postwar years, when every European nation was preoccupied with reconstruction. And because thousands of victims died before being able to benefit, the justice achieved was incomplete. Moreover, the monetization of loss is always approximate and grows more so as the interval between offense and redress increases, and many of the countries where the thefts were most extensive, notably Poland and Romania, have yet to grapple seriously with their obligations.\n\nSo despite enormous expenditures, gaps still yawn between what people suffered and what they got back and between what a perpetrating entity did or gained and what it ultimately paid. Every major restitution or compensation settlement since 1950 has been an instance of \"negotiated justice,\" in which the amounts made available have had less to do with what real compensation required or real criminality deserved than with the momentary bargaining strength of the parties. This was as true of the sums distributed pursuant to the Luxembourg Agreement of 1952 as of those raised by the German Foundation Initiative of 2000. Political realities also explain why Switzerland never has been forced to indemnify any person or agency for the agreements that the Alpine republic signed with the governments of Poland and Hungary shortly after World War II. These deals allowed Switzerland to seize the heirless Swiss assets of dead Polish and Hungarian citizens, most of whom were Jews, as compensation for the nationalization of Swiss property in these newly communist states.\n\nMoreover, the settlements involving corporations have been instances of rough justice: The enterprises bought valuable advantages by paying arbitrarily determined sums that bore no relation to the firms' earlier conduct, while sometimes guiltier parties walked away untouched. The Union Bank of Switzerland, in effect, purchased the right to complete a merger and do further business in the United States in return for a payment that vastly exceeded the value of all Holocaust-related dormant bank accounts and gold deposits in the country's commercial banks. Yet the National Bank of Switzerland, the recipient of 92 percent of the gold in Switzerland that came from Nazi Germany, escaped with its underpayment under the Washington Agreement because it had no business interests in the United States that later could be threatened. German companies are not obligated to contribute to the Foundation Initiative, regardless of their involvement in slave labor or other dimensions of the Holocaust, and the extent of each voluntary contribution is pegged to a company's recent annual sales, not its degree of culpability, and is tax-deductible.\n\nThese are not the only blemishes on the quest for recompense. Although lawyers for restitution plaintiffs provoked numerous German firms into opening their archives and thus precipitated many significant historical studies, these advocates also spread a lot of misconceptions about the origin and worth of several forms of spoliation. Historians will be busy correcting the record for a long time. The admiring accounts of class-action suits that have been published also warrant rebuttal, not least because several lawyers in those and other restitution proceedings of the 1990s turned out to be awful role models for their profession. A number of them were censured, disbarred, forced to resign their positions, or sentenced to jail in subsequent years for legal and financial misconduct. Finally, recent settlements have opened old wounds within the Jewish community worldwide regarding the propriety of accepting money as indemnification for death and whether funds received should go exclusively to survivors or, at least in part, to Jewish cultural undertakings.\n\nAll that said, hundreds of thousands of survivors and heirs have benefited from the persistence of people who refused to settle for the first round of restitution and compensation in the immediate postwar years, and, as with regard to the relentless pursuit of the last Nazi war criminals at large, an important point has been made. That point is that statutes of limitations do not apply to the crimes of mass murder and mammoth larceny. Sooner or later, the repressed returns and, contrary to the legal axiom, justice delayed is not necessarily justice denied.\n\nMEMORY, MYTHS, AND MEANINGS\n\n_Why?_ has examined a subject full of pain: pain of separation and exile, of persecution and torture, of degradation and murder, and of harrowing and haunted survival. To enter into the Holocaust is to risk enormous disillusionment with human beings and to awaken deep anxiety about how badly things can go wrong in this world. How can we sum up what we can and should learn from putting ourselves through this experience? What are the lessons and legacies of the topic?\n\nIn seeking an answer to that large question, perhaps we should begin by asking why anyone should study the Holocaust. The answer is not self-evident, and many people criticize our culture's fascination with the topic. In fact, Peter Novick's bestselling _The Holocaust in American Life_ insisted that we can learn almost nothing useful from human conduct in so extreme a historical situation. Elsewhere, specialists in the field have been charged with engaging in \"shoah business,\" and courses like the one on the Holocaust that I taught at Northwestern for many years have been derided as a form of special pleading that puts the miseries of Jews above those of many other populations that have suffered grievous onslaughts. Essentially, most responses to these criticisms stress that what makes the Holocaust stand out from other mass murders of the twentieth century is the sort of place that perpetrated it (an advanced and ostensibly civilized country) and the cause that propelled it (race, the most pressing issue of our time, not just in a polyglot country like the United States but also in a globalizing world). One should study the Holocaust, in other words, because its setting and impetus are highly relevant to the modern world.\n\nThe implicit corollary to that argument is that the Holocaust is a deadly precedent (after all, anything that has happened once can happen again), so we must learn about it in order to act effectively to prevent a recurrence. This practical argument can come in both universal and parochial variations. Some evidence vindicates the universal one, which emphasizes how learning can impede genocide, since the memory of the Holocaust helped impel Americans and Europeans to intervene, however belatedly, to stop the killing in Bosnia and Kosovo during the 1990s. But examples from outside Europe suggest that learning goes, literally, only so far. It clearly made no difference to the course of events in Rwanda in the 1990s, only slightly more to that in Darfur in the 2000s, and, thus far, very little to what has happened in Syria in the 2010s. The parochial version of the practical justification for studying the Holocaust\u2014because the Holocaust is a warning against Jews depending on others\u2014has been far more consistently consequential, but for both good and ill. It has stiffened the resolve of the citizens of a Jewish state in a hostile region, but it also has reinforced condescension toward Jews in the diaspora and an \"us alone against the world\" attitude that threatens to become self-fulfilling.\n\nA related and important preliminary question is: How should we study the Holocaust? I have tried to indicate that I think the answer is \"carefully and soberly,\" with a mix of precision and feeling, and without engaging in sentimentality or sanctification. Unfortunately, a certain amount of sanctification is built into the word \"Holocaust,\" which derives from the ancient Greek term for \"an offering totally consumed by fire\"\u2014in other words, a religious sacrifice. But many of those who were killed would have rejected an attribution of religious meaning to their deaths. To avoid this sort of ascription of meaning, even holiness, to mass murder, the Hebrew word \" _Shoah_ ,\" which means \"destruction,\" probably would be preferable. But the biblical uses of that word also are religiously inflected. In any case, the terminology has become firmly entrenched. Despite that, I hope readers of _Why?_ come to see what happened as a set of historical events, to be recovered, studied, and comprehended by the usual historical means. We have to approach the record neither in awe nor in anger if we hope to learn anything valuable, rather than merely to have our preconceptions confirmed and our righteousness aroused.\n\nYes, the subject challenges our sense of the comprehensible, but that is because of our revulsion. We reflexively call the Holocaust unfathomable or unbelievable as a way of distancing ourselves from it and expressing our disgust. Nonetheless, the _Shoah_ is comprehensible in the same way that any other catastrophic human or life experience is: with difficulty, patience, and application to the task. To say that the subject is incomprehensible is to despair, to give up, to admit to being too lazy to make the long effort, and, worst of all, to duck the challenge to our most cherished illusions about ourselves and each other that looking into the abyss of this subject entails. And the alternative to trying to understand how and why the Holocaust happened is to capitulate to a belief in fate, divine purpose, or sheer randomness in human events.\n\n_Why?_ has approached the problem of comprehensibility by breaking the topic down into four primary questions:\n\n1. _Why the Jews?_ Because their emancipation in the nineteenth century from centuries of residential and occupational confinement aroused a backlash that gave new impetus and new form to a chimerical hatred\u2014that is, to a belief that they constituted the single cause for everything that others opposed and feared.\n\n2. _Why the Germans?_ Because a massive and multidimensional national crisis, a perfect storm of economic, political, cultural, and social upheavals, opened the way for believers in this hatred to acquire power in Germany and to reinforce or indoctrinate others in their views.\n\n3. _Why murder and with these means?_ Because of a process of problem-solving mission creep, a cumulative radicalization of policy, as increasingly harsh efforts to \"remove\" Jews from German territory proved insufficient or unworkable and gave way to ever more extreme methods of \"elimination.\"\n\n4. _Why was the eradication of the Jews so nearly successful, resulting in the deaths of two-thirds of those in Europe and at least three-quarters of those within reach of the Nazis?_ Because indifference and self-interest in Germany and then the occupied or satellite states during World War II cleared the way for the haters; because the logistics of murder proved uncomplicated and self-financing; because the Nazis' ferocious onslaught peaked during the period of their greatest military success; and because most of the killing was done when the Allies against Germany could neither observe nor interdict it.\n\nAlong the way, we have debunked or at least complicated a number of myths. A few years back, I developed a lecture about how wide the gap has grown between what specialists know and what much of the public believes about the Holocaust. I was not alone in sensing this problem. Paul Levine also has perceived a growing \"gap between scholarship and public memory\" and called it a veritable \"clash between 'town' and 'gown.' \" My talk listed nine prevailing myths and misconceptions about the Holocaust and tried to explain why they are not so. As I list the first eight erroneous propositions, you will notice that much of this book has sought to undermine them:\n\nFirst, that antisemitism played a primary or decisive role in bringing Hitler to power; it did not. Its persistence undermined and corroded a sense of solidarity between Jewish and non-Jewish Germans, but belief in an international Jewish conspiracy or a need to \"remove\" Jews from the German body politic was never strong or widespread enough in Germany to propel Hitler to high office. Without the Depression and the collusion of conservative leaders who expected to use Hitler for their purposes, he would not have come to power.\n\nSecond, that Hitler planned to murder the Jews from the day he took office, if not before; as far as historians can tell, he did not. Massacre was always a possibility implicit in Nazi ideology, but only gradually became a semi-explicit policy of the German state\u2014as a result of the clash between the ethnic mathematics of Hitler's drive for living space and his conviction that military victory depended on the disappearance of Jews from his realm.\n\nThird, that the Allies could have done much to impede the killing once it began; given where and when most of the slaughter took place\u2014in the northeast quadrant of the European continent and in the eighteen months following Germany's invasion of the Soviet Union, when the Reich was continuously on the offensive and winning\u2014they could not. As David Cesarani has shown, the only ways Germany's opponents could have reduced the carnage significantly were for the British and\/or the Soviets to lose the war in 1941, thus salvaging the prospect of deporting Jews elsewhere, or for the Allies to win the conflict in 1942\u201343, which was clearly beyond their power.\n\nFourth, that greater passive or active resistance by Jews could have reduced the death toll considerably; not realistically speaking. Such behavior would have required an almost unimaginable degree of clairvoyance on the part of Jews, an equally unimaginable degree of solidarity among them, and a far different balance of forces between Jews and their Nazi captors.\n\nFifth, that popular attitudes toward Jews, rather than political structures and interests, were the principal determinants of survival; not in the aggregate. More courage to help on the part of non-Jews would have produced more survivors, but nowhere near as many as remained alive because of the cynical political and personal calculations of collaborationist regimes in Europe.\n\nSixth, that the Holocaust diverted resources from the German war effort and weakened it in significant ways; not really. Germany sent more trains to the staging areas of Operation Barbarossa, the invasion of the Soviet Union, every day in mid-1941 (2,500) than the SS deployed to transport Jews to camps during the entire Holocaust (2,000), so clearly the deportations did not stress the capacity of the Reich's railroads. The nation's reliance on forced and slave labor would have been just as chaotic, inefficient, and insufficient with the retention of the murdered Jews as it proved to be without them.\n\nSeventh, that the slave labor system was driven principally by greed; it was not. It was the creation of a regime that lacked the population to sustain the massive war on which Germany had embarked and the imagination and generosity to enlist enough other Europeans in the cause.\n\nEighth, that most of the leading perpetrators of the Holocaust escaped punishment after World War II; in fact, the great majority of the vilest ones were already dead by 1945 or caught and penalized fairly shortly thereafter. To be sure, the Germans and the victors of World War II could have tried harder to find the killers who got away and could have rested less content with punishment that concentrated more on the order givers than the order executers in the camps and the shooting units. But the reckoning after 1945 for the Holocaust was more comprehensive than for any other modern instance of genocide.\n\nAt one point or another, the chapters in _Why?_ have presented detailed evidence that refutes each of those assertions. Nonetheless, I do not expect them to disappear. Sometimes historical work is an extended game of whack-a-mole.\n\nBut _Why?_ has said little thus far about the ninth common misconception. This is the idea, associated with the widely read books of Zygmunt Bauman and Detlev Peukert, that the Holocaust was a product of modernity and a demonstration of its dangers. The prevailing image is of mechanized murder, epitomized by ubiquitous references to \"factories of death.\" But, although Auschwitz was a human disassembly line, it resembled a nineteenth-century slaughterhouse more than a modern manufacturing plant, and the other killing centers, with the partial exception of Majdanek, were ramshackle affairs. Most of the camps killed with a rather simple and at most early industrial device: a gasoline engine. Even the designation of the intended victims was done the old-fashioned way: by drawing up deportation lists with ink on paper, a task that was usually delegated to Jewish organizations in Western Europe and Germany and to Jewish Councils in the ghettos, if it was done at all. In occupied Russia and Ukraine, the non-Jewish locals just pointed out the Jewish ones. Finally, almost half of the killing occurred by starvation and exposure or by one-on-one bludgeoning or shooting\u2014in short, by rather primitive means.\n\nNeither is the broader form of this identification of the Holocaust with modernity accurate\u2014namely, that the Holocaust represented the modern world's aspiration and achievement of the means to carry out vast forms of social engineering. The ambition to wipe out a whole group is not specifically modern: The goal is as old as the Israelites' extirpation of the Amalekites and the Romans' erasure of the Carthaginians, both of which were more complete than the Nazi murder of the Jews, despite being accomplished with mere fire and sword. Moreover, the pseudoscience that gave a supposedly modern gloss to the attempt at racial purification\u2014eugenics\u2014was, in fact, the very opposite of modern. It was the application of animal husbandry to human society, an argument that people can and should be bred like racehorses, and nationalities can and should be considered as breeds. Nazi racism was fundamentally rooted in an agricultural, not an industrial, world, and in an understanding of genetics that approximated that of the medieval or pre-modern eras. Furthermore, in scientific terms, eugenics was a fraud. Far from being modern in either conception or means, the Holocaust was an outbreak of extraordinary primitivism, a fitting product of an ideology that believed that all life is governed by the law of the jungle. In the astute words of Dan Stone, \"Modernity was less the driving force of the Holocaust than the setting for it.\"\n\nFinally, of course, the biggest myth about the Holocaust is another one not yet discussed, the claim that it never happened, and this book cannot close without discussing how ridiculous this claim is and why it continues to get made. On the ridiculousness, the first point to make emphatically is that the Holocaust is, quite simply, one of the most amply documented events in world history. To be sure, historians had to dig for several decades to arrive at as complete a picture of what happened as we now have, and, along the way, interpretations evolved as the state of our knowledge did. After all, the perpetrators went to considerable trouble to destroy the evidence of what they had done, though it was fortunately too voluminous to eradicate. Thus, to cite the most significant examples, we still have many of the passenger lists of the deportation trains, the prisoner death registries at Auschwitz and Mauthausen, some of the receipts for orders of Zyklon, most of the _Einsatzgruppen_ reports that itemized and categorized the dead, photos of the victims' belongings piled up at Babi Yar, Lodz, and Birkenau, the minutes of the Wannsee Conference, H\u00f6fle's tally of the death toll at the Reinhard camps, SS statistician Richard Korherr's report from the spring of 1943 on the extent of the final solution to date, a vinyl recording of Himmler delivering his speech at Posen in 1943, Joseph Goebbels' extensive diaries, Alfred Rosenberg's somewhat more episodic ones, the postwar confessions of Rudolf H\u00f6ss and numerous other killers, and so on.\n\nYet a vocal group of deniers persists in asserting that gas chambers did not exist and genocide did not occur during the Third Reich, that the number of Jews who died in World War II was small and an incidental outcome of the fighting, that the evidence mentioned above consists of forgeries or coerced testimonies, and that Jews and communists contrived the \"hoax\" of the Holocaust after World War II in order to discredit Germany, extract money from it, and gain support for a Jewish state in Palestine. Calling themselves \"revisionists,\" these deniers drape themselves in the trappings of scholarship, but their strained arguments so clearly resemble the conspiracy theories that animated nineteenth-century antisemitism that their role as the real driving force behind denial shows through.\n\nA British judge examined the claims of David Irving, perhaps the leading Holocaust denier of recent decades, during a libel trial in 2000 and pronounced them a deliberate falsification of the historical record. More recently, Bettina Stangneth's _Eichmann Before Jerusalem_ has shown how a group of Nazi exiles and sympathizers in Argentina assembled most of the core arguments of denial and published them under a pseudonym in an \u00e9migr\u00e9 German journal called _Der Weg_ (The Way) in 1954. Their article, \"On the Streets of Truth,\" bearing the byline of a fictitious American journalist named Warwick Hester, who revisionists later claimed was the equally imaginary \"American jurist Stephen F. Pinter,\" still circulates on the Internet. Stangneth considers it \"the principal source text\" for Holocaust deniers. Arguing with people who believe this nonsense is pointless, because the real source of their belief is not evidence or reasoning but incorrigible and circular fantasies about Jewish power and malevolence.\n\nThe title of a fine book by Eva Hoffman, the daughter of Holocaust survivors, is _After Such Knowledge_ , and a way to bring this book to an end is to put that title in the form of a question. What should we do \"after such knowledge\"? What are the implications of all that we have learned about the Holocaust? Few subjects seem to cry out more for an attempt to establish their \"meaning\" or \"message,\" and few subjects can make the person trying to formulate such conclusions feel so inadequate. Raul Hilberg often said that he was afraid to address the big questions raised by the _Shoah_ for fear of giving small answers. Can we nonetheless draw any larger conclusions from our examination of these terrible events, despite all appropriate cautiousness about the attempt?\n\nI think we can, but before I try, let me underline three features of our world that have profoundly changed since the end of the Second World War and that have affected the potential for renewed outbreaks of antisemitism.\n\nFirst, the European world of the first half of the twentieth century was caught up in a kind of civil war between ideologies that prized individualism, discussion, and fulfillment\u2014such as liberalism, representative government, and free enterprise\u2014and ones that prioritized collectivism, obedience to group goals, and submission to authority: for example, fascism, Nazism, communism, and in those days most forms of Christianity. Many of the dangers to the Jews arose out of the way they were used in this conflict, as symbols of individualism or wealth or communism or freethinking and unbelief. These days are largely gone. Western nations are nearly all individualist, secular, and capitalist now. It is difficult to depict Jews as threats because the ideologies once tied to them have either triumphed and become generally shared or, in the case of communism, collapsed. That does not mean that antisemitism has disappeared, only that it has become, for the moment, largely powerless in the Western world.\n\nOther parts of the globe are another matter, however. Wherever individualism, religious or ethnic pluralism, and enterprise remain ideologically suspect or are perceived as alien, Jews and all other minorities remain endangered, and the wretched lies of the _Protocols of the Elders of Zion_ continue to be circulated and believed, as they are currently in Russia and many predominantly Muslim lands and among non-Jewish immigrants from these lands to other places. Just as in nineteenth- and twentieth-century Central and Eastern Europe, in the rest of the world today, the security of Jews, like that of most minorities, is least wherever the liberal values of toleration, coexistence, and openness to change are weak. To prevent other Holocausts, it is not enough to combat antisemitism; one has also to fight for these broader values, and not only at home. This is one of the central insights of the much-maligned European Union, which has insisted on increased protections of minority rights, especially for Roma and gay people, as preconditions for admitting countries to its ranks. In an increasingly globalized world, the obligation to combat and reduce parochialism and intolerance is an increasingly global matter.\n\nSecond, even in Western Europe and North America, the lessons drawn after 1945 about the world that spawned the Holocaust and the countermeasures put in place then are now under attack. In economically difficult times, Europe is experiencing a widespread resurgence of nationalism in the forms of hostility to foreigners, especially immigrants and the bureaucrats of the European Union, and a retreat from the welfare state under the cover of reducing debts. The current condition of Greek and Hungarian politics gives us a sense of what we have to look forward to if these trends continue and strengthen: the rise of neo-fascist parties and the enlistment of the energies of young and often unemployed men in brutality. Antisemitism, remember, rises and falls in inverse relationship to the stock market. Moreover, in this country and in Europe, economic inequality is growing, as the proponents of a certain version of free market capitalism increasingly lose sight of the implicit contract that most Western nations made with their populations in response to World War II. That contract traded a promise that governments would provide basic services and security in return for citizens abandoning political extremism. Communism and fascism were the outgrowths of societies in which the distribution of wealth and opportunity were massively unequal, and the postwar architects of European unification and social safety nets knew that reducing inequality was the essential prerequisite for social peace. As governments cease to keep their part of this bargain, they invite citizens to cease to keep theirs, and in such a context, no minority (and perhaps no democracy) will be safe. This is why the sort of political rhetoric that categorizes people as \"makers vs. takers,\" often implying that the latter group consists heavily of immigrants, is a profoundly dangerous and ignorant throwback to a vastly destructive era.\n\nThird, something else has changed in the past sixty years that may provide cause for worry. Ironically, that something else is the existence of a Jewish state. Nowadays, hostility to the existence and policies of the state of Israel tends in some quarters to slide into hostility to Jews in general and to the revival of vicious stereotypes about them. A potential for antisemitism to grow, a temptation to depict Jews once more as aliens with different purposes and priorities from those of their fellow citizens, exists in Europe (and to a lesser extent in the United States) because of a gap between European and Israeli interests and sensitivities.\n\nFor non-Jews in Europe, the top priority in the Middle East is not the survival of a Jewish state; the top priorities are political calm, access to oil, and sufficient economic development of the region so that its burgeoning and overwhelmingly young population does not swamp Europe's declining and aging one. Non-Jewish Europeans would prefer the problem of who gets what parts of what used to be Palestine simply to go away because the problem not only poses a threat of war on their doorstep, but also engenders militancy and unrest among the millions of Muslim immigrants already in Europe. At the same time, many American and European Jews, for emotional and practical reasons, including the memory of the Holocaust and the view that Israel is a potential home of last resort in the event of new eruptions of antisemitism, do not think they can afford such indifference.\n\nIn this division of interest lies a danger that demagogues may arise to accuse Jews of divided loyalties and of dragging the entire nations of which they are part into conflicts in which more is at stake for them than for those nations. Should that happen, a situation not unlike that of the 1930s will arise, antisemites will have an opening, and the strength of inclusive and liberal values will face powerful challenges. In other words, the existence of a Jewish state, especially one in which the most insular segments of the population play an increasingly decisive role, presents dangers to Jews elsewhere as well as benefits. In 2003, Tony Judt, a distinguished historian of Jewish descent, aroused an explosive debate by implicitly asking, in the _New York Review of Books_ , \"Is Israel good for the Jews?\" and more or less answering no. Peter Beinart, the author of _The Crisis of Zionism_ and himself an Orthodox Jew, has now taken Judt's place in highlighting the divergence between many Israeli practices and the liberal values that protect Jews elsewhere and in urging Jews to face up to the implications of this divergence as a matter of both principle and prudence.\n\nIn short, current conditions differ in hopeful and worrisome ways from those that produced the Holocaust. What, then, are the implications today of what we have learned for those of us fortunate enough to be living in relatively free societies? I think the Holocaust has two important lessons for minorities in the United States in general and for Jews in particular.\n\nLesson One is: Be alert but not afraid. Some degree of antisemitism is ineradicable for the foreseeable future; it has too long a pedigree and is too much the dark side of apartness and normal social frictions to disappear. But antisemitism is not necessarily always dangerous; it made Hitler possible, but it did not make him succeed. An irony of the history of antisemitism is that this ideology that called Jews parasites always has been a parasitic issue. To succeed, it has needed a host that it can exploit\u2014a pervasive sense of crisis and victimization that allegedly justifies lashing out in reprisal. That is the essential prerequisite for widespread demonizing of Jews as the root of all evil, and the presence of this sort of sweeping crisis is what brought Hitler to power.\n\nOne can argue that the Great Recession sorely tested America, yet demonstrated that the will to demonize cannot get the upper hand in this country for several reasons. First, we have the example of the Holocaust to serve as a warning of what happens when such demonization triumphs. If Holocaust education has any prophylactic value, it probably lies in dampening impulses to attack Jews and in multiplying the number of antiantisemites. Second, the spread of education and of more complicated notions of causation may have made more people resistant to simplified blame games. I hope this is so. Third, we benefit from the freedom of the media to expose stereotyping, but with the fragmentation of news outlets and market segments into increasingly walled-off camps, this protection may be waning. Fourth, and above all, the internal diversity of American culture is a form of protection against demonization. We have no dominant faith or ethnic group anymore\u2014in a sense, we are all members of some minority or another. As a result, many and perhaps most of us should and often do behave like those groups during the Holocaust whose own minority status led them to sympathize with Jews.\n\nConsider what has NOT happened regarding Jews in the United States in recent years. At the heart of three of the nation's most sensational recent corruption scandals were three Jews, Andrew Fastow at Enron, Jack Abramoff of the congressional lobbying payoffs, and Bernard Madoff, who perpetrated the largest Ponzi scheme of all time. Moreover, a majority of the heads of the big banks and brokerage houses that recklessly sold derivative contracts and mortgage-backed securities and thus brought on the recent recession also were Jews. Yet outside of several neo-Nazi websites, no one has been idiotic enough to advance the proposition that these people are typical of American Jewry, and no political movement has arisen around a program of reforming Wall Street by \"cleansing\" it and the nation of Jews. Look how far we have come from the Strousberg and Panama affairs of the late 1800s.\n\nSome commentators have noted the prominence of Jews among the proponents of an unnecessary and enormously costly war in Iraq, figures such as Paul Wolfowitz, Scooter Libby, and former senator Joseph Lieberman. Their role has given rise to muted suggestions that such people have been motivated by a desire to protect Israel and to muffled debates about the supposed power of pro-Israeli lobbying groups, such as AIPAC (American Israel Public Affairs Committee), to suppress discussion in the United States over Israeli policy in the occupied territories. But none of this conversation has turned virulent or violent. Most importantly, no political movement has emerged that presents any person's behavior as the expression of categorical beliefs and flaws rather than individual ones.\n\nAnd consider the situation of the American minority that is in some ways most comparable to the Jews in Germany prior to 1933: gay people. They, too, say no to fundamental beliefs\u2014in this case about gender roles; they, too, are present in small enough numbers to be easily attackable; they, too, have been depicted as degenerate and corrupting\u2014the Bible contains scriptural passages frequently invoked to stigmatize gay people just as the Gospel of John and the Easter service used to be quoted to stigmatize Jews; they, too, are simultaneously derided for supposedly hanging together but also trying to blend in; and above all, gays, too, are often depicted as threatening\u2014associated with child molestation and AIDS, as Jews once were with the blood libel and plague, and decried as people so unclean that they subvert and sully marriage by seeking to engage in it. Yet a \"chimerical\" image of gay people has failed to take hold in the United States, and resistance to a supposed \"homosexual agenda\" appears to be losing even its primary function of rallying the religious right now that \"godless communism\" is no longer available. The so-called defense of marriage and the hypocritical and cruel policy of \"don't ask, don't tell\" are gone.\n\nNonetheless, to expect bigotry to evaporate as if it had never existed would be foolhardy. Look at the way anti-immigrant feeling, much of it echoing the rhetoric of the nineteenth-century Know-Nothing Party, has surged in America in recent years, now turned not against Irish, Italians, and Jews but against Latinos, Muslims, and people of color. Overcoming these ugly repetitions of American exclusionism will take time, but it will happen, and in the same way it always has in the past, by sheer force of numbers. So, the first lesson of the study of the Holocaust for all minority groups in American society is \"be alert, but not afraid.\" The general trend in America remains toward pluralism, freedom, and Jefferson's right to \"the pursuit of happiness\" for each person in his or her own way. We all have a responsibility to see to it that the trend continues; its opposite is the oppression, the stasis, and the homogeneity that Nazism prized.\n\nLesson Two of the Holocaust for minority groups in America and Jews in particular is: Be self-reliant but not isolationist. That means taking care with two very dangerous and common words nowadays: memory and identity. We tend to glorify both with cries such as \"never again\" or \"never forget\" and assertions of our heritage or loyalties before every utterance. But both practices have downsides.\n\nThis may sound like an odd, even heretical thing for a historian to write, but there is such a thing, in every culture as in every life, as too much memory. It can block learning, change, and trust. Looking perpetually back can seem to justify endless bitterness and to authorize fatalism. But, as Susan Sontag once wrote, \"To make peace is to forget.\" The assumption that the future cannot help but resemble the past, that people who once hated me always will hate me, is often self-confirming. George Mitchell, the architect of the Good Friday agreement that brought peace to Northern Ireland, notes in his memoirs that on the eve of the deal, 83 percent of the people there thought a resolution of their civil war impossible. Sometimes one of the most valuable skills in life is the ability to think outside the box of the past, as Mitchell did. Not always, of course, but sometimes, and one of the purposes of studying history is to acquire a feel for the difference.\n\nThere is also such a thing, in every culture as in every life, as too much pride in what one's kind has been and currently is, rather than in what it can achieve in concert with others. The history of the Holocaust suggests that minorities run risks when they depend too much on others, since the others generally will be guided by self-interest, but also that cutting oneself off from others poses its own, perhaps equal, dangers. Groups, like individuals, cannot make their ways alone; they need friends.\n\nIn addition to those two lessons with special relevance to members of minority groups, I believe that the study of the Holocaust has three broad implications for all citizens, whether members of minorities or not. First, the Holocaust highlights the primacy of avoiding situational causes. The veneer of civilization is thin, the rule of law is fragile, and the precondition of both is economic and political calm. This means that politics matters, and none of us can ever afford to fail to participate in making responsible public policy. Nazism stemmed from German racism, but that ideology would never have become national policy without the presence of an economic, national, and ideological crisis that fostered demagoguery and irresponsibility. Everyone's first goal in a decent society must be to avoid contributing to such a crisis or to those responses. Remember, more Germans became antisemites because they became Nazis than vice versa. Some of them became Nazis before 1933 because of the mess and the impasse in which their country found itself, and even more of them did so later because the Nazis became the apparently rather successful holders of power.\n\nI have often thought that one of the great injustices of the Nuremberg trials was that Franz von Papen, the man who did more to bring about Hitler's appointment as chancellor of Germany than anyone else, was acquitted because he had not committed an actual war crime. True, but he had made all the war crimes possible. The court held that political misjudgment is not a criminal offense, and I concede the point. But historians rightly vilify Papen, and his name will be forever odious. Something similar can be said of the financiers and bankers whose recklessness brought on the stock market crash of 1929 and the collapse of Germany's banks in 1931. Like Papen, they are permanent reminders that our first responsibility as citizens, regardless of our walk of life, is to do no harm. That is not a doctrine of passivity. _Why?_ has shown how much harm doing nothing can do. It is a doctrine of activity informed by seriousness, prudence, restraint, and unselfishness. These were not Franz von Papen's chief attributes, any more than they were the chief attributes of the German financial wizards of the 1920s or, for that matter, of the American ones during the first decade of this century.\n\nSecond, the Holocaust illustrates the fundamental importance and difficulty of individual courage and imagination. This dreadful history shows the necessity of standing up to categorization and conspiracy peddling, of refusing to turn a blind eye or a deaf ear to defamation. There can be no drawing of distinctions between citizens when it comes to fundamental human rights, no hair-splitting about who gets to have them and who does not. In fact, such rights are for the people whom we fear or dislike because they are the people who need them. But this dreadful history also shows that doing the right thing can have costs that are multiplied by the unwillingness of most people to pay them, so bravery is not enough\u2014wit, wiliness, shrewd judgment, persistence, and creativity in challenging evil are also indispensable. Resistance is never easy and seldom comfortable, and compassion has to be practiced in order to hold up when challenged. Rising to that challenge begins with a refusal to be cowed, followed by alertness to opportunity. According to the philosopher Philip Hallie, who several decades ago wrote a powerful account of the villagers in Le Chambon-sur-Lignon, their principal leader, Pastor Andr\u00e9 Trocm\u00e9, \"believed that if you choose to resist evil, and you choose this firmly, then ways of carrying out that resistance will open up around you. His kind of originality generated originality in others.\"\n\nThird, the Holocaust testifies to the need to preserve the essential distinction between means and ends. Antinomianism\u2014the idea that moral restrictions do not apply to us because of some special nobility or necessity of our purposes\u2014is the fatal temptation that the Nazis proffered and the fateful rationalization they used. Still endemic, it always feeds on fear. In times of extreme crisis, the history of the Holocaust demonstrates, a person's most profound moral commitments\u2014to family, faith, community, country, organization, party, and principle, for example\u2014can be made to seem like reasons to choose to do great harm, can be deeply corrupted. Franz Neumann, one of the pioneer analysts of National Socialism, highlighted its adeptness at \"surrounding every perfidy with the halo of idealism.\" The dreadful events of the Holocaust should be a reminder that calls to self-defense and for retribution are among the most corruptible of ideals. As William Pitt, a British prime minister in the mid-eighteenth century, once warned: \"Necessity is the plea for every infringement of human freedom. It is the argument of tyrants; it is the creed of slaves.\" The politics of division and emergency, of bullying and rage\u2014the politics that says desperate times require the political equivalent of \"stand-your-ground\" laws\u2014that sort of politics always deserves opposition and scorn because it is the politics that is just itching to get out of hand.\n\nThe Holocaust was not mysterious and inscrutable; it was the work of humans acting on familiar human weaknesses and motives: wounded pride, fear, self-righteousness, prejudice, and personal ambition being among the most obvious. Once persecution gathered momentum, however, it was unstoppable without the death of millions of people, the expenditure of vast sums of money, and the near destruction of the European continent. Perhaps no event in history, therefore, better confirms that very difficult warning embedded in a German proverb that captures the meaning I hope readers will take away from this book: _Wehret den Anf\u00e4ngen_ , \"Beware the beginnings.\"\n\nThat proverb comes to mind whenever I am asked at public forums when and how I think the Holocaust could have been prevented or stopped. My response is to name a time and place exactly: April 1\u20135, 1933, in Berlin. April 1 is well known as the date of the Nazi boycott of Jewish-owned shops across Germany. But something else occurred that day, the occupation by a company of Nazi storm troopers of the offices of the National Association of German Industry, headed by Gustav Krupp von Bohlen und Halbach, who also was the leader of the Krupp armaments and steel firm. The thugs made clear their intention to stay and disrupt the association's work until it dismissed all its employees who were Jews or affiliated with other political parties. When Krupp, who was a very powerful and prominent man, tried to persuade Hitler to call off his dogs, the Nazi F\u00fchrer simply declined, explaining that he could not restrain the enthusiasm of people who had been through thick and thin with him as he rose to power. Krupp then gave in, firing everyone of whom the Nazis disapproved on April 5 and thus breaking his contracts with each of those people.\n\nOne of the members of the National Association's governing board, a man named Georg von M\u00fcller-Oerlinghausen, wrote a prophetic protest to Krupp eight days later, saying that his actions amounted to capitulation to bullying and that they deprived the organization of all basis for future noncompliance with Nazi demands. If the German industrialists would not stand up for the contractual legal rights of their own personnel, M\u00fcller-Oerlinghausen asked, for whom would they stand up and on what grounds? He was right, and the more powerful the Nazis became, the more irreversibly right he was.\n\nBeware the beginnings.\nACKNOWLEDGMENTS\n\nNaturally, a book that took shape over almost thirty years owes a lot to a great many people, too many to list most of them by name. I have the privilege of working in a vibrant field, full of indefatigable and intelligent researchers from whom I have learned something new every day, so I want to express my appreciation to the scholars on whose publications I have drawn heavily in this book, both explicitly and implicitly. I also thank the thousands of Northwestern University students who completed History 349 between 1987 and 2015 and whose curiosity and eagerness to learn motivated me to keep trying, year after year, to make my presentation of the evidence and my reasoning from it ever clearer and tighter. Many colleagues and graduate students contributed valuable input at a History Department workshop on chapter 3 in Evanston in May 2015. I am especially indebted to Professor Amy Stanley for prompting me to rethink one minor and one major issue and to Professor Robert Lerner for alerting me to a significant omission. Thanks, too, to the participants in the Silberman Seminar at the United States Holocaust Memorial Museum in June 2015, who heard these chapters as lectures and provided useful feedback. Several generous colleagues and friends read the manuscript and offered numerous suggestions that enhanced it: Christopher Browning, Benjamin Frommer, Richard Levy, Wendy Lower, Thomas Lys, and Michael Marrus. The Jewish Foundation for the Righteous and Oxford University Press kindly granted permission to reprint several passages that I wrote for the chapter introductions in _How Was It Possible? A Holocaust Reader_ (2015) and Chapter 35 of _The Oxford Handbook of Holocaust Studies_ (2010). My agent, Peter Bernstein, and my editor, John Glusman, saw exactly the virtues in the manuscript that I tried to put there, and that carried me over the finish line. Everyone mentioned here earned and has my gratitude, but I alone am responsible for any errors or defects that remain.\n\nSpecial thanks to Volt and the dogs: Offsetting the bleakness of what I was working on, they made each day a pleasure.\nNOTES\n\nPage numbers listed correspond to the print edition of this book. You can use your device's search function to locate particular terms in the text.\n\nINTRODUCTION\n\n(xiv) **\"Impossible to remember,\"** Judt, _Postwar_ , 830.\n\nCHAPTER 1: TARGETS\n\n() **A professor of mine** ; he put the matter more elegantly in writing: \"antisemitism is a cluster of behaviors with a single name;\" Gay, _Freud, Jews and Other Germans_ , 13.\n\n() **Germany took pains** , Motadel, _Islam_ , 56\u201360.\n\n() **xenophobic and chimerical forms** , Langmuir, _Toward_ , 306, 328\u201352.\n\n() **Ancient Roman attitudes** , Lindemann and Levy, _Antisemitism_ , 38\u201340.\n\n() **Freud, Samuel, Poliakov, and Cohn** , Hand and Katz, _Post-Holocaust France_ , 177\u201384.\n\n() **\"doctrine of Jewish witness,\"** Lindemann and Levy, _Antisemitism_ , 64\u201365; Bauer, _History_ , 9.\n\n() **surge of attacks . . . blood libel** , Lindemann and Levy, _Antisemitism_ , 68\u201370, 74.\n\n() **Luther and Erasmus** , Nirenberg, _Anti-Judaism_ , 254, 262, 266.\n\n() **\"beliefs in racial or ethnic determinism,\"** Lindemann, _Esau's Tears_ , xiv.\n\n() **\"A Jew can no more** , **\"** Stern, _Politics_ , 141.\n\n() **On Gobineau and Schlegel** , see Weitz, _Century_ , 33\u201335; Arvidsson, _Aryan_ , 26\u201330.\n\n() **On Galton and Ploetz** , see Burleigh and Wippermann, _Racial State_ , 29, 32.\n\n() **Patents of Toleration** , Beller, _Antisemitism_ , 33\u201334; Meyer, _German-Jewish History_ , v. 2, 16\u201317.\n\n() **Bavarian petition . . . opposing equality for Jews** , Hochstadt, _Sources_ , 24.\n\n() **Country and city population figures** , Mitchell, _Statistics_ , 3\u201315.\n\n() **Jews seemed disproportionately present . . . illustrative figures** , Slezkine, _Jewish Century_ , 47\u201350; Pulzer, _Rise_ , 12; Hamann, _Hitler's Vienna_ , 327\u201328; Elon, _Pity_ , 259.\n\n() **That may have been what Albert Einstein had in mind** , Elon, _Pity_ , 274.\n\n() **Dreyfus and Beilis** , Lindemann, _Jew Accused_ , passim.\n\n() **3 percent** , ibid., 60.\n\n() **\"enemies of the antisemites, not of antisemitism,\"** ibid., 126.\n\nCHAPTER 2: ATTACKERS\n\n() **On Herder** , see Burleigh and Wippermann, _Racial State_ , 25; Smith, _Handbook_ , 242\u201343; Arvidsson, _Aryan_ , 26, 29, 74\u201375.\n\n() **On Fichte** , see Katz, _Prejudice_ , 57\u201359; Smith, _Handbook_ , 245\u201346.\n\n() **the most famous tales that the Grimms reproduced** , Smith, _Handbook_ , 263.\n\n() **\"Jewishness in Music,\"** Katz, _Darker Side_ , 33\u201346.\n\n() **On Hep-Hep** , see Hoffmann et al., _Exclusionary Violence_ , 23\u201342\n\n() **\"freedom to choose their own trades,\"** Aly, _Why_ , 34.\n\n() **\"No longer should we tolerate,\"** Katz, _Prejudice_ , 252.\n\n() \" **almost exclusively in favor of our co-citizens,\"** ibid., 253.\n\n() **six editions** , ibid., 256.\n\n() **\"natural reaction. . . . misfortune,\"** Hochstadt, _Sources_ , 27.\n\n() **265,000 German men signed** , Levy, _Antisemitism_ , v. 1, 21.\n\n() **Stoecker's party was overwhelmed** , Pulzer, _Rise_ , 87.\n\n() **Progressive Party gains** , Ritter, _Wahlgeschichtliches Arbeitsbuch_ , 39.\n\n() **figure 2** , ibid., 40\u201341, 146.\n\n() **electoral base small . . . narrow** , Pulzer, _Rise_ , 189\u201390; Lindemann and Levy, _Antisemitism_ , 130.\n\n() **\" _Gegen Junker und Juden_ ,\"** Levy, _Downfall_ , 58.\n\n() **Wilhelm Marr . . . \"a business,\"** Zimmermann, _Marr_ , 103.\n\n() **Krupp and the usual breakdown in election districts** , Ritter, _Wahlgeschichtliches Arbeitsbuch_ , 133\u201335 (Prussia), 164\u201366 (Saxony).\n\n() **63 percent** , Lindemann, _Esau's Tears_ , 149.\n\n() **Jewish population, birthrate, intermarriage, immigration, urbanization** , Richarz, _Leben_ , v. 2, 12\u201323.\n\n() **concentration of Jews' occupations** , ibid., 23\u201334.\n\n() **Jewish immigrants from Poland** , ibid., 18\u201319.\n\n() **\"They lived like bankers,\"** Elon, _Pity_ , 255.\n\n() **Jewish officers** , Vital, _People Apart_ , 135.\n\n() **2 percent of the professors** , Richarz, _Leben_ , v. 2, 32.\n\n() **\"cultural code,\"** Volkov, _Germans_ , 115.\n\n() **The Prussian state had taken firm action** , see Smith, _Butcher's Tale_.\n\n() **Prominent Jewish industrialists** , Elon, _Pity_ , 265\u201367.\n\n() **election of 1912** , ibid., 293; Levy, _Downfall_ , 250.\n\n() **\" _Kinderkrankheit_ ,\"** Gay, _Freud, Jews, and Other Germans_ , 15.\n\n() **\"Jew count,\"** Levy, _Antisemitism_ , v. 1, 371\u201372; Pulzer, _German State_ , 205\u20136; Elon, _Pity_ , 338\u201339; Rosenthal, _Ehre_ , passim.\n\n() **if only 12,000 or 15,000 more Jews** , Hitler, _Mein Kampf_ , 679.\n\n() **Wilhelm II and Ludendorff** , Tooze, _Deluge_ , 135; Liulevicius, _War Land_ , 198.\n\n() **the incidence of violent acts** , see Walter, _Kriminalit\u00e4t_ , and Hecht, _Juden_.\n\n() **figure 3** , J. Falter et al., _Wahlen_ , 44.\n\n() **On the origins of the _Protocols_** , Segel, _A Lie_ , 65\u201369; Bronner, _Rumor_ , 80\u201388.\n\n() **\"the best proof,\"** Hitler, _Mein Kampf_ , 307.\n\n() **Reparations and war debts** , Tooze, _Deluge_ , 369, 444; Balderston, _Economics_ , 20\u201321.\n\n() **Scheunenviertel riot** , Hoffmann et al., _Exclusionary_ , 123\u201340.\n\n() **\"theozoology,\"** one of Hitler's ideological forerunners in Vienna, Jorg Lanz von Liebenfels, coined the term as the title of a book he published in 1904.\n\n() **\"His speeches,\"** Konrad Heiden, quoted in Rees, _Charisma_ , 28.\n\n() **\"biological materialism,\"** Aly, _Why_ , 11.\n\n() **\"We know only one people,\"** Hamann, _Hitler's Vienna_ , 212.\n\n() **\"thoughtlessness,\"** Arendt, _Eichmann_ , 49, 287\u201388; compare Stangneth, _Eichmann_ , 201\u20132, 217\u201319.\n\n() **\"a blemish,\"** Rauschning, _Voice_ , 220.\n\n() **Twenty-five Point Program** , Noakes and Pridham, _Nazism_ , v. 1, 14\u201316.\n\n() **programs laid down in 1931 and G\u00f6ring's speech** , Adam, _Judenpolitik_ , 26\u201331.\n\n() **\"racial tuberculosis\" . . . Robert Koch** , Fest, _Hitler_ , 212; Kershaw, _Hitler_ , v. 2, 470.\n\n() **downplayed antisemitism** , Allen, _Seizure_ , 142; Wistrich, _Hitler_ , 45.\n\n() **\"the opposite of what exists today,\"** Fest, _Face_ , 296.\n\n() **On Hirschfeld** , see Beachy, _Gay Berlin_ , 160\u201386; on Fromm, Aly and Sontheimer, _Fromms_.\n\n() **unemployment . . . 15 percent** , Balderston, _Economics_ , 79; Overy, _Recovery_ , 20; and James, _Slump_ , 357.\n\n() **The way the Nazis campaigned** , Bracher, _Dictatorship_ , 179, 182.\n\n() **Northeim** , Allen, _Seizure_ , 88\u201389, 126, 142.\n\n() **40 percent** , Noakes and Pridham, _Nazism_ , v. 1, 84.\n\n() **Alone among the parties** , M\u00fchlberger, _Social Bases_ , 71\u201380.\n\n() **\"emancipate women,\"** Stibbe, _Women_ , 17.\n\n() **New Year's Day 1933** , Turner, _Thirty Days_ , 1.\n\n() **\"were drawn to antisemitism,\"** Allen, _Seizure_ , 84.\n\nCHAPTER 3: ESCALATION\n\n() **two-tier approach** , Barkai, _Boycott_ , Chapter 2.\n\n() **\"social death,\"** Kaplan, _Between_ , 5.\n\n() **Since 1933 . . . working for themselves or each other** , Barkai, _Boycott_ , 106\u20138, and Bajohr, _Aryanisation_ , 108.\n\n() **\"A law making the whole of Jewry liable,\"** Tooze, _Wages_ , 221.\n\n() **\"in the event of his death,\"** Noakes and Pridham, _Nazism_ , v. 3, 73.\n\n() **The gist was** , ibid., 72\u201379.\n\n() **carted off to concentration camps** , Cesarani, _Final_ , 164\u201365.\n\n() **willing to join in the violence** , see Steinweis, _Kristallnacht_ , and as background, Wildt, _Volksgemeinschaft_ , chapters 5\u20137.\n\n() **36,000, 26,000, and 600 men** , W\u00fcnschmann, _Before Auschwitz_ , 197, 204.\n\n() **allowed the German insurance companies to renege** , Feldman, _Allianz_ , 221, 227.\n\n() **emergence of a new word** , Hayes, _How_ , 172\u201373.\n\n() **he told the Czech foreign minister** , Adam, _Judenpolitik_ , 235.\n\n() **\"[t]he Germans. . . . have embarked,\"** Breitman and Lichtman, _FDR_ , 120.\n\n() **German planners actually** , Browning, _Origins_ , 86; Gerwarth, _Hangman_ , 179\u201381; Cesarani, _Final_ , 300\u20131.\n\n() **\"the bolshevist method,\"** Breitman, _Architect_ , 119.\n\n() **Hermann G\u00f6ring charged Reinhard Heydrich** , Roseman, _Wannsee_ , 53.\n\n() **murders reached a crescendo** , Burds, _Rovno_ , 20\u201321.\n\n() **\"the soldier must have full understanding,\"** Megargee, _Annihilation_ , 125.\n\n() **Events proceeded along parallel lines in German-occupied Serbia** , Browning, _Origins_ , 334\u201346.\n\n() **_Selbstgleichschaltung_ and the diplomats**, Hayes, _How_ , 111\u201317.\n\n() **group of leading business executives and Krupp** , Berenbaum and Peck, _Holocaust and History_ , 198\u201399.\n\n() **Degussa** , Hayes, _From Cooperation_ , 38.\n\n() **Weizs\u00e4cker's remarks** , Hayes, _How_ , 113.\n\n() **Roessler's remarks** , Hayes, _From Cooperation_ , 26.\n\n() **\"you reckon that you,\"** ibid., viii.\n\n() **\" _Sind Sie arisch?_ ,\"** Haffner, _Defying_ , 150\u201351.\n\n() **comrade** , ibid., 290\u201391.\n\n() **\"From now on,\"** Noakes and Pridham, _Nazism_ , v. 2, 252.\n\n() **cutting off contact with Jewish friends and neighbors** , Fulbrook, _Dissonant_ , 103\u201313.\n\n() **\"work towards the F\u00fchrer,\"** Kershaw, _Hitler_ , v. 1, 529.\n\n() **warping . . . worked especially powerfully on young people** , Fulbrook, _Dissonant_ , 136\u201339.\n\n() **behavior of Ernst Busemann** , Hayes, _From Cooperation_ , 88\u201390, 93\u201398 (\"it is pointless,\" 90).\n\n() **Potsdam and Kiel** , Bankier, _Germans_ , 70\u201371.\n\n() **Magdeburg** , Kulka and J\u00e4ckel, _Jews_ , 155.\n\n() **many farmers had to be forced** , Stephenson, _Home Front_ , 139\u201340.\n\n() **shame and disgust on the morning after** , Schrafstetter and Steinweis, _Germans_ , 9, 60, 67\u201368.\n\n() **\"The images of the arrest of the Jews,\"** Kulka and J\u00e4ckel, _Jews_ , 529.\n\n() **local offices from all around the country** , ibid., 537\u201342.\n\n() **\"our intellectuals,\"** Browning, _Origins_ , 390.\n\n() **\"Jew-friendly behavior,\"** ibid; Stargardt, _German War_ , 242; Bajohr and Pohl, _Holocaust_ , 56.\n\n() **the first contingents. . . . When the shipments resumed** , Morehouse, _Berlin_ , 168, 171.\n\n() **those descended from or in marriages to non-Jewish Germans** , B\u00fcttner, _Not_ , 11\u201371; Tent, _Shadow_ , 1\u201319; Meyer, _Balancing_ Act, 346; and Gruner, _Widerstand_ , 178\u201389.\n\n() **Transfer Agreement, 20,000, and 1.5 percent** , Bauer, _Brother's_ , 128\u201329; Barkai, _Boycott_ , 51\u201353, 100\u20134; Barkai, \"German Interests,\" 245, 251\u201352, 261\u201366; Yisraeli, \"Third Reich,\" 139, 141\u201342, 147.\n\n() **some people had better chances of being accepted elsewhere than others** , Barkai, _Boycott_ , 55, 153\u201354; Kaplan, _Between_ , 138\u201344; Richarz, _Leben_ , v. 3, 49, 51\u201352; Wasserstein, _Eve_ , 417.\n\n() **They fought back the only way they collectively could** , Bauer, _Brother's_ , 105\u201337, 257\u201358; Barkai, _Boycott_ , 85\u201399; Barkai, _Centralverein_ , 307\u201317; Richarz, _Leben_ , v. 3, 42\u201347; Benz, _Juden_ , Chapter 4.\n\n() t **he effort proved hopeless. . . . The Reichsvereinigung thus degenerated** , Meyer, _Balancing_ , chapters 1\u20132; Richarz, _Leben_ , v. 3, 58\u201364; Benz, _Juden_ , 71\u201374.\n\n() **In Vienna** , Rabinovici, _Eichmann's_ , 2\u20133, 119, 129\u201331.\n\n() **Emblematic of the viciousness** , Meyer, _Balancing_ , 158\u201361; Moorhouse, _Berlin_ , 268\u201371.\n\n() **appeasers actually were inclined to blame Jews** , Cesarani, _Final_ , 216.\n\n() **France signed a new treaty** , Caron, _Uneasy_ , 196\u2013200; McCullough and Wilson, _Violence_ , 54\u201369.\n\n() **Joseph Lyons . . . resolutely refused** , ibid., 144.\n\n() **the Hollywood film distribution companies** , Doherty, _Hollywood_ , 38.\n\n() **the Gestapo used the card files** , Meyer, _Balancing_ , 127.\n\n() **The SS experimented briefly in 1944** , Wachsmann, _KL_ , 453.\n\n() **GM's Opel division** , Turner, _General Motors_ , 42\u201344, 86\u2013103.\n\n() **Ford-Werke in Cologne** , Ford Motor Co., _Findings_ , 35\u201340.\n\nCHAPTER 4: ANNIHILATION\n\n() **how concentrated the time and place** , Browning, _Ordinary Men_ , xv; Hilberg, _Destruction_ , 1321; Stargardt, _Witnesses_ , 9; Dwork, _Children_ , xi.\n\n() **the effect on his men** , Roseman, _Wannsee_ , 63\u201364; Rhodes, _Masters_ , 150\u201354, 167\u201368, 223\u201328.\n\n() **None of the experts balked. . . . to assure the people involved of immunity** , Bryant, _Confronting_ , 37\u201338.\n\n() **propaganda campaign in the 1930s** , Proctor, _Racial Hygiene_ , 181\u201385.\n\n() **he expected potential religious objections to decline** , Bryant, _Confronting_ , 27.\n\n() **the MDs in charge of the program had decided** , ibid __., 43\u201344.\n\n() **Lange soon modified the killing process** , Browning, _Fateful_ , 59.\n\n() **14f13** , Wachsmann, _KL_ , 250\u201358.\n\n() **Dachau. . . . Most . . . were transported** , Morsch and Perz, _Studien_ , 241, 338\u201340.\n\n() **Tests on mental patients** , Browning, _Origins_ , 283, 304.\n\n() **whom he regarded in the typically Catholic fashion** , Griech-Polelle, _Bishop_ , 107\u20138, 113\u201314, 118, 150\u201351.\n\n() **Less than three weeks. . . . did not begin applying** , Berger, _Experten_ , 30, 34\u201336; Bryant, _Eyewitness_ , 3, 54, 78, 151, 159, 161; Arad, _Belzec_ , 17\u201319.\n\n() **were discussing setting up \"gassing devices,\"** Hochstadt, _Sources_ , 116\u201317.\n\n() **work began on the Belzec death camp** , Browning, _Origins_ , 360\u201365; see also Witte et al., _Dienstkalendar_ , 233\u201334.\n\n() **identified the derelict manor house** , Montague, _Chelmno_ , 49\u201353.\n\n() **solved the carbon monoxide supply problem** , Browning, _Fateful Months_ , 57\u201362; C\u00fcppers, _Rauff_ , 109\u201318.\n\n() **1\/3000th of an ounce** , Hayes, _From Cooperation_ , 273.\n\n() **the average cost of murder per head** , ibid., 293, 296\u201397.\n\n() **an instruction . . . that forbade further emigration** , Arad et al., _Documents_ , 153\u201354.\n\n() **Beyond the addition of two officials** , Cesarani, _Final_ , 454\u201355.\n\n() **Heydrich laid out a plan** , Hochstadt, _Sources_ , 132\u201336.\n\n() **Rosenberg . . . had briefed trusted German reporters** , Browning, _Origins_ , 403\u20134; Matth\u00e4us and Bajohr, _Political Diary_ , 385\u201389, quotation at 388.\n\n() **\"this is as close . . . as historians will get,\"** Fritzsche, \"The Holocaust,\" 604.\n\n() **As . . . Raul Hilberg emphasized** , Hilberg, _Destruction_ , v. 1, 49\u201359.\n\n() **Mortality at Chelmno** , Montague, _Chelmno_ , 185\u201388.\n\n() **jerry-rigged edifices** , Berger, _Experten_ , 49, 96; Arad, _Belzec_ , 25; Kuwalek, _Belzec_ , 61\u201362, 66\u201367.\n\n() **Death tolls and survivors of the Operation Reinhard camps** , Berger, _Experten_ , 9, 52, 64, 116, 140\u201341, 177, 252\u201355, 272, 276, 388; Bryant, _Eyewitness_ , 5\u20137, 99, 110, 113, 125; Arad, _Belzec_ , 84, 87, 99, 127\u201330, 258\u201369, 341\u201348; Schelvis, _Sobibor_ , 197\u201398; Kuwalek, _Belzec_ , 14, 170, 225\u201327, 244\u201346.\n\n() **second group of death camps** , Gruner, _Jewish_ , 217\u201329, 255\u201356; Gutman and Berenbaum, _Anatomy_ , 114; Hayes, _Industry_ , 347\u201360; Dlugoborski and Piper, _Auschwitz_ , v. 2, 100\u2013136; Megargee, _Encyclopedia_ , v. IB, 875\u201388; Morsch and Perz, _Studien_ , 219\u201327; Mail\u00e4nder, _Female_ , 172\u201373.\n\n() **deaths at and survivors of Auschwitz** , Hayes, \"Capital,\" 330.\n\n() **Majdanek was far less lethal** , Mail\u00e4nder, _Female_ , 44.\n\n() **Mauthausen** , Wachsmann, _KL_ , 163\u201366, 214; Morsch and Perz, _Studien_ , 126\u201328, 244\u201359; Caplan and Wachsmann, _Camps_ , 131; Jardim, _Mauthausen_ , 54\u201356; Megargee, _Encyclopedia_ , v. IB, 900\u2013907; Horwitz, _Shadow_ , 17\u201318.\n\n() **Durchgangstrasse IV camps and Janowska** , Brandon and Lower, _Shoah_ , 190\u2013223, 324.\n\n() **the camps took in enormous plunder** , Hayes, \"Capital,\" 337; Hochstadt, _Sources_ , 170\u201378; Arad, _Belzec_ , 154\u201364; Berger, _Experten_ , 180; Montague, _Chelmno_ , 88.\n\n() **the example of the Netherlands** , Dean, _Robbing_ , 285.\n\n() **Chelmno consisted** , Montague, _Chelmno_ , 76\u201384.\n\n() **obtained from IG Farben** , Dwork and van Pelt, _Auschwitz_ , 207\u20138.\n\n() **Potemkin villages** , see the keyed maps in Arad, _Belzec_ , 34\u201335, 38\u201339.\n\n() **Quantity and cost of the Zyklon used at Auschwitz** , Hayes, _From Cooperation_ , 295.\n\n() **some 7,000 Germans** , Dlugoborski and Piper, _Auschwitz_ , v. 5, 102.\n\n() **about one-third as many** , Hagen, _German History_ , 343.\n\n() **Germans and _Hiwis_ at Belzec, Sobibor, and Treblinka**, Berger, _Experten_ , 138, 218; Arad, _Belzec_ , 19, 22; Kuwalek, _Belzec_ , 79\u201380, 111.\n\n() **4,750 of these people** , Black, \"Foot Soldiers,\" 7.\n\n() **earned substantially more** , Berger, _Experten_ , 329\u201330.\n\n() **operated in the black** , Bryant, _Confronting_ , 39.\n\n() **Priority, pace, and equipment of deportation trains** , Mierzejewski, _Asset_ , v. 2, 117\u201319; Hilberg, _Sonderz\u00fcge_ , 59, 81\u201382, 86; Gerlach and Aly, _Kapitel_ , 273; Lichtenstein, _Tod_ , 22, 34, 51\u201353, 96, 105, 135.\n\n() **German and Hungarian train statistics** , Mierzejewski, _Asset_ , v. 2, 127, 166; Gall and Pohl, _Eisenbahn_ , 228, 239; Lichtenstein, _Tod_ , 14; P\u00e4tzold and Schwarz, _Bahnhof_ , 104\u20136.\n\n() **the same one or two slow and rickety trains** , Hilberg, _Sonderz\u00fcge_ , 208\u201312; Arad, _Belzec_ , 52, 65\u201366; Mierzejewski, _Asset_ , v. 2, 117; Lichtenstein, _Tod_ , 67.\n\n() **On the doctrine of \"base motive,\"** see Bryant, _Eyewitness_ , 92\u201394.\n\n() **\"cognitive dissonance,\"** see Newman and Erber, _Understanding_ , 52\u201354.\n\n() **\"repulsive duty\" . . . \"horrible task,\"** Breitman, _Architect_ , 196.\n\n() **\"all had an intense need to talk,\"** Lower, _Furies_ , 93.\n\n() **\"political soldiers,\"** Westermann, _Hitler's_ , 15.\n\n() **\"dichotomist ethics,\" \"moral grammar,\" \"too weak,\"** K\u00fchne, _Belonging_ , 59, 87, 167.\n\n() **\"By claiming weakness,\"** Beorn, _Marching_ , 241.\n\n() **\"they were always capable of such violence,\"** R\u00f6mer, _Kameraden_ , 465.\n\n() **\"particular National Socialist morality,\"** Welzer, _T\u00e4ter_ , 31.\n\n() **they became willing . . . identified** , Berger, _Experten_ , 312.\n\n() **Neuser and Glas** , Mierzejewski, _Asset_ , v. 2, 125\u201326.\n\n() **Oskar Gr\u00f6ning** , Rees, _Auschwitz_ , 155\u201358.\n\n() **only 30 percent of the SS men . . . _Volksdeutsche_ made up a large percentage**, Hayes, \"Capital,\" 336. On the predominance of _Volksdeutsche_ and _Hiwis_ in the guard force at Majdanek, see Mail\u00e4nder, _Female_ , 67, 146\u201347.\n\n() **Numbers of German women in the occupied East** , Lower, _Furies_ , 6\u20137, 21.\n\n() **\"In favoring perceived duty over morality,\"** Lower, ibid., 111. On the propensity for violence among the women guards at Majdanek, see Mail\u00e4nder, _Female_ , 71\u201372, 274\u201379.\n\n() **\"I did not want to stand behind the SS men,\"** Lower, _Furies_ , 155.\n\n() **Major Karl Plagge** , Hayes, _How_ , 658\u201374.\n\n() **Anton Schmidt** , Wette, _Feldwebel_ , 234\u201335\n\n() **outcomes of this sort were rare** , ibid., 139\u201342.\n\n() **\"inner identification with evil,\"** Segev, _Soldiers_ , 214.\n\n() **60 percent . . . and another 17 percent** , Wildt, _Generation_ , 23, 458.\n\n() **more than 83 percent of them** , Berger, _Experten_ , 292\u201393.\n\n() **upwardly mobile, well educated, and with long records of involvement** , Wildt, _Generation_ , 38\u201347, 429\u201332. See also Ingrao, _Believe_ , 17\u201331, and Perz, \"Austrian Connection,\" 418\u201319.\n\n() **the T4 personnel . . . constituted a highly indoctrinated group** , Berger, _Experten_ , 302\u20134, 316\u201318.\n\n() **\"our India,\"** Kershaw, _Hitler_ , v. 2, 401\u20132.\n\n() **likened Germany's eastward expansion to America's westward one** , Tooze, _Wages_ , 8\u201311, and Fritzsche \"The Holocaust,\" 601.\n\n() **\"the majority of Nazi genocide,\"** Mann, _Dark Side_ , 276, 278.\n\n() **\"If I looked like him,\"** Breitman, _Architect_ , 4.\n\n() **\"[I]f National Socialism had looked in the mirror,\"** Smelser and Zitelmann, _Braune Elite_ , 100.\n\n() **His favorite adjective was \" _unerh\u00f6rt_ ,\"** ibid., 105.\n\n() **Burckhardt's and Hitler's descriptions of Heydrich** , Fest, _Face_ , 100, 110.\n\n() **\"I feel free of all guilt,\"** Smelser and Zitelmann, _Braune Elite_ , 111.\n\n() t **heir removal was the job of another SS officer** , Berger, _Experten_ , 79\u201381; Arad, _Belzec_ , 44\u201345.\n\n() **he had come, during the 1930s, to believe deeply** , Cesarani, _Becoming_ , Chapter 2; Rabinovici, _Eichmann's_ , 35\u201336.\n\n() **how proud he was of his SS service in retrospect and how thoroughly he rationalized it** , Stangneth, _Before_ , 221\u201330, 242\u201381, 302\u20137.\n\n() **\"a functionary in the true sense. . . . had never really wasted much thought,\"** Fest, _Face_ , 277, 284.\n\n() **\" _\u00dcbervater_ ,\"** Smelser and Zitelmann, _Braune Elite_ , 167.\n\n() **Kaltenbrunner gave vent to his fervent Nazism by attesting** , Mann, _Dark Side_ , 244\u201345.\n\n() **The last two figures** , the best treatments of these men are in Allen, _Business_ , passim; the most thorough studies of the SS economic empire are Kaienburg, _Wirtschaft_ , and Naasner, _SS-Wirtschaft_.\n\n() **Himmler's speech to the assembled SS commanders** , Hochstadt, _Sources_ , 163\u201365.\n\n() **A nation is not only what it does** , Craig, _Germany_ , 638.\n\n() **Awareness . . . was widespread. . . . Germans spoke with open dread** , Bajohr and Pohl, _Holocaust_ , 59\u201372; Longerich, _Davon_ , 223\u201340.\n\n() **diary entry by Curt Pr\u00fcfer** , McKale, _Rewriting_ , 11.\n\n() **Klemperer diary entries** , Klemperer, _I Will_ , v. II, 28, 41, 155, 371.\n\n() **\"the Nazis wanted to manage,\"** Fritzsche, _Life_ , 286.\n\n() **Goebbels announced in the journal _Das Reich_. . . . the _V\u00f6lkischer Beobachter_ . . . reported,** Bajohr and Pohl, _Holocaust_ , 57; Friedl\u00e4nder, _Nazi Germany_ , v. 2, 276, 337\u201338.\n\n() **Hitler reminded Germans** , Longerich, _Davon_ , 201.\n\n() **If such partial revelations had a purpose** , ibid., 325\u201326.\n\n() **Perhaps 10,000. . . . Konrad Latte** , Schneider, \"Saving,\" 52\u201357.\n\n() **Arndt and Krakauer** , Moorhouse, _Berlin_ , 180, 295.\n\n() **plundered Jewish property sent to Hamburg** , Bajohr, _Aryanization_ , 279; Aly, _Beneficiaries_ , 127\u201329. See also Mierzejewski, _Asset_ , v. 2, 127; Fritzsche, _Life_ , 258\u201359.\n\n() **food and goods shipped home by far-flung troops** , Aly, _Beneficiaries_ , 94\u2013152.\n\n() **\"silent protest\" and \"to the hardest manual labor,\"** Gruner, _Rosenstra\u00dfe_ , 139, 200. See also Friedl\u00e4nder, _Nazi Germany_ , v. 2, 425.\n\n() **the reality of resistance generally goaded the Reich** : the classic example is the crackdown precipitated by the Dutch general strike of 1941; see Moore, _Victims_ , 72\u201373; Presser, _Ashes_ , 56\u201357.\n\n() **Forced laborer statistics** , Hayes, _How_ , 315\u201330.\n\n() **they were not necessarily cheap** , Tooze, _Wages_ , 534\u201337; Spoerer, _Zwangsarbeit_ , 183\u201390; Hayes, _From Cooperation_ , 262\u201364, 268\u201371; Wachsmann, _KL_ , 452.\n\n() **Relative fates of male and female slave laborers at Gleiwitz** , Hayes, _From Cooperation_ , 267\u201368.\n\n() **five to ten times more likely to die** , Neander, _Beispiel_ , 59.\n\n() **the mathematics of the German labor force during World War II** , Overy, _War_ , 291\u2013311.\n\n() **compulsory labor program for German Jewish males** , Barkai, _Boycott_ , 159\u201362.\n\n() **extended this program to . . . Poland** , Browning, _Nazi Policy_ , 61\u201365.\n\n() **Autobahn and Organisation Schmelt** , Gruner, _Jewish_ , 214\u201329; Gutterman, _Narrow_ , 43\u201355.\n\n() **first use of slave labor by German private industry** , Pohl, _Holzmann_ , 264\u201365.\n\n() **Volkswagen and IG Farben** , Mommsen, _Volkswagenwerk_ , 433\u201341, 496\u2013515, and Hayes, _Industry and Ideology_ , 347\u201353.\n\n() **Project Giant** , Pohl, _Holzmann_ , 266\u201367; Gutterman, _Narrow_ , ch. 8.\n\n() **Alderney** , Deak, _Europe_ , 59.\n\n() **Half the inmates of Auschwitz never even got labor assignments** , Hayes, \"Capital,\" 337.\n\n() **SS companies were neither profitable, nor usually successful in their joint ventures . . . though one initiative . . . made money** , Wachsmann, _KL_ , 405\u20136; Tooze, _Wages_ , 630.\n\n() **Changing female selection and mortality rates at Auschwitz** , Dlugoborski and Piper, _Auschwitz_ , v. II, 180\u201382; Gutman and Berenbaum, _Anatomy_ , 466; Wachsmann, _KL_ , 353, 455, 477\u201378.\n\n() **On Starachowice** , see Browning, _Remembering_ , passim.\n\n() **On Skarzysko-Kamienna** , see Ofer and Weitzman, _Women_ , 285\u2013309.\n\n() **one-third of the German infantry's ammunition** , Karay, _Death_ , 70.\n\n() **On the design, conception, dimensions, and working conditions at Dora** , Sellier, _History_ , 31\u201332, 511\u201315; Neander, _Mittelbau_ , 179\u201384, 189\u201395; Allen, _Business_ , 222\u201332; Neufeld, _Rocket_ , 208\u201313, 224\u201328; Wachsmann, _KL_ , 444\u201347; and Neander, _Beispiel_ , passim.\n\n() **Rocket production and deaths at Dora (26,500) and deaths from rockets (15,386)** , Wachsmann, _KL_ , 453\u201354, and Seiler, _History_ , 398, 403\u20134. On the additional murderous effects of V-2 production at Mauthausen, see Horwitz, _Shadow_ , 20-21.\n\n() **Fighter Staff Program** , Allen, _Business_ , 232\u201339; Tooze, _Wages_ , 627\u201334; Wachsmann, _KL_ , 448\u201351.\n\n() **mortality rates fluctuated** , Buggeln, _Slave_ , 27\u201332.\n\n() **to salvage their machinery** , Gregor, _Daimler-Benz_ , 194\u201396, 221\u201352.\n\n() **about 15 percent of the construction work** , Hayes, \"Capital,\" 347.\n\n() **principal profiteer from the slave labor program** , Neander, _Mittelbau_ , 55;\n\n() **estimated at 600 to 700 million reichsmark** , Wachsmann, _KL_ , 410.\n\n() **Marches from Auschwitz and Gross-Rosen** , Blatman, _Marches_ , 81\u2013105; Rees, _Auschwitz_ , 264; Wachsmann, _KL_ , 554\u201357.\n\n() **Marches from Stutthof and killing at Palmnicken** , Blatman, _Marches_ , 111\u201325.\n\n() **the camps that received retreating prisoner groups** , Morsch and Perz, _Neue Studien_ , 25; Stangneth, _Eichmann_ , 53; Bessel, _1945_ , 50; Blatman, _Marches_ , 127\u201332; Buggeln, _Slave_ , 60\u201361.\n\n() **Bergen-Belsen** , Blatman, _Marches_ , 132\u201336; Rees, _Auschwitz_ , 265\u201367; Stone, _Liberation_ , 83.\n\n() **These decisions were Heinrich Himmler's** , Blatman, _Marches_ , 53\u201354, 137; Wachsmann, _KL_ , 572\u201376.\n\n() **\"no inmate may fall into the enemy's hands alive,\"** Blatman, _Marches_ , 154, 181.\n\n() **Not all of them . . . but most did** , Blatman, _Marches_ , 155\u201379; Wachsmann, _KL_ , 580.\n\n() **Deaths at Buchenwald** , Blatman, _Marches_ , 152.\n\n() **When the British bombed the city** , Bessel, _1945_ , 52.\n\n() **Dachau, Mauthausen, and their subcamps** , Blatman, _Marches_ , 197\u2013217; Jardim, _Mauthausen_ , 59\u201360.\n\n() **\"many of the living people look dead,\"** Blatman, _Marches_ , 242.\n\nCHAPTER 5: VICTIMS\n\n() **in Cracow** , Henry, _Resistance_ , 51.\n\n() **inmate killed a German** , Arad, _Belzec_ , 98\u201399.\n\n() **twentieth transport** , Henry, _Resistance_ , 129\u201330, and Gilbert, _Holocaust_ , 574\u201375.\n\n() **Number of underground movements in Polish ghettos and camps** , Gutman and Krakowski, _Unequal_ , 106.\n\n() **Arendt quotations** , _Eichmann_ , 117.\n\n() **_amidah_** , Bauer, _Rethinking_ , 120.\n\n() **Hilberg is probably right** , Hilberg, _Destruction_ , 1106.\n\n() **Numbers of Jews in resistance units** , Henry, _Resistance_ , xix, xxv, xxvii, xxxiii, 142\u201357, 168\u201375, 201\u201319, 432\u201337; Bauer, _Rethinking_ , 137\u201339.\n\n() **\"the concentration of the Jews,\"** Hochstadt, _Sources_ , 87\u201389.\n\n() **modeled on the body . . . in Vienna** , Rabinovici, _Eichmann's_ , 40.\n\n() **In Lodz, for instance, twenty-two of the first thirty council members were killed** , Dobroszycki, _Chronicle_ , xlvi; Trunk, _Judenrat_ , 23; Trunk, _Lodz_ , xxxiii, 34.\n\n() **Lodz ghetto area** , ibid., 16\n\n() **Lodz ghetto population** , Dobroszycki, _Chronicle_ , xxxix, but Horwitz, _Ghettostadt_ , 335, gives 163,777, and Trunk, _Lodz_ , xxx, says \"about 164,000.\"\n\n() **Warsaw ghetto population and area** , Engelking and Leociak, _Warsaw_ , 49; Gutman, _Jews_ , 63\n\n() **permeability . . . remained much greater. . . . at many of the smaller sites** , Perechodnik, _Am I?_ , 68.\n\n() **villages of the largely rural Lublin district** , Silberklang, _Gates_ , 29, 212\u201314.\n\n() **attritionists and productionists** , Browning, _Path_ , 28\u201356.\n\n() **figure 5** , Dobroszycki, _Chronicle_ , xxxix, lxvi, 50, 52, 107, 193, 314, 352, 444, 519; Trunk, _Lodz_ , xlvi\u2013xlvii.\n\n() **pitted against each other** , Redner, _Policeman_ , 86, 106.\n\n() **his own father seized and ate** , Adelson, _Diary_ , 176\u201377.\n\n() **Internal disunity among Jews** , Trunk, _Judenrat_ , 29\u201335, 368\u201387; Corni, _Ghettos_ , 172\u201389; Wasserstein, _Ambiguity_ , 154.\n\n() **\"the community's social structure disintegrated,\"** Lensky, _Physician_ , 163.\n\n() **Why would the Germans kill people who could be useful** , Redner, _Policeman_ , 127\u201328.\n\n() **refusal of ghetto residents in both Lodz and Bialystok** , Hayes, _Lessons I_ , 11.\n\n() **the extent of Jews' denial** , Perechodnik, _Am I?_ , 12, with slight corrections to the translation from Polish by my colleague Jacek Nowakowski. See also Redner, _Policeman_ , 175.\n\n() **Nazi camouflage measures** , for example, Horwitz, _Ghettostadt_ , 283\u201384; Wasserstein, _Ambiguity_ , 141\u201342; Redner, _Policeman_ , 166.\n\n() **mixture of bait and threats** , Dawidowicz, _War_ , 301; Dobroszycki, _Chronicle_ , 125, 164\u201365; Horwitz, _Ghettostadt_ , 277\u201379; Corni, _Ghettos_ , 69; Wasserstein, _Ambiguity_ , 141.\n\n() **procedure re deportations from the Netherlands** , Moore, _Victims_ , 91\u201397, 109; Wasserstein, _Ambiguity_ , 138\u201339, 193, 195.\n\n() **Rosenblatt quotation** , Bauer, _Rethinking_ , 80\u201381.\n\n() **the conduct of Asscher and Cohen** , Wasserstein, _Ambiguity_ , 174\u201376.\n\n() **According to David Daube's** , ibid., 251.\n\n() **Rumkowski's \"give me your children!\" speech** , Trunk, _Lodz_ , 272\u201375.\n\n() **Administration and police numbers in Lodz** , ibid., 38, 40, 44; **in Warsaw** , Gutman, _Encyclopedia_ , 1609; Engelking and Leociak, _Ghetto_ , 409. See also Corni, _Ghettos_ , 74.\n\n() **On Szerynski and the Warsaw ghetto police** , Trunk, _Judenrat_ , 475\u201394, 498\u2013501, 552\u201353; Gutman, _Jews_ , 88\u201390, 237\u201340; Corni, _Ghettos_ , 107\u201311; Perechodnik, _Am I?_ , 104.\n\n() **increasingly corrupt and extortionist . . . these police did the footwork** , Redner, _Policeman_ , 130\u201335, 155\u201360.\n\n() **Composition of the Dutch Jewish police** , Moore, _Victims_ , 220\u201321; Wasserstein, _Ambiguity_ , 190\u201391; Cesarani, _Final_ , 679, 681\u201382.\n\n() **Daily food intake . . . hovered** , ibid., 274\u201375.\n\n() **in Warsaw in 1941** , the lower estimate is in Gutman, _Encyclopedia_ , 1609, the higher in Bauer, _History_ , 170.\n\n() **at Otwock** , Perechodnik, _Am I?_ , 232\u201333.\n\n() **5,550 people were dying in the Warsaw ghetto per month** , Gutman, _Jews_ , 64.\n\n() **German and Jewish casualties in the Warsaw Ghetto Uprising** , Engelking and Leociak, _Ghetto_ , 51; Henry, _Resistance_ , 31 (Hilberg, _Destruction_ , 1105, gives slightly lower German figures, so does Friedl\u00e4nder, _Nazi Germany_ , v. 2, 526).\n\n() **resistance against the German drive to empty the Bialystok ghetto resulted in** , Bender, _Bialystok_ , 258\u201365.\n\n() **Outcomes of Treblinka and Sobibor uprisings** , Arad, _Belzec_ , 363\u201364; Schelvis, _Sobibor_ , 168, 175, 231\u201342.\n\n() **Shootings at Majdanek and Poniatowa** , Silberklang, _Gates_ , 402\u20137.\n\n() **On the extent of smuggling in and out of the Warsaw ghetto** , see Hilberg et al., _Czerniakow_ , 306; Cesarani, _Final_ , 435\u201336.\n\n() **On Ringelblum and Oyneg Shabes** , see Kassow, _Who?_\n\n() **On Lodz** , Dobroszycki, _Chronicle_.\n\n() **several Jewish ghetto administrations adopted different survival strategies . . . but . . . they ultimately came to the same end** , Bauer, _History_ , 157\u201367; Polonsky, _Jews_ , v. III, 479\u2013500.\n\n() **\"No Jewish action caused any significant difference,\"** Silberklang, _Gates_ , 440.\n\n() **\"living in the expectation of death,\"** Arendt, _Eichmann_ , 119.\n\n() **\"running a race against time,\"** Vagi et al., _Hungary_ , 256.\n\n() **2 percent of the French population** , Paxton, _Vichy_ , 294\u201395.\n\n() **Dutch civil servants and police** , Wasserstein, _Ambiguity_ , 143; Romijn et al., _Persecution_ , 13\u201326.\n\n() **Population figures for the Warsaw ghetto** , Engelking and Leociak, _Warsaw Ghetto_ , 50\u201351; Gutman, _Jews of Warsaw_ , 270\u201371.\n\n() **Her last name was Neyer, and she is walking beside** , according to Yisrael Gutman in Laqueur, _Encyclopedia_ , 693.\n\n() **Courts of Honor in Italy, Germany, and the Netherlands** , Trunk, _Judenrat_ , 553\u201355; Jockusch and Finder, _Honor_ , 107\u201336; Wasserstein, _Ambiguity_ , 253\u201354.\n\n() **Kastner case** , Segev, _Seventh_ , Part V; the quotations appear on pp. 283 and 318, respectively.\n\n() **who fell into the hands of the Soviet Union** , Anonymous, _Clandestine_ , xv; Meyer, _Balancing_ , 359.\n\n() **Ben-Gurion's letters** , Segev, _Seventh_ , 294.\n\n() **the last prosecution** , Jockusch and Finder, _Honor_ , 320\u201321.\n\n() **the number of camps** , van Pelt, \"Nazi,\" 150.\n\n() **Such installations and their satellites . . . about one million died** , Wachsmann, _KL_ , 627.\n\n() **at most, about 150,000 Jewish veterans** , estimated from Wachsmann, _KL_ , 771.\n\n() **survival rates were infinitesimal** , Montagu, _Chelmno_ , 126\u201341, 195; Arad, _Belzec_ , 258\u201369; Bryant, _Eyewitness_ , 35, 42\u201343; Kuwalek, _Belzec_ , 14, 170, 225\u201327.\n\n() **a hierarchy of prisoner categories developed . . . constant struggle to control the most important trustee assignments** , Orth, _System_ , 57\u201361, Wachsmann, _KL_ , 122\u201335.\n\n() **Hermann Langbein . . . has left a vivid account** , Langbein, _People_ , 12\u201314.\n\n() **Sinti and Roma** , Hayes and Roth, _Handbook_ , 275\u201381; Lewy, _Persecution_ , 221\u201326; Hayes, _How_ , 495\u2013505; Weiss-Wendt, _Genocide_ , 2, 16\u201317; Weiss-Wendt, _Murder_ , 144\u201348; Bryant, _Eyewitness_ , 41; Deletant, _Forgotten_ , 187\u201396.\n\n() **The treatment of gays** , Hayes and Roth, _Handbook_ , 281\u201383; Jellonek, _Homosexuelle_ , 19\u201336, 327\u201332; Longerich, _Himmler_ , 231\u201340; Gellately and Stoltzfus, _Outsiders_ , 233\u201355; Berenbaum and Peck, _Holocaust_ , 338\u201357; Wachsmann, _KL_ , 127\u201328, 665.\n\n() **not all Slavs were the same in German eyes** , Hayes and Roth, _Handbook_ , 283\u201387.\n\n() **how people arrived at them** , Gigliotti, _Train_ , especially chapters 4\u20135.\n\n() **\"the most complete totalitarian structure to have been devised by man,\"** Marrus, _History_ , 147.\n\n() **\"a mixture of Hell and an insane asylum,\"** Langbein, _People_ , 477.\n\n() **the inhabitants of the \"family camp\" for Czech Jews** , Henry, _Resistance_ , 584.\n\n() **when 419 . . . Soviet POWs succeeded in breaking out of Mauthausen** , Blatman, _Marches_ , 400\u2013401; Horwitz, _Shadow_ , 124\u201343.\n\n() **The only successful form of resistance in the camps was escape, although the odds were long** , Bryant, _Eyewitness_ , 42\u201343; Arad, _Belzec_ , 258\u201369; Schelvis, _Sobibor_ , 135\u201342; Hayes, \"Capital,\" 340; Wachsmann, _KL_ , 534\u201336.\n\n() **Hanna L\u00e9vy-Hass . . . wrote** , Confino, _World_ , 203.\n\n() **\"Here there is no why,\"** Levi, _Survival_ , 25.\n\n() **\"the Resistance in the camp is not geared for an uprising,\"** Henry, _Resistance_ , 587.\n\n() **Auschwitz consumed 75,000 Poles . . . but it took the lives of probably four-fifths of the Jews ever registered** , Hayes, \"Capital,\" 330, 332.\n\n() **\"There are no roads from Auschwitz but those of improbability,\"** Rosenberg, _Brief_ , 106.\n\n() **\"excremental assault,\"** Des Pres, _Survivor_ , 51\u201371.\n\n() **\"pairing,\"** Henry, _Resistance_ , 566\u201367.\n\n() **As Imre Kertesz . . . writes** , ibid., 580.\n\nCHAPTER 6: HOMELANDS\n\n() **Minority religious status** , Bauer, _History_ , 286; Bauer, _Death_ , 93\u201395, 106\u20137, 111; Engelmann, _Hitler's_ , 71\u201378; Henry, _We Only_ , 9\u201340.\n\n() **Minority status was not always necessary** , Petrow, _Bitter_ , 116; Todorov, _Fragility_ , 9, 25, 97\u2013101; Bar-Zohar, _Beyond_ , 167\u201377; Rhodes, _Vatican_ , 319; Marrus and Paxton, _Vichy_ , 271\u201373; Dwork and van Pelt, _Holocaust_ , 332\u201333.\n\n() **certain character traits . . . were better predictors** , Tec, _Light_ , 152\u201354, 188\u201391; Oliners, _Altruistic_ , Chapter 6.\n\n() **Otto Jodmin . . . \"I simply had to do it,\"** Moorhouse, _Berlin_ , 297.\n\n() **Teresa Prekerowa . . . \"ordinary people who differed greatly,\"** Libionka, \"Polish Literature,\" 61\u201362.\n\n() **Aristides de Sousa Mendes** , Gutman, _Encyclopedia_ , 1381\u201382.\n\n() **the Dutch and Japanese consuls . . . in Kovno** , Hayes, _How_ , 648\u201357.\n\n() **Varian Fry** , Wyman, _Paper_ , 142.\n\n() **Ernest Prodolliet** , Independent Commission, _Switzerland_ , 109; Bauer, _Jewry_ , 276; Wasserstein, _Ambiguity_ , 165.\n\n() **Berthold Beitz** , K\u00e4ppner, _Beitz_ , 47\u2013113.\n\n() **Alfred Rossner** , Fulbrook, _Small Town_ , 156\u201358.\n\n() **Otto Weidt** , Moorhouse, _Berlin_ , 296.\n\n() **puppet regimes that carried out German orders** , Pavlowitch, _Disorder_ , 58\u201359; Mazower, _Inside_ , 18\u201322; M\u00fcller, _Seite_ , 159, 168\u201369, 174.\n\n() **Recherchegruppe (or Colonne) Henneicke** , Dean, _Robbing_ , 283; Moore, _Victims_ , 207\u201310; Presser, _Ashes_ , 354, 366, 392\u201393.\n\n() **The majority of the Jews ever deported from both France and Belgium** , Benz, _Dimension_ , 124, 127\u201328, 132\u201333, 135.\n\n() **Even Slovakia . . . had second thoughts** , Ward, _Priest_ , 224\u201335.\n\n() **Germany had allowed various national liberation groups to set up offices in Berlin** , Friedl\u00e4nder, _Nazi Germany_ , v. 2, 220; Polonsky, _Jews_ , v. III, 409\u201311.\n\n() **Jews were overrepresented compared to their share of the Lithuanian population** , Kosmala and Verbeeck, _Facing_ , 79; Barkan et al., _Shared_ , 380\u201381.\n\n() **the Soviet Union brought life in prison, but Nazi Germany brought the death sentence** , Bauer, _Death_ , 37\u201338.\n\n() **to Ukrainian and Baltic nationalists . . . Germany appeared the lesser evil** , Snyder, _Bloodlands_ , 190\u201394, 397; Gitelman, _Bitter_ , 67.\n\n() **calling on Ukrainians to \"destroy\" Jewry, and a pogrom took place** , Petrovsky-Shtern and Polonsky, _Polin_ 26, 339; Lower, _Empire-Building_ , 94\u201395; Redner, _Policeman_ , 34\u201337; Bartov and Weitz, _Shatterzone_ , 371\u201373.\n\n() **Lithuanian Activist Front declared that Jews had \"betrayed,\"** Dieckmann, _Litauen_ , 252\u201353; see also K\u00fchne, _Belonging_ , 81; Polonsky, _Jews_ , v. III, 406.\n\n() **Ukrainian police and militias played an active part** , Struve, _Herrschaft_ , passim.\n\n() **Himmler had about 300,000** , Cesarani, _Final_ , 382.\n\n() **\"For the Germans 300 Jews are . . .,\"** ibid., 394.\n\n() **Of the roughly 350,000 Jews in France in 1940, more than half** , Marrus and Paxton, _Vichy_ , 364.\n\n() **Statistics on deportations from France** , Benz, _Dimension_ , 127, 133\u201334; Paxton, \"Jews: Vichy,\" 40\u201343.\n\n() **the French government dragged its feet** , Marrus and Paxton, _Vichy_ , 372.\n\n() **Hungarian deportations and death toll** , Braham, _Politics_ , 153, 251; Wachsmann, _KL_ , 460.\n\n() **the thoroughness of this operation . . . was largely homegrown** , Braham, _Studies_ , 71\u201378, 86.\n\n() **the apt summation of Peter Kenez** , Kenez, _Coming_ , 250.\n\n() **H\u00f6ss . . . repeatedly sought to slow the overwhelming pace** , Wachsmann, _KL_ , 459.\n\n() **the deportation had a war-related purpose** , Buggeln, _Slave_ , 46\u201349.\n\n() **history of antisemitism in Hungary** , Braham, _Politics_ , 20\u201325; Vagi et al., _Holocaust_ , xxxviii\u2013xliv.\n\n() **the new territories nearly doubled the Hungarian Jewish population** , Vagi et al., _Holocaust_ , 368\u201369.\n\n() **\"Jewish workers for German war production purposes,\"** Braham, _Politics_ , 59.\n\n() **Antonescu's policies and motives** , Hayes, _How_ , 445\u201365, excerpting the fundamental study by Ancel; Ioanid, _Romania_ , especially 271\u201381; Deletant, _Forgotten_ , 209\u201314.\n\n() **a strong moral stand . . . proved counterproductive when the timing was not right** , Moore, _Victims_ , 73, 79\u201390; Presser, _Ashes_ , 56\u201357; Friedl\u00e4nder, _Nazi Germany_ , v. 2, 410\u201311.\n\n() **Many other pieces of good fortune were involved** , Lidegaard, _Countrymen_ , 31\u201335, 44\u201351, 65\u201373, 96\u201397, 154, 289, 329\u2013332, 339\u201340; Friedl\u00e4nder, _Nazi Germany_ , v. 2, 545\u201347.\n\n() **In Italy, Mussolini had just announced** , Knox, \"faschistische Italien,\" 56, 61, 65, 79; Schlemmer and Woller, \"italienische Faschismus,\" 182\u201387.\n\n() **around Trieste . . . 90 percent of the Jewish community perished** , Zimmerman, _Italy_ , 247\u201351.\n\n() **Giovanni Palatucci** , Bess, _Choices_ , 81.\n\n() **In Italy . . . more than one-third** , Sarfatti, _Jews_ , 27\u201328; Zuccotti, _Italians_ , 20.\n\n() **Gross . . . overstated . . . but established** , Gross, _Neighbors_ , 73\u201389; Bikont, _Crime_ , 521\u201324; David-Fox, _Holocaust_ , 19\u201320; **a curious feature of survivors' testimonies** , Browning, _Remembering_ , 50.\n\n() **50,000\u201360,000 by December 1939 . . . liquidated much of the Polish intelligentsia** , Matth\u00e4us et al., _War_ , 3; Rossino, _Hitler_ , 234; Snyder, _Bloodlands_ , 126\u201327, 153\u201354; Gross, _Neighbors_ , 7.\n\n() **how complete the purge at some local levels was** , Libionka, \"Church Hierarchy,\" 86; see also Phayer, _Pius XII_ , 23\u201324; and Huener, \"Kirchenpolitik,\" 113\u201316, 128\u201329.\n\n() **official rations provided Poles** , Winstone, _Dark_ , 115.\n\n() **\"bread prices . . . hovered,\"** ibid., 118\u201319.\n\n() **\"economically speaking, an empty body,\"** ibid., 73.\n\n() **\"[W]e have decided. . . . [I]t was like living in a country,\"** ibid., 50, 53.\n\n() **More Poles died in the bombing of Warsaw . . . more Poles may have been killed in the suppression** , Snyder, _Bloodlands_ , 405\u20136.\n\n() **about 720,000 people** , Paulsson, _Secret_ , 1.\n\n() **Jakub Berman . . . simply cooked up the number** , Snyder, _Bloodlands_ , 356\u201357, 407; Gross, _Fear_ , 4.\n\n() **The Jewish survival rate in Warsaw was equal to that in Amsterdam** , Paulsson, _Secret_ , 2, 5, 229\u201331.\n\n() **newspaper column by FBI Director** , James Comey, \"Why I Require FBI Agents to Visit the Holocaust Museum,\" _Washington Post_ , April 16, 2015.\n\n() **a number of prominent Jewish scholars** , e.g., the reviews by Dan Diner in _Contemporary European History_ 21 (2012), 125\u201331, and Omer Bartov in _Slavic Review_ 71 (2012), 424\u201328.\n\n() **antisemitism in Poland was considerable before 1939 and on the rise** , Bauer, _Brother's_ , 194; Polonsky, _Jews_ , v. III, 80\u201381, 85\u201388; Blobaum, _Antisemitism_ , 158\u201370; Mendelsohn, _Jews_ , 71\u201376; Zimmerman, _Underground_ , 16\u201320; Watt, _Bitter_ , 361-66.\n\n() **\"forcible emigration of the Jews\" . . . sent a delegation to Madagascar** , Wasserstein, _Eve_ , 40, 359; Hamerow, _Why_ , 62.\n\n() **The Polish foreign minister even discussed . . . and tried to lease . . . \"supplemental Jewish homeland,\"** Bauer, _Brother's_ , 193; Zimmerman, _Contested_ , 22\u201323; Hamerow, _Why_ , 62, 87.\n\n() **trained right-wing Zionist fighters in Poland** , Snyder, _Black_ , 64\u201366, 281.\n\n() **Church leaders and publications. . . . \"It is a fact that,\"** Polonsky, _Jews_ , v. III, 81\u201384; Libionka, \"Church Hierarchy,\" 77\u201386.\n\n() **\"Hitler called the Jews the microbe of the world,\"** Blobaum, _Antisemitism_ , 261.\n\n() **\"regrettable excesses\" . . . disrespect \"for the faith and traditions of Christians,\"** Libionka, \"Church Hierarchy,\" 81.\n\n() **separate ethnic communities . . . survey conducted before the war** , Wasserstein, _Eve_ , 224, 330.\n\n() **Jews and Poles were divided by residence and occupations** , Mendelsohn, _Jews_ , 23\u201332, 42\u201343; Bauer, _Brother's_ , 180\u201389; Watt, _Bitter_ , 365.\n\n() **11,500, 70,000\u201390,000, 25,000, 3,500** , Paulsson, _Secret_ , 229\u201331, 236.\n\n() **the Polish army interned** , Hamerow, _Why_ , 44.\n\n() **Jews composed more than half** , Gross, _Fear_ , 195\u201397.\n\n() **Jews there did recognize** , Bauer, _Death_ , 35\u201341; Zimmerman, _Contested_ , 61\u201368.\n\n() **\"This is nothing to be surprised at,\"** Perechodnik, _Am I?_ , 2, with slight corrections to the translation from the Polish by my colleague Jacek Nowakowski.\n\n() **the massacre there was hardly an isolated occurrence** , Polonsky, _Jews_ , v. III, 421, 425; Bauer, _Death_ , 92\u2013120; Zimmerman, _Underground_ , 95\u201398; Barkan et al., _Shared_ , 306, 316.\n\n() **Stefan Rowecki . . . reported** , Kosmala and Verbeeck, _Facing_ , 66.\n\n() **\"is creating something of a narrow bridge,\"** Polonsky, _Jews_ , v. III, 408; Zimmerman, _Underground_ , 74\u201375.\n\n() **Jewish inmates who escaped Sobibor** , Schelvis, _Sobibor_ , 181\u201382.\n\n() **Barwy Biale detachment . . . slaughtered** , Mazurek and Skibinska, \"Barwy Biale,\" 433\u201380; Zimmerman, _Underground_ , 290.\n\n() **\"The farmers are seizing the Jews,\"** Polonsky, _Jews_ , v. III, 450.\n\n() **the so-called Blue Police. . . . Germans offered rewards . . . and threatened** , Grabowski, _Hunt_ , 101\u201320.\n\n() **what happened in Dabrowa Tarnowska County** , ibid., 61.\n\n() **\"[W]e have to punish those who want to hide Jews,\"** ibid., 58.\n\n() **Most people who hid Jews there did so in return for money** , ibid., 135\u201348.\n\n() **The AK did pass its knowledge . . . warned Poles against . . . blackmailing . . . and . . . carried out executions** , Fleming, _Auschwitz_ , 27; Zimmerman, _Underground_ , 84, 129\u201331, 134\u201339, 141\u201350, 154\u201360, 162, 224, 227, 264, 300\u2013302; Polonsky, _Jews_ , v. III, 461.\n\n() **made no effort to impede the transports . . . provided only modest support for the Warsaw Ghetto Uprising** , Zimmerman, _Underground_ , 54, 161, 167\u201368, 179, 197\u2013209, 214\u201317, 241; Fleming, _Auschwitz_ , 254\u201355; Polonsky, _Jews_ , v. III, 463, 511\u201312; Friedl\u00e4nder, _Nazi Germany_ , v. 2, 523.\n\n() **Komorowski . . . banditry** , Zimmerman, _Underground_ , 251\u201356, 262, 267\u201386, 297\u201398, 417\u201318.\n\n() **Zegota . . . \"Our feelings toward the Jews have not changed.\" . . . most of its funds** , Zimmerman, _Underground_ , 175\u201378, 184, 303\u201312; Bauer, _American_ , 332\u201333.\n\n() **favored liquidation or emigration . . . by a ratio of nine to four** , Polonsky, _Jews_ , v. III, 445.\n\n() **Even among political prisoners in the concentration camps** , Langbein, _Against_ , 146, and _People_ , 75\u201376.\n\n() **currency and jewelry dealers set up shop around Treblinka** , Gross and Gross, _Golden_ , 28\u201338.\n\n() **the first thing her protectors asked** , Tec, _Tears_ , 214.\n\n() **omit them in the future** , David-Fox, _Holocaust_ , 13.\n\n() **emigrated to Chicago** , Gross, _Neighbors_ , 131; Polonsky, _Jews_ , v. III, 424.\n\n() **Hirszman. . . . Kielce pogrom. . . . tried to cover their tracks** , Bryant, _Eyewitness_ , 35; Gross, _Neighbors_ , 152\u201367; Grabowski, _Hunt_ , 86. Cf. Kuwalek, _Belzec_ , 315\u201317.\n\n() **Jewish \"overrepresentation,\"** Gross, _Fear_ , 220\u201322, 226\u201331\n\n() **to discredit a competing candidate . . . \"a Jew who tries to make money,\"** Gross, _Fear_ , 30; Judt, _Postwar_ , 827.\n\n() **Ringelblum . . . was hidden . . . by a non-Jew** , Gutman and Krakowki, _Unequal_ , iii; Kassow, _Who?_ , 362\u201365, 383\u201385.\n\n() **almost 1,000 cases of Poles executed for helping** , Wette, _Feldwebel_ , 154; Grabowski, _Hunt_ , 56, gives \"slightly more than seven hundred\" as the figure arrived at by Polish researchers.\n\n() **fifteen times more likely** , Snyder, _Bloodlands_ , 406.\n\nCHAPTER 7: ONLOOKERS\n\n() **France enacted various rules that made immigration less appealing** , Caron, _Uneasy_ , 28\u201333.\n\n() **After 1936, four other arguments . . . narrowed** , Hamerow, _Why_ , 72\u201389; Weber, _Hollow_ , 87\u2013110; Caron, _Uneasy_ , 187\u2013205.\n\n() **\"taken as a whole not very desirable,\"** Wasserstein, _Eve_ , 218.\n\n() **even sentenced the aunt and uncle** , McCullough and Wilson, _Violence_ , 59.\n\n() **The trend . . . in the Netherlands, Belgium, and Czechoslovakia** , Bauer, _Brother's_ , 170\u201372, 177, 243, 267; Hamerow, _Why_ , 61.\n\n() **Switzerland provided the most glaring illustration** , Independent Commission, _Switzerland_ , 105\u20139, 128\u201330; Caestecker and Moore, _Refugees_ , 82\u2013102; Bauer, _Brother's_ , 172\u201376, 239\u201340, 267\u201368.\n\n() **several discouraging and . . . mutually contradictory preconditions** , David-Fox, _Holocaust_ , 37.\n\n() **Britain saw its role . . . as that of a \"transit nation,\"** London, _Whitehall_ , chapters 3\u20135; Hamerow, _Why_ , 90\u2013119, 156\u201361; McCullough and Wilson, _Violence_ , 108\u201350; Abella and Troper, _None_ , xx, 6\u20139, 48\u201349.\n\n() **Britain pursued similarly restrictive policies in Palestine** , Dwork and van Pelt, _Flight_ , 28\u201351; Bauer, _History_ , 127\u201328; Wasserstein, _Eve_ , 339, 363, 413.\n\n() **haunted by the specter of what might happen** , Hamerow, _Why_ , 104, 112, 114\u201316; Caestecker and Moore, _Refugees_ , 64; London, _Whitehall_ , 95.\n\n() **Poland's ambassador in London tried to blackmail Britain** , Wistrich, _Hitler_ , 21; Hamerow, _Why_ , 63; London, _Whitehall_ , 91.\n\n() **an average of only 22 percent** , Bauer, _Brother's_ , 163.\n\n() **the almost 310,000 . . . Jews who actually applied for entrance by 1939** , Breitman and Kraut, _American_ , 74.\n\n() **probably about 225,000** , Friedl\u00e4nder, _Nazi Germany_ , v. 2, 783, says 211,000 as of the end of 1943; London, _Whitehall_ , 12, says \"no more than 250,000 . . . in the years 1933\u201345.\" Wyman, _Paper_ , 218\u201319, calculates that just over 250,000 \"refugees from Nazism\" got into the U.S. by the autumn of 1944, but not all of these people were Jews.\n\n() **\"FDR's second-term policies likely helped save the lives of well over 100,000 Jews,\"** Breitman, _FDR_ , 317.\n\n() **more than five-sevenths of its total refugees at the last minute** , London, _Whitehall_ , 11\u201312, 103, 115\u201318, 131\u201334, 141; Bauer, _Brother's_ , 270\u201371.\n\n() **fear of economic competition** , Wyman, _Paper_ , 3\u20139; Breitman and Kraut, _American_ , 11\u201317, 21\u201322, 33\u201337, 49\u201350; see Hamerow, _Why_ , 252\u201353.\n\n() **The American public opposed letting more people in** , Breitman and Kraut, _American_ , 58; Breitman and Lichtman, _FDR_ , 116.\n\n() **Father Charles Coughlin. . . . Jew Deal . . . polls of 1938 and 1939** , Wyman, _Paper_ , 17\u201319, 22; Breitman and Lichtman, _FDR_ , 75\u201377; Hamerow, _Why_ , 251 (on the Jew Deal).\n\n() **\"is a perfect opening to Germany to load the United States with agents,\"** Hamerow, _Why_ , 281; Breitman and Kraut, _American_ , 112\u201345.\n\n() **State Department instructed its consuls worldwide** , Wasserstein, _Ambiguity_ , 110.\n\n() **FDR's caution** , Breitman and Kraut, _American_ , 222\u201335.\n\n() **a scheme for smuggling agents into the Americas under the cover of releasing Jews** , Wasserstein, _Ambiguity_ , 118.\n\n() **The two groups also differed in their attitudes toward the creation of a Jewish state. . . . Joint Distribution Committee . . . preferred** , Bauer, _Brother's_ , 157\u201366.\n\n() **Shanghai** , Hochstadt, _Exodus_ , especially chapters 3\u20134; Caestecker and Moore, _Refugees_ , 109\u201321.\n\n() **\"divided into places where they cannot live and places they cannot enter\" . . . \"Dutch Guiana, Angola, Cyprus,\"** Wasserstein, _Eve_ , 360, 403.\n\n() **Statistics on the _St. Louis_** , Vincent, \"Voyage,\" 255, 270\u201371, 274, 288; Breitman and Lichtman, _FDR_ , 138.\n\n() **Emigrants from Poland in 1937 and U.S. quota** , Bauer, _Brother's_ , 194, 249.\n\n() **the Church's leaders in Rome recognized . . . glorification of race and nation as \"idolatrous,\"** Wolf, _Pope_ , 230, 268; Kornberg, _Dilemma_ , 228\u201329; Godman, _Vatican_ , 102\u20136, 129, 141\u201353.\n\n() **As Mussolini pointed out** , Kertzer, _Mussolini_ , 307\u201315.\n\n() **\"The Jewish Question,\" . . . \"It is an evident fact.\" . . . \"messianic craving for world domination,\"** Kertzer, _Mussolini_ , 211, 289\u201391.\n\n() **\"Spiritually, we are all Semites\" . . . \"the enemy of the Cross of Christ,\"** Kertzer, _Popes_ , 280.\n\n() **Content and fate of \"The Unity of the Human Race,\"** Kertzer, _Popes_ , 280\u201382; Wolf, _Pope_ , 206\u201312; Passelecq and Suchecky, _Hidden_ , passim.\n\n() **Pacelli had opposed issuing _Mit brennender Sorge_ . . . suggested a mere pastoral letter**, Wolf, _Pope_ , 265\u201368.\n\n() **was he the candidate the Nazi envoys in Rome hoped would prevail . . . destroyed the copies and plates** , Kertzer, _Mussolini_ , 370\u201381; Ventresca, _Soldier_ , 130\u201332, 134\u201335.\n\n() **A Roman aristocrat by descent . . . and critical of the Catholic Center Party** , Ventresca, _Soldier_ , 7\u201318, 38\u201365, 72\u201384.\n\n() **Though not happy with the form the Concordat took** , Wolf, _Pope_ , 170\u201378.\n\n() **Pius XII considered his chief duty to be to the Church and to Catholics** , Kornberg, _Dilemma_ , 4\u20136, 255\u201367; Godman, _Vatican_ , 82\u201383.\n\n() **Preysing vs. Bertram** , Hayes and Roth, _Handbook_ , 238\u201341; Phayer, _Catholic_ , 67\u201381.\n\n() **On the importance of the sacraments to the Church's political conduct** , Kornberg, _Dilemma_ , 3\u20134, 272\u201373; Spicer, _Resisting_ , 6\u20139.\n\n() **approximately 72,000 Jews** , Bauer, _Jewry_ , 66.\n\n() **Swiss factory owners in Poland . . . reported** , Straumann and Wildmann, _Schweizer_ , 116\u201320.\n\n() **British intelligence intercepted** , Breitman, _Official_ , 89\u201398.\n\n() **the Vatican's ambassador in Slovakia** , Kornberg, _Dilemma_ , 81.\n\n() **Father Pirro Scavizzi . . . the Jewish Bund Party in Poland** , Phayer, _Catholic_ , 47\u201348.\n\n() **As late as December 1944, a majority of the British public did not believe** , see Hamerow, _Why_ , 410; Stone, _Liberation_ , 68.\n\n() **Gerhart Riegner and Eduard Schulte** , Breitman and Laqueur, _Breaking_ , passim; Riegner, _Never_ , 35\u201343, 50.\n\n() **three unimpeachable sources** , Friedl\u00e4nder, _Nazi Germany_ , v. 2, 458\u201361; Riegner _Never_ , 48\u201350.\n\n() **BBC broadcast by Thomas Mann** , Longerich, _Davon_ , 240\u201345.\n\n() **a tally by H\u00f6fle** , Friedl\u00e4nder, _Nazi Germany_ , v. 2, 479\u201380.\n\n() **making too much of Jewish suffering would play into the claims of Nazi propaganda** , Aronson, _Hitler_ , passim; Hamerow, _Why_ , 398, 400\u2013403, 409, 411\u201312, 414.\n\n() **the USSR never considered the idea** , David-Fox, _Holocaust_ , 31\u201336.\n\n() **The Russians first learned. . . . But nothing happened** , Orbach and Solonin, \"Calculated,\" 90\u2013113.\n\n() **Churchill, Eden, and Sinclair** , Wasserstein, _Britain_ , 307\u201320; Neufeld and Berenbaum, _Bombing_ , 261\u201371.\n\n() **\"frightful prospect,\"** see Wasserstein, _Britain_ , 340\u201341.\n\n() **Only 37,451** , Ofer, _Escaping_ , 319.\n\n() **both the United States and the UK purposefully ignored** , Fleming, _Auschwitz_ , 167\u2013218.\n\n() **The Mufti and his effects on the British** , Wasserstein, _Britain_ , 28\u201329, 71, 79\u201380.\n\n() **The Mufti's hopes and disappointments** , Motadel, _Islam_ , 41\u201343, 87\u201392, 96\u201397, 107\u20138, 113\u201314, 188\u201394, 226\u201335, 250, 274\u201382; Nicosia, _Nazi_ , 71, 267, 276\u201379.\n\n() **the Mufti scored a few victories . . . [his] association with the Axis ultimately had . . . disastrous consequences** , Motadel, _Islam_ , 43\u201344; Nicosia, _Nazi_ , 242\u201357; Achcar, _Arabs_ , 150\u201373.\n\n() **Pope Pius XII was more worried about** , Phayer, _Catholic_ , 57\u201366; Kornberg, _Dilemma_ , 253.\n\n() **He had his ambassador to Vichy . . . tell its leader** , Marrus and Paxton, _Vichy_ , 262.\n\n() **used Vatican diplomatic channels to persuade Spain** , Zuccotti, _P\u00e8re_ , 127\u201328; Ventresca, _Soldier_ , 199\u2013200.\n\n() **left decisions . . . withheld . . . information** , Phayer, _Catholic_ , 43, 46, 49.\n\n() **declined to intervene . . . put off pressing . . . Horthy . . . refused to send another protest** , ibid., 104\u20139; Phayer, _Pius_ , 91\u201393.\n\n() **\"divine law knows no compromise,\"** \"Pius XII,\" 16; see also Ventresca, _Soldier_ , 174.\n\n() **\"Push never came to shove,\"** Bess, _Choices_ , 86.\n\n() **Sheptytsky . . . tried to impede Ukrainian collaboration . . . in two extraordinary ways** , Petrovsky-Shtern and Polonsky, _Polin_ 26, 347\u201349.\n\n() **\"Deeply moved. . . . platonic,\"** Friedl\u00e4nder, _Nazi Germany_ , v. 2, 420.\n\n() **Catholic hierarchy in Slovakia** , Ward, _Tiso_ , 225\u201328, 232\u201339; Kornberg, _Dilemma_ , 78\u201386.\n\n() **In Belgium, a network** , Moore, _Survivors_ , 276\u201395.\n\n() **in Rome** , Schlemmer and Woller, \"italienische Faschismus,\" 195.\n\n() **emphasized the dangers that might flow** , Ventresca, _Soldier_ , 162\u201370, 174\u201376.\n\n() **although the pope never explicitly drew this comparison** , Kornberg, _Dilemma_ , 253.\n\n() **neither the Dutch prime minister nor the queen of the Netherlands was cowed** , Wasserstein, _Ambiguity_ , 244.\n\n() **arrested thirty-seven clerics . . . six of them died** , Griech-Polelle, _Galen_ , 217; Spicer, _Resisting_ , 137.\n\n() **such fears did not stop Bernhard Lichtenberg** , Hayes and Roth, _Handbook_ , 239; Spicer, _Resisting_ , 171\u201382.\n\n() **\"In the fulfillment of . . . Our duty . . . it is not allowed,\"** Kornberg, _Dilemma_ , 266.\n\n() **the incidence of antisemitism in the American population actually increased during the conflict** , Dinnerstein, _Antisemitism_ , 128\u201349; Wyman, _Abandonment_ , 14\u201315, Dinnerstein, _Survivors_ , 6; Hamerow, _Why_ , 311.\n\n() **in 1940\u201341 . . . only about 30,000 German Jews got into the country** , Bauer, _Jewry_ , 66.\n\n() **many munitions ships returned empty from Europe** , Wyman, _Abandonment_ , 335.\n\n() **Karski in Izbica and with FDR** , Karski, _Story_ , 368\u201384, 419, 446\u201347.\n\n() **War Refugee Board funding** , Bauer, _American_ , 407\n\n() **food that the board paid for and stockpiled in Swedish ports saved thousands of lives** , Rosenberg, _Brief_ , 139\u201340, 149\u201350.\n\n() **The non-bombing of Auschwitz** , Hamerow, _Why_ , 402\u201318; Neufeld and Berenbaum, _Bombing_ , passim, but especially 249\u201360, 271\u201380.\n\n() **bombing the camp might not have saved many lives** , Rees, _Auschwitz_ , 246\u201347.\n\n() **The SS transferred** , Czech, _Kalendarium_ , 701, 821.\n\n() **30,000 in October, for example** ; Steinbacher, _Auschwitz_ , 124.\n\n() **collateral damage would have occurred** , Wachsmann, _KL_ , 586; Hayes, _From Cooperation_ , 256.\n\n() **Stephen Wise . . . refused to pressure him** , Hamerow, _Why_ , 269, 345; Riegner, _Never_ , 71.\n\n() **\"constitutionally incapable of serious questioning,\"** Bauer, _American Jewry_ , 52.\n\n() **the _Yishuv_** , Porat, _Blue_ , 251, 256\u201358, 261\u201362; Ofer, _Escaping_ , 23\u201331, 318\u201319.\n\n() **\"Refugees who have fled purely on racial grounds,\"** Independent Commission, _Switzerland_ , 114.\n\n() **enforcement was inconsistent** , ibid., 110, 117.\n\n() **Evolution of Swedish policy** , Hayes, _How_ , 735\u201352, excerpting the fundamental work of Paul Levine.\n\n() **George Mantello** , Kranzler, _Man_ , chapters 7\u201311.\n\n() **Giorgio Perlasca** , Levine, _Wallenberg_ , 310\u201311, 324\u201348.\n\nCHAPTER 8: AFTERMATH\n\n() **The toll at Belsen** , Stone, _Liberation_ , 83\u201385, 107\u20138, 111\u201312.\n\n() **some of them went on a rampage . . . used bayonets and rifle butts** , Abzug, _Inside_ , 93; Bessel, _1945_ , 162\u201364.\n\n() **\"The punishment they got,\"** Stone, _Liberation_ , 100.\n\n() **the object of Allied revulsion soon changed** , Fritz, _Endkampf_ , 53\u201356, 227\u201338; Abzug, _Inside_ , 154\u201355.\n\n() **Patton's remarks** , ibid., 157.\n\n() **\"As matters now stand,\"** Brenner, _After_ , 11; Fritz, _Endkampf_ , 236\u201337.\n\n() **18,000\/97,000\/167,000** , Wyman, _DPs_ , 149.\n\n() **encountered the same sort of reluctance** , Petrovsky-Shtern and Polonsky, _Polin_ 26, 368\u201379.\n\n() **UNRRA spent almost $4 billion** , Gutman, _Encyclopedia_ , 1540.\n\n() **They were often received somewhat insensitively** , Hayes, _How?_ , 775\u201387.\n\n() **readiness to turn a blind eye** , Douglas, _Right_ , 28; Dinnerstein, _America_ , 251\u201371.\n\n() **faced incomprehension of their experience** , Cohen, _Case_ , passim.\n\n() **the reckoning was pretty intense** , Frei, _Transnationale_ , 31\u201332; Heberer and Matth\u00e4us, _Atrocities_ , 49\u201371; Jardim, _Mauthausen_ , 1, 197.\n\n() **The British tried** , Wachsmann, _KL_ , 608.\n\n() **Soviet courts convicted** , Frei, _Transnationale_ , 193; Bazyler and Tuerkheimer, _Forgotten_ , 40\u201341.\n\n() **The Poles tried** , Wachsmann, _KL_ , 608\u20139.\n\n() **The Dutch followed up** , Wasserstein, _Ambiguity_ , 223\u201324; Deak, _On Trial_ , 204.\n\n() **only seven . . . were still alive in 1950** , Wachsmann, _KL_ , 612.\n\n() **Only about 10 percent of the Germans who ever worked at Auschwitz** , Dlugoborski and Piper, _Auschwitz_ , v. 5, 102\u20133, 108, 116 (789 out of perhaps 7,200 Germans ever stationed there).\n\n() **In 1969, East Germany executed** , Raskin, _Child_ , 94\u201398.\n\n() **The record . . . regarding the 121 men from T4** , Berger, _Experten_ , 363\u201371; Bryant, _Eyewitness_ , 13\u201319.\n\n() **Catholics developed several escape routes** , Phayer, _Pius XII_ , 173\u201394;\n\nPhayer, _Catholic_ , 165\u201375; Stangneth, _Eichmann_ , 79, 90\u201392, 292\u201393.\n\n() **Alois Hudal** , Phayer, _Pius XII_ , 195\u2013207.\n\n() **Draganovic, Barbie, Pavelic** , ibid., 208-51; Deak, _On Trial_ , 217\u201318.\n\n() **Pius XII . . . held to the theory of pastoral responsibility that he had followed** , Kornberg, _Dilemma_ , 235, 255\u201374\n\n() **Galen . . . went even further** , Phayer, _Catholic_ , 139, 162\u201363.\n\n() **Muench . . . wrote a pastoral letter that contrasted** , Brown-Fleming, _Conscience_ , 5\u20136.\n\n() **their advocacy was too much for even Muench** , Phayer, _Pius XII_ , 165.\n\n() **ODESSA, appears to have been largely mythical** , Stangneth, _Eichmann_ , 89\u201390.\n\n() **An independent historians' commission . . . reached the conclusion** , Schneppen, _Odessa_ , 208\u20139. For evidence of a higher number of Croatian criminal immigrants, see Phayer, _Pius XII_ , 246.\n\n() **owed much more to the efforts of their friends and families** , Kulish and Mekhennet, _Eternal_ , 83\u201386, 91\u201394, 210\u201314.\n\n() **total payments . . . have come** , Marrus, _Measure_ , 68\u201376; Dean et al., _Robbery_ , 99\u2013133; Goschler, _Schuld_ , 474\u201375, 539.\n\n() **The survivors who came off best** , Hayes and Roth, _Handbook_ , 548\u201350.\n\n() **Other categories of victims came away with much less** , ibid., 551\u201354.\n\n() **a few companies made token postwar payments** , Ferenc, _Less_ , 188.\n\n() **German Foundation Initiative** , see Spiliotis, _Verantwortung_ , passim; Eizenstat, _Imperfect_ , 243\u201378; Dean et al., _Robbery_ , 128.\n\n() **Catholic religious institutions and orphanages . . . often declined** , Marrus, \"Custody,\" 378\u2013403; Ventresca, _Soldier_ , 222\u201327.\n\n() **the French government endowed a new Foundation** , Dean et al., _Robbery_ , 139.\n\n() **Switzerland and its payments** , Eizenstat, _Imperfect_ , 90\u2013186; Independent Commission, _Switzerland_ , 274\u201379, 442\u201349.\n\n() **\"negotiated justice,\"** Barkan, _Guilt_ , 309.\n\n() **The Union Bank of Switzerland, in effect . . . the National Bank of Switzerland, the recipient of 92 percent of the gold** , Spiliotis, _Verantwortung_ , 54; Independent Commission, _Switzerland_ , 238, 252\u201353.\n\n() **these advocates also spread a lot of misconceptions . . . awful role models** , Marrus, _Measure_ , 124\u201326; Petropoulos and Roth, _Gray_ , 7\u20139; Bazyler and Alford, _Restitution_ , 197\u2013204; Eizenstat, _Imperfect_ , 182.\n\n() **\"gap\" . . . \"clash,\"** Levine, _Wallenberg_ , 12\u201313.\n\n() **As David Cesarani has shown** , Cesarani, _Final_ , passim.\n\n() **more trains to the staging areas of Operation Barbarossa . . . every day** , Gall and Pohl, _Eisenbahn_ , 227.\n\n() **\"less the driving force . . . than the setting,\"** Stone, _Histories_ , 126.\n\n() **A British judge** , Lipstadt, _History_ , passim; Evans, _Lying_ , 104\u201348; van Pelt, _Case_ , 488\u2013506.\n\n() **\"On the Streets of Truth\" . . . \"principal source text,\"** Stangneth, _Before_ , 152\u201353, see also 142\u201344.\n\n() **Tony Judt . . . aroused an explosive debate** , reprinted in Judt, _Change_ , 115\u201323; see also Judt, _Reappraisals_ , 286\u201395.\n\n() **\"To make peace is to forget,\"** Sontag, _Pain_ , 103.\n\n() **83 percent of the people there thought a resolution . . . impossible** , Mitchell, _Negotiator_ , 315.\n\n() **\"believed that if you choose to resist evil . . . ways . . . will open up around you,\"** Bess, _Choices_ , 129.\n\n() **\"surrounding every perfidy,\"** Neumann, _Behemoth_ , 379.\n\n() **wrote a prophetic protest** , Hayes \"Industry under the Swastika,\" 28.\nSELECTED BIBLIOGRAPHY\n\nABELLA, IRVING, AND HAROLD TROPER. _None Is Too Many: Canada and the Jews of Europe, 1933\u20131948_. 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New Haven, CT: Yale University Press, 2005.\n\n________. _German Big Business and the Rise of Hitler_. New York: Oxford University Press, 1985.\n\n________. _Hitler's Thirty Days to Power_. Reading, MA: Addison-Wesley, 1996.\n\nUNITED STATES HOLOCAUST MEMORIAL MUSEUM. _Historical Atlas of the Holocaust_. New York: Macmillan, 1996.\n\nVAGI, ZOLTAN, ET AL. _The Holocaust in Hungary_. Lanham, MD: AltaMira Press, 2013.\n\nVAN PELT, ROBERT JAN. _The Case for Auschwitz: Evidence from the Irving Trial_. Bloomington: Indiana University Press, 2002.\n\n________. \"Nazi Ghettos and Concentration Camps: The Benefits and Pitfalls of an Encyclopedic Approach.\" _German Studies Review_ 37 (2014): 149\u201359.\n\nVAN RAHDEN, TILL. _Jews and Other Germans: Civil Society, Religious Diversity, and Urban Politics in Breslau, 1860\u20131925_. Madison: University of Wisconsin Press, 2000.\n\nVENTRESCA, ROBERT. _Soldier of Christ: The Life of Pope Pius XII_. Cambridge, MA: Harvard University Press, 2012.\n\nVINCENT, C. Paul. \"The Voyage of the St. Louis Revisited.\" _Holocaust and Genocide Studies_ 25 (2011): 252\u201389.\n\nVITAL, DAVID. _A People Apart: The Jews in Europe 1789\u20131939_. Oxford: Oxford University Press, 1999.\n\nVOLKOV, SHULAMIT. _Germans, Jews, and Antisemites_. New York: Cambridge University Press, 2006.\n\nWACHSMANN, NIKOLAUS. _KL: A History of the Nazi Concentration Camps_. New York: Farrar, Straus and Giroux, 2015.\n\nWALLER, JAMES. _Becoming Evil: How Ordinary People Commit Genocide and Mass Killing_. New York: Oxford University Press, 2002.\n\nWALTER, DIRK. _Antisemitische Kriminalit\u00e4t und Gewalt: Judenfeindschaft in der Weimarer Republik_. Bonn: J. H. W. Dietz Nachfolger, 1999.\n\nWARD, JAMES MACE. _Priest, Politician, Collaborator: Josef Tiso and the Making of Fascist Slovakia_. 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Ithaca: Cornell University Press, 1998.\n\nYISRAELI, DAVID. \"The Third Reich and the Transfer Agreement.\" _Journal of Contemporary History_ 6 (1971): 129\u201348.\n\nZIMMERMAN, JOSHUA D. _The Polish Underground and the Jews, 1939\u20131945_. New York: Cambridge University Press, 2015.\n\nZIMMERMAN, JOSHUA D., ED. _Contested Memories: Poles and Jews during the Holocaust and Its Aftermath_. New Brunswick: Rutgers University Press, 2003.\n\n________. _The Jews in Italy under Fascist and Nazi Rule, 1922\u20131945_. New York: Cambridge University Press, 2005.\n\nZIMMERMANN, MOSHE. _Wilhelm Marr: The Patriarch of Antisemitism_. New York: Oxford University Press, 1986.\n\nZUCCOTTI, SUSAN. _The Italians and the Holocaust_. New York: Basic Books, 1987.\n\n________. _P\u00e8re Marie-Benoit and Jewish Rescue_. Bloomington: Indiana University Press, 2013.\n\n________. _Under His Very Windows: The Vatican and the Holocaust in Italy_. New Haven, CT: Yale University Press, 2000.\nINDEX\n\nPage numbers listed correspond to the print edition of this book. You can use your device's search function to locate particular terms in the text.\n\nacculturation\n\nof Jews in Imperial Germany, 48\u201349\n\nas protective factor for Jews, 239\n\nand resistance to immigration, 269\n\nAction 14f13, 119\u201320, 124, 172\n\nadaptation, to concentration camps, 215\u201316\n\nAdenauer, Konrad, 315\u201316\n\nage, and Jewish emigration, 105\n\nAge of Enlightenment, 13\u201315\n\naid to Jews from general public; _See also_ prewar aid to Jews from general public; wartime aid to Jews from general public\n\nby businessmen, 222\u201324\n\nin Denmark, 237\n\nin Europe, 219\u201320\n\nin Italy, 237\n\nin Poland, 256\n\nand survival rates, 218\u201324\n\nAK (Armia Krajowa), 250, 252\u201353\n\nal-Husseini, Muhammad Amin, 283\u201385\n\nAllen, William Sheridan, 71\n\nAllied nations\n\nability of, to stop Holocaust, 328\n\nappeasement of Hitler by, 109\u201310\n\npassivity of, 278\u201382\n\nAmerican businesses, in Germany, 110\u201311\n\nAmerican Jewish Committee, 271\u201372\n\nAmerican Jewish Congress, 271\u201372\n\nAmerican Jewish Joint Distribution Committee, 272\n\nAmsterdam, 187\u201389, 191, 222, 243, 308\n\nAnger, Per, 297\n\nannihilation, 114\u201360\n\nconsequences of German resistance to, 142, 145\u201346\n\nemergence of concept, 84\u201388\n\nemergence of death camps, 125\u201331\n\nlack of effect of, on war effort, 131\u201336, 328\u201329\n\nmeans for, 116\u201317\n\npolitical evolution of, 121\u201325\n\npsychological explanations for German compliance with, 137\u201342\n\nself-delusion of public about, 154\u201360\n\nsenior officers' roles in, 146\u201354\n\nand T4 program, 117\u201321\n\nantinomianism, 341\u201343\n\nAntisemites' Petition, 44, 52\n\nantisemitism, 3\u201335\n\nand appeasement, 108\u201310\n\nas backlash against Jewish success, 27\u201331\n\nand Christianity, 6\u20137\n\ncultural basis for, 13\u201315\n\ndefining, 3\u20135\n\nand European societal changes, 24\u201327\n\nhistorical evolution of, 7\u20139\n\nin Imperial Germany, 40\u201348\n\nin interwar Germany, 66\u201367\n\nin interwar Hungary, 233\n\nand Jewish emancipation, 20\u201324\n\nin politics, 30\u201335\n\nin postwar Poland, 255\u201356\n\nin prewar Italy, 274\u201375\n\nin prewar Poland, 244\u201347\n\nin prewar United States, 109, 269\u201370\n\npotential for resurgence of, 332\u201336\n\nreligious basis for, 9\u201313\n\nrole of, in Hitler's rise, 54\u201355, 65\u201367, 327\n\nsupposed genetic basis for, 15\u201320\n\nin wartime United States, 291\u201392\n\nxenophobic and chimerical forms of, 5\u20136\n\nAntonescu, Ion, 225, 234\u201336, 309\n\nArendt, Hannah\n\non Adolf Eichmann, 62, 146, 152\n\n_Eichmann in Jerusalem_ , 177\n\non lack of Jewish resistance, 177\u201378\n\narmed Jewish resistance, 178\u201379\n\nArmia Krajowa (AK), 250, 252\u201353\n\nArndt, Arthur, 157\n\nAryanization, 75\u201379\n\nAsscher, Abraham, 188\u201389, 200\n\nAttlee, Clement, 303\n\nAugustine, Saint, 9\u201310\n\nAuschwitz-Birkenau concentration camp, 127\u201329, 133, 231, 233, 308\n\nAuschwitz concentration camps\n\nescapes from, 211\n\nevacuation of, 171\n\ngarrison of, 134, 310\n\nlack of resistance at, 210\n\nmortality rates at, 213\n\noriginal inhabitants of, 241\n\nplunder from, 131\n\nrejection of plans to bomb, 293\u201395\n\nas slave labor camp, 165\u201366\n\nsmuggling at, 215\u201316\n\nSoviet information about, 282\u201383\n\nuse of Zyklon at, 122\u201323\n\nAustria, 81\u201382\n\nBabi Yar, 89, 156, 228, 307, 331\n\nBach-Zalewski, Erich von dem, 116\n\nBaeck, Leo, 196\n\nBalfour Declaration, 263\n\nBalkan states\n\ndeportation of Jews from, 226\n\nforeign vs. native-born Jews in, 230\u201331\n\nsurvival rates in, 114\n\nBaltic states, 87, 89, 124, 224, 227\u201329\n\nBandera, Stepan, 228\n\nBarbie, Klaus, 313\n\nBartov, Omer, _The Eastern Front, 1941\u201345_ , 140\n\nBauer, Hermann, 311\n\nBauer, Yehuda, 178, 249\u201350, 295\n\nBaum, Herbert, 108\n\nBauman, Zygmunt, 329\n\nbehavior\n\nof perpetrators, 137\u201339\n\nof German public, 92\u2013101, 156\u201360\n\nwith-and-against in camps, 215\u201317\n\nBeilis, Mendel, 32\u201334\n\nBeinart, Peter, 335\u201336\n\nBeitz, Berthold, 223\n\nBelarus, 23, 88\u201389, 122, 124, 127, 140, 178, 194, 208, 224, 240\n\nBelgium, 23, 177, 224\u201326, 260\u201362, 273, 289\n\nBelzec death camp\n\nconstruction of, 121\n\ndeath toll of, 126\u201327\n\nescapes from, 210\n\nas labor camp, 163\n\nBen-Gurion, David, 202\n\nBeorn, Waitman, 140\u201341\n\nBergen-Belsen camp, 130\n\ndeath toll at, 300\n\nand evacuation of labor camps, 172\u201373\n\ninmate conditions at, 212\n\nBerger, Sara, _Experten der Vernichtung_ , 142\n\nBergson, Peter, 292\n\nBerl, Emmanuel, 261\n\nBerlin, 87, 108, 306\n\ndeportations from, 101\u20132\n\nJews in, 25, 28, 50\u201352, 58, 66, 76, 157\u201359, 163, 201, 221, 223\n\nBerman, Jakub, 243\n\nBertram, Adolf, 277\n\nBess, Michael, 287\n\nBessarabia, 234\u201336\n\nBest, Werner, 237\n\nBialas, Max, 177\n\nBialystok ghetto, 185, 192\n\nBiebow, Hans, 181, 307\n\nbigotry, 336\u201339\n\n_Bildung_ , 49\n\n\"biological materialism,\" 61\u201362\n\nBismark, Otto von, 41, 44\n\nBlobel, Paul, 307\n\nblock elders, 203\u20134\n\nBl\u00f6sche, Josef, 310\n\nB\u00f6ckel, Otto, 44, 46\n\nBoger, Wilhelm, 311\n\nBosch, Carl, 92\n\nBouhler, Philipp, 117\u201318, 309\n\nboycotts, of Jewish businesses, 76\n\nBrack, Viktor, 118, 309\n\nBrandt, Karl, 117\u201318, 309\n\nBraun, Wernher von, 315\n\nbreeding, as public policy, 18\u201319\n\nBritain, 263\u201365, 283, 307\n\nBrothers Grimm, 39\u201340\n\nBrowning, Christopher, 137\u201339, 240\n\n_Ordinary Men_ , 137\n\nBryant, Michael, 311\n\nBuchenwald concentration camp, 83, 129, 168, 172, 173, 295, 309\n\nBukovina, 28, 234\u201336\n\nBulgaria, 87, 208, 220, 224, 226, 230\u201331, 231, 239, 285, 310, 319\n\nBund members, 184, 200, 279\n\nBurzio, Giuseppe, 279\n\nBusemann, Ernst, 97\u201398\n\nbusinesses\n\nAmerican, in Germany, 110\u201311\n\nboycotts of Jewish, 76\n\nrestitution by, 321\u201323\n\nbusinessmen, aid from, 222\u201324\n\nCanada (Birkenau), 216\n\nCanada and refugees, 263, 267\n\ncarbon monoxide (CO)\n\ndeath camps, 125\u201327\n\ndemand for, 120\n\nfrom exhaust pipes, 122\n\nin T4 program, 119\n\nCentral Association of German Citizens of Jewish Faith, 103, 105\n\nCentral Office for Combatting Homosexuality and Abortion, 207\n\nCentral Welfare Office of German Jews, 106\n\nChamberlain, Houston Stewart, 46\n\nChamberlain, Neville, 110\n\nChelmno death camp, 122, 133, 183, 279\n\ndeath toll of, 127\n\ngas vans used in, 126\n\nplunder from, 131\u201332\n\nsurvivors of, 203\n\nchildren, in ghettos, 198\u2013200\n\nchimerical antisemitism, 5\u20136\n\nChristianity, antisemitism and, 6\u20137\n\nChristian Social Workers' Party, 43\n\nChurchill, Winston, 227, 279, 283\n\nChvalkovsky, Frantisek, 85\n\n_Civilta Cattolica, La_ , 274, 275\n\nCO, _See_ carbon monoxide\n\ncognitive dissonance, 139\n\nCohen, David, 188\u201389, 200\n\ncollaborators, 198\u2013202\n\ncollective punishments, 209\n\nComey, James, 243\u201344\n\ncommunism\n\nand aid to Jews, 219\n\nand German invasion of Baltic states, 227\u201328\n\nin interwar Germany, 68\n\nJewish involvement in, 56\n\nRoman Catholic Church concern over, 274\u201375\n\ncompulsory labor, 83\n\nconcentration camps, 202\u201317; _See also specific camps_\n\nbombing of, 295\n\ncosts of building and operating, 133\u201334\n\ndeath camps, 125\u201331\n\nfates of commanders of, 308, 309\n\nhierarchy within, 203\u20134\n\ninmate conditions in, 209\u201310\n\nNazi control in, 211\u201312\n\nnon-Jewish victims of, 204\u20138\n\nnumber of, 202\u20133, 309\n\noriginal use of gas chambers at, 119\u201320\n\nprimitivism of , 329\u201330\n\nresistance in, 210\u201311\n\nsatellite, 165\n\nSS firms at, 163, 165\n\nsurvival in, 212\u201317\n\ntransit camps, 130\n\ntypes of, 129\u201331\n\nConcordat with Third Reich, 276\u201377\n\nConfino, Alon, _A World Without Jews_ , 7, 9\n\nconspiracy theories, about Jews, 27\u201330, 331\n\nCoughlin, Charles, 269\n\ncourage, individual, 341\n\nCracow, Poland, 177\n\nCroatia, 206, 224, 238, 288, 310, 313\n\nCrystal Night, 82\u201383\n\nCuhorst, Fritz, 242\n\ncultural basis, for antisemitism, 13\u201315\n\ncultural roles, Jews expelled from, 76\u201377\n\nCzech family camp, 210\n\nCzechoslovakia, 80, 84, 127, 260, 262\n\nCzerniakow, Adam, 187, 194\n\nDabrowa Tarnowska County, Poland, 252\n\nDachau concentration camp, 83, 119\u201320, 172\u201374, 203, 239, 290, 301, 307, 309\n\n_Daily Northwestern_ , 268\u201369\n\nDanielsson, Carl Ivar, 297\n\nDaube, David, 189\n\ndeath camps, 125\u201331\n\ndebt burden, of Germany after World War I, 57\u201358\n\nDeclaration of the Rights of Man, 21\n\n_Defying Hitler_ (Sebastian Haffner), 94\n\nDe Gaulle, Charles, 309\n\nDegussa, 97\u201398, 162, 170\n\ndehumanization, of concentration camp inmates, 211\u201312\n\ndelegation, of unpleasant duties, 143\u201344\n\ndemocratization, in nineteenth-century Europe, 26\n\ndenaturalization, of Jewish citizens, 76, 77\n\nDenmark, 236\u201338\n\ndeportation of Jews\n\nafter gas chamber development, 123\u201324\n\nafter Polish invasion, 86\n\nfrom Balkan states, 226\n\nfrom Germany, 82, 90\u201391, 101\u201302\n\nfrom ghettos, 185\n\nfrom Hungary, 195, 231\u201334\n\nJewish attempts to disrupt, 177\n\nfor _Mischlinge_ , 102\n\nNazi attempts to disguise, 100\u2013101\n\npayment for, 132\n\nDes Pres, Terrence, 214\u201317\n\n_The Survivor_ , 214\n\n_Destruction of the European Jews, The_ (Raul Hilberg), 177\n\n_Deutsche Hollerith Maschinen Gesellschaft_ , 112\n\ndiplomats, 221\u201322, 297\u201399\n\ndiscrimination, _See_ Jewish discrimination\n\ndisease, in Polish ghettos, 182\n\ndisplaced persons (DPs), 301\u20135\n\nDisraeli, Benjamin, 24\n\nDmowski, Roman, 244, 246\n\n\"doctrine of Jewish witness,\" 9\u201310\n\ndocumentation, of Holocaust, 331\n\nDora-Mittelbau concentration camp, 168\u201369, 309, 315\n\nDPs (displaced persons), 301\u20132\n\nDraganovic, Krunoslav, 313\n\nDreyfus, Alfred, 32\u201333\n\nDreyfus affair, 32\u201333\n\n_Dry Tears_ (Nechama Tec), 255\n\n_Duckwitz, Georg, 237_\n\nDurchgangstrasse IV, 128, 130, 164\n\nduty, sense of\n\nNazi manipulation of, 93\u201395\n\nof senior officers, 148\n\nand willingness to kill, 140\u201341\n\nEastern Europe\n\nescalation of violence in, 88\u201390\n\nJewish refugees from, 302\u20133\n\nlocal Nazi collaboration in, 228\u201329\n\nrestitution to Jews in, 318, 319\n\neconomic competition, 268\n\neconomic crises\n\nand antisemitism, 30\n\ncurrent, 334\n\nand German unification, 42\n\nGreat Recession, 336\n\nin interwar Germany, 54, 55, 57\u201359\n\nand rise of Nazi Party, 67\u201368\n\nEden, Anthony, 283\n\nEdict of Tolerance, 21\n\neducation\n\nfor Jews, 28\u201329, 49, 76\u201377\n\nof senior officers, 146, 147\n\nEichmann, Adolf\n\nage of, 147\n\ndeportations coordinated by, 132\n\nas head of Jews Department, 85, 180\n\nin Hungary, 201, 232, 234\n\nself-centeredness of, 62\u201363\n\nzealotry of, 151\u201352\n\n_Eichmann Before Jerusalem_ (Bettina Stangneth), 152, 332\n\n_Eichmann in Jerusalem_ (Hannah Arendt), 177\n\n_Einsatzgruppen_ , 88\u201389\n\nfates of commanders of, 308\u20139\n\ngas trucks used by, 122\n\nmotivations for behavior of, 139\n\nsurvival rates in areas with, 114\u201315\n\nEinstein, Albert, 29\n\nElectoral Hesse, 46\n\nelectoral process, in Imperial Germany, 47\u201348\n\nemancipation, Jewish, 14\u201315, 20\u201324, 37\u201338\n\nemigration, _See_ Jewish emigration\/immigration\n\nErasmus, 12\n\nescalation of violence, 73\u2013113\n\nand Aryanization, 75\u201379\n\nin Eastern Europe, 88\u201390\n\nemergence of annihilation concept, 84\u201388\n\nand expansion of Germany, 79\u201380\n\nexpulsion of Jews, 80\u201384\n\nand general public's attitude toward Jews, 97\u2013102\n\nindoctrination of non-Jews, 94\u201396\n\ninternational response to, 108\u201313\n\nintimidation of non-Jews, 90\u201394\n\nJewish response to, 102\u20138\n\nescapes\n\nfrom concentration camps, 210\u201311\n\nof war criminals, 311\u201315, 329\n\n\"Essay on Man, An\" (Alexander Pope), 13\n\n_Essay on the Inequality of the Human Races_ (Arthur de Gobineau), 16\n\nEstonia, 206, 227\n\neugenics\n\nemergence of, 19\n\nin Hitler's political platform, 61\n\nprimitivism of, 330\n\nEurope; _See also_ Eastern Europe\n\ndemocratization of, 26\n\nJewish emancipation in, 23\n\npolitical changes in, 332\u201333\n\nprewar immigration to, 260\u201365\n\nsocietal changes in, 24\u201327\n\nWestern, 319\u201322\n\nEuthanasia Action, _See_ T4 program\n\nevacuations, of labor camps, 170\u201375\n\nEvian Conference of 1938, 272\u201373\n\nexhaustion, of concentration camp inmates, 212\n\n_Exodus_ (Leon Uris), 305\n\n_Experten der Vernichtung_ (Sara Berger), 142\n\nfarmland, prohibition on Jews owning, 77\n\n_Fear_ (Jan Gross), 255\n\nFerry Laws, 26\u201327\n\nFichte, Johann Gottlieb, 39\n\nFighter Staff Program, 169\u201370, 309\n\nFinal Solution of the Jewish Question, 123\u201331\n\nFlossenb\u00fcrg concentration camp, 173\u201374\n\nfood\n\nfor German army, 90\n\nin ghettos, 191, 193\n\nsmuggling, 193\n\nfor Soviet prisoners of war, 90\n\nin wartime Poland, 241\u201342\n\nforced labor\n\ndevelopment of, 162\u201363\n\nby Poles, 241\n\nslave vs., 160\u201361\n\nforeign-owned companies, in Germany, 110\u201313\n\nForsyth, Frederick, _The Odessa File_ , 314\n\nFrance; _See also_ Vichy France\n\nimmigration to, 260\u201361\n\nJewish armed resistance in, 178\u201379\n\nrestitution by, 320\n\nsurvival rates in, 229\u201330\n\nFrank, Hans, 87, 241\u201342\n\nFrench Revolution, 21\u201322\n\nFritzsch, Karl, 122\u201323\n\nFritzsche, Peter, 98, 124, 156\n\nFromm, Julius, 67\n\nFry, Varian, 222\n\nF\u00fcnten, Ferdinand aus der, 308\n\nGalen, Clemens Graf von, 120\u201321, 286, 290, 314\n\nGall, Franz Joseph, 17\n\nGalton, Francis, 19\n\ngas chambers, 119\u201320, 126\u201329, 133, 172\n\ngas vans , 119, 122, 126, 130, 133, 172\n\nGeist, Raymond, 85\n\nGemmeker, Albert, 308\n\ngender\n\nat Auschwitz, 165\u201366\n\nand propensity for violence, 144\u201345\n\nand slave labor system, 162\n\nand Jewish emigration, 105\u20136\n\nGeneral Government (occupied Poland), 86\u201387, 124, 126, 130, 142, 151, 156, 181, 241\u201342, 281, 307, 310\n\nGeneral Plan East, 208\n\ngeneral public\n\naid from, _See_ aid from general public\n\nattitude toward Jews of, 91, 97\u2013102, 328\n\nindoctrination of, 94\u201396\n\nintimidation of, 90\u201394\n\nknowledge about Holocaust of, 155\u201356\n\nprofit made from Holocaust by, 157\u201358\n\nself-delusion about annihilation of, 154\u201360\n\ngenetic basis, for antisemitism, 15\u201320\n\ngenocide, since Holocaust, 325\n\nGens, Jacob, 194\n\nGerman compliance, explanations of, 137\u201342\n\nGerman military, Jews banned from, 77\n\nGerman restitution, 316\u201319\n\nGerman women, in war effort, 144\u201345\n\nGermany, 36\u201372\n\nexpansion of, and escalation of violence, 79\u201380\n\nHitler's political platform, 59\u201362\n\nImperial, _See_ Imperial Germany\n\nin interwar period, 53\u201355, 57\u201359\n\nNazi ideology, 62\u201365\n\npopular support of Nazi party in, 65\u201371\n\npostwar condition of, 306\n\npostwar rebuilding of, 315\u201316\n\nprofitability of Holocaust for, 132\n\nrise of Hitler in, 55\u201359\n\nunification of, 36\u201338\n\nwar criminals tried by, 310\n\nGerstein, Kurt, 93\u201394\n\nGestapo, 98\u2013100\n\nghettoization; _See also specific ghettos_\n\ninternal disunity in, 184\u201385\n\nand Jewish resistance, 179\u201383\n\nof Jews in Poland, 85\n\nghetto police forces, 190\u201391\n\nGilligan, James, 60\n\nGinsberg, Benjamin, _How the Jews Defeated Hitler_ , 179\n\nGlagau, Otto, 42\n\nGlas, Alfons, 142\n\nGleiwitz concentration camp, 162\n\nGlobke, Hans, 316\n\nGlobocnik, Odilo, 121, 310\n\nGobineau, Arthur de, 16\u201317\n\n_Essay on the Inequality of the Human Races_ , 16\n\nGoebbels, Joseph, 100, 156\n\nGoldhagen, Daniel, 137\u201339\n\n_Hitler's Willing Executioners_ , 137\n\nG\u00f6ring, Hermann\n\nas Acting Economics Minister, 80\n\non Jewish segregation, 64\n\non overall solution to Jewish question, 88, 117\n\nG\u00f6th, Amon, 202, 307\n\nGreat Depression, 65\u201366\n\nGreat Recession, 336\n\nGreece, 87, 178, 224\u201326, 231, 237\n\nGreene, Graham, _The Power and the Glory_ , 277\u201378\n\nGreiser, Arthur, 307\n\nGrimm Brothers, 39\u201340\n\nGr\u00f6ning, Oskar, 142\u201343\n\nGross, Jan\n\n_Fear_ , 255\n\n_Neighbors_ , 240\n\nGross-Rosen concentration camp, 171, 203, 309\n\nGruenwald, Malchiel, 201\n\nGr\u00fcninger, Paul, 262\n\nGrynszpan, Herschel, 82\n\nGustav V, king of Sweden, 298\n\nGypsies, death toll, 205\u20136\n\nHaffner, Sebastian, _Defying Hitler_ , 94\n\nHallie, Philip, 341\n\nhandicapped people, 117, 118\n\nHanneken, Hermann von, 237\n\nHarrison, Earl, 302\n\nHasidic Jews, 184\n\nHeim, Aribert, 315\n\nHep-Hep riots, 41\n\nHerder, Johann Gottfried, 38\u201339\n\nHeuss, Theodor, 61\n\nHeydrich, Reinhard\n\nage of, 147\n\nghettoization of Polish Jews by, 179\n\nas head of Reich Security Main Office, 179\u201380\n\nrole in annihilation of, 117\n\nat Wannsee conference, 124\n\nzealotry of, 150\u201351\n\nHielscher, Friedrich, 188\n\nhierarchy, in concentration camps, 203\u20134\n\nHilberg, Raul\n\n_The Destruction of the European Jews_ , 177\n\non resistance, 178\n\non scholarship about Holocaust, 332\n\nHimmler, Heinrich\n\nage of, 147\n\non annihilation of Jews, 86, 139\n\non \"Germanization\" of Slavs, 208\n\non philosophy of SS, 154\u201355\n\nin Poland, 87, 241\n\nslave labor evacuations ordered by, 173\n\nT4 program personnel transferred by, 121\n\nzealotry of, 149\u201350\n\nHindenbrug, Paul von, 67, 71, 75\u201377\n\nHirschfeld, Magnus, 67\n\nHirszman, Chaim, 210, 255\n\nhistorical narratives, compiled by Jews, 193, 214\n\nHitler, Adolf\n\naccusations of Jewish draft dodging by, 54\n\nacknowledgment of annihilation by, 156\n\non annihilation of Jews, 85, 124\n\nantisemitism of, 59\u201361, 63\u201365, 327\u201328\n\non German expansion, 79\u201380\n\non \"Germanization\" of Slavs, 208\n\n_Mein Kampf_ , 54\n\non Nazi morality, 62\n\npolitical platform of, 59\u201362\n\npolitical rise of, 55\u201359\n\non _Protocols of the Elders of Zion_ , 57\n\nT4 program initiated by, 117\u201318\n\nand violence toward Jews, 64\u201365\n\n_Hitler's Furies_ (Wendy Lower), 144\u201345\n\n_Hitler's Willing Executioners_ (Daniel Goldhagen), 137\n\n_Hiwis_ , 134, 143, 192, 307\n\nHlond, August, 246\n\nHoffman von Fallersleben, Heinrich, 41\n\nH\u00f6fle, Hans, 151, 281, 310\n\nHolland, 236\n\nHolocaust, public awareness of, 278\u201382\n\nHolocaust deniers, 330\u201332\n\nHolocaust scholarship, 324\u201343\n\nmyths debunked by, 327\u201332\n\npurpose of, 324\u201327\n\n_Holocaust vs. Wehrmacht_ (Yaron Pasher), 136\n\nhomosexuals, 206\u20137, 338\n\nhopelessness, of Jewish deportees, 209\n\nHorthy, Miklos, 225, 234, 298\n\nH\u00f6ss, Rudolf, 122, 123, 147, 152\u201353, 307\n\nHossbach, Friedrich, 79\n\nH\u00f6ssler, Franz, 307\n\nHotel Polski, 248\n\n_How the Jews Defeated Hitler_ (Benjamin Ginsberg), 179\n\nHudal, Alois, 312\u201313\n\nHundt-Radowsky, Hartwig von, 41\n\nHungary, 28\u201329, 56, 205, 230, 264, 275, 309\u201310, 322\n\ndeportations from, 135, 166, 174, 196, 224\u201326, 231\u201334, 294\n\nrescue in, 297\u201399\n\nIG Farben, 128, 164, 170, 294\n\nimmigration, _See_ Jewish emigration\/immigration\n\nImperial Germany, 38\u201353\n\nantisemitism in, 40\u201348\n\nJews in, 48\u201353\n\nnationalism in, 38\u201340\n\nindifference, of non-Jews, 71\u201372, 91\n\nindividual courage, 341\n\nindoctrination\n\nof German youth, 140\n\nof non-Jews, 94\u201396\n\nof senior officers, 147\u201348\n\nindustrialization, of nineteenth century Europe, 25\n\ninflation, in interwar Germany, 58\n\ninmate conditions, in concentration camps, 209\u201310\n\nintelligentsia, massacre of, 241\n\nInternational Jewish organizations, 295\u201396\n\ninternational response, to escalation of violence, 108\u201313\n\nInternational Settlement (Shanghai), 272\n\nintimidation, of non-Jews, 90\u201394\n\nIrving, David, 332\n\nisolationism, 339\n\nIsrael\n\ncreation of, 303\u20134\n\nand Middle Eastern politics, 334\u201336\n\nrestitution to, 317\n\nItaly, 31, 224,236\u201339, 274\u201375\n\nJanowska labor camp, 130\u201331\n\nJeckeln, Friedrich, 307\n\nJedwabne, 240, 249, 255\u201356\n\nJehovah's Witnesses, 205\n\n\"Jew Count,\" 53\u201354\n\nJewish Central Association, 105\n\nJewish Claims Conference, 317, 321\n\nJewish communities\n\ndeportation of Jews paid for by, 132\n\ndisunity of, 103, 271\u201372, 295\u201396\n\nin ghettos, 184\u201385\n\nJewish cooperation, 107\u20138\n\nJewish Councils of Elders, 179, 180, 187\u201391, 200\n\nJewish Courts of Honor, 200\n\nJewish discrimination\n\nat local level, 77\u201379\n\nat national level, 80\u201381\n\nas patriotic, 92\u201393\n\nJewish emancipation, 14\u201315, 20\u201324, 37\u201338\n\nJewish emigration\/immigration\n\nadvantages in, 105\u20136\n\nbanning of, 123\n\nand Central Association of German Citizens of Jewish Faith, 105\n\ndifficulties with, 272\u201373\n\nas goal of Zionist Jews, 103\u20134\n\nin Imperial Germany, 50\u201352\n\nto Palestine, 34\u201335, 264\u201365, 303\u20134\n\nin prewar Europe, 260\u201365\n\nas result of treatment in Nazi Germany, 83\n\nto United States, 265\u201372, 304\n\n\"Jewishness in Music\" (Richard Wagner), 40\n\nJewish refugees, 300\u2013305, 317\n\nJewish resistance, 176\u2013202\n\narmed, 178\u201379\n\nand German ghettoization of Jews, 179\u201383\n\nGerman punishment for, 108, 192\u201393\n\nand internal disunity in ghettos, 184\u201385\n\nand Jewish Councils of Elders, 187\u201391\n\nand Jewish postwar response to perceived collaborators, 200\u2013202\n\nlack of organized, 177\u201379\n\nin Lodz ghetto, 195\u201396\n\nmyths about, 328\n\nand physical condition of Jews, 191\u201392\n\nand resistance movements by other groups, 196\u201397\n\nand self-delusion, 185\u201387\n\nsurvival strategies practiced by, 193\u201395\n\nJewish segregation\n\nhistorical, 10\u201311\n\nby Nazi Party, 73\n\nin Nazi Party platform, 63\u201364\n\nin prewar Poland, 245, 247\u201348\n\nJewish success\n\nbacklash against, 27\u201331\n\nin Imperial Germany, 50\n\nJews\n\ncommunist, 184, 249\n\nexpulsion from Germany of, 80\u201384\n\nGerman public's attitude toward, 97\u2013102\n\nHasidic, 184\n\nhistorical narratives compiled by, 193, 214\n\nin Imperial Germany, 48\u201353\n\nin Nazi ideology, 63\u201364\n\nOrthodox, 103, 184\n\nphysical condition of, 191\u201392\n\npolitical views of Poles and, 249\u201350\n\npostwar response of, to perceived collaborators, 198\u2013202\n\nrecent scandals and political controversies involving, 337\u201338\n\nrescuers of, 219\u201324\n\nresponse of, to escalation of violence, 102\u20138\n\nrestitution to, 316\u201317\n\ntrying to escape \"underground,\" 156\u201357\n\nvilification of, in Middle Ages, 11\u201312\n\nviolence in Poland toward, 250\u201355\n\nZionist, 103\u20134, 184\n\nJews Department, 85, 180\n\nJodmin, Otto, 221\n\nJoint Distribution Committee, 261, 272, 279, 292, 295\n\nJoseph II, Holy Roman Emperor, 21\n\n_Judenz\u00e4hlung_ , 53\u201354\n\n_Jud S\u00fcss_ , 100\n\nJudt, Tony, xiv\u2013xv, 335\n\nKaltenbrunner, Ernst, 147, 153\u201354\n\nKamenets-Podolsk, 89\n\nKammler, Hans, 149, 154, 309\n\n_Kapos_ , 200, 203\u20134, 211, 213, 216\n\nKarski, Jan, _See_ Kozielewski, Jan\n\nKastner, Rudolf \"Rezso,\" 200\u2013201\n\nKenez, Peter, 232\n\nKertesz, Imre, 217\n\nKielce pogrom, 255, 302\n\n_Kindertransport_ , 263\n\nKlemperer, Victor\n\n_I Will Bear Witness_ , 91\n\nknowledge about Holocaust of, 155\u201356\n\nas _Mischling_ , 102\n\nKlukowski, Zygmunt, 251\n\n_Kommando_ units, 88\u201389\n\nKopelman, Moshe, 201\n\nKorherr, Richard, 331\n\nKossak, Zofia, 253\n\nKovno, 185, 191, 195, 201, 222, 228\n\nKozielewski, Jan, 250, 292\n\nKrakauer, Max, 157\n\n_Kristallnacht_ , 82\u201383, 99, 109, 261, 267\u201370\n\nKrumey, Hermann, 310\n\nKrupp, Gustav, 48, 92, 342\u201343\n\nKruszynski, Jozef, 247\n\nK\u00fchne, Thomas, 140\u201341\n\nlabor\n\ncompulsory, 83\n\nforced, _See_ forced labor\n\nslave, _See_ slave labor system\n\nlabor camps\n\nAuschwitz-Birkenau and Majdanek as, 128\n\ndefined, 130\u201331\n\nevacuation of, 170\u201375\n\nfor slave labor system, 166\u201370\n\nLaFarge, John, 275\u201376\n\nLages, Willy, 308\n\nLangbehn, Julius, 16\n\nLangbein, Hermann, _People of Auschwitz_ , 204, 254\n\nLange, Herbert, 119, 122, 126\n\nLanger, Lawrence, 180\n\nLangmuir, Gavin, 5\n\nlanguages\n\nhierarchical classification of, 17\u201318\n\nand nationalism, 38\u201339\n\nof Polish Jews, 247\n\nLanzmann, Claude, 240\n\nLatte, Konrad, 157\n\nLatvia, 206, 227\u201328, 304\n\nLaval, Pierre, 309\n\nLavater, Johann, 17\n\nLeague of German Students, 42\n\nLe Chambon-sur-Lignon, 220, 341\n\nLedochowski, Wlodzimierz, 275\u201376\n\nLensky, Mordechai, 184\u201385\n\nLevi, Primo, 212, 217\n\nLevine, Paul, 327\n\nL\u00e9vy-Hass, Hanna, 212\n\nliberal politics, 23\u201324, 333\n\nLichtenberg, Bernard, 290\u201391\n\n_Life Is Beautiful_ , 202\n\nLikely to Become a Public Charge (LPC) rule, 268\n\nLindemann, Albert, 16\n\nLithuania, 23, 114, 127, 178, 206, 227\u201329, 239, 264, 289\n\nLodz ghetto\n\ncreation of, 181\n\nfate of, 194\n\nhistorical narratives compiled at, 193\n\nJewish Council of Elders members of, 180\n\nJewish resistance in, 195\u201396\n\npopulation in, 182\u201383\n\nLong, Breckenridge, 270\u201371, 291\u201392\n\n_Longest Hatred, The_ (Robert Wistrich), 4\n\n\"long nineteenth century,\" 20\u201324\n\nLower, Wendy, _Hitler's Furies_ , 144\u201345\n\nLPC (Likely to Become a Public Charge) rule, 268\n\nLublin ghetto, 127, 181, 185, 193\n\nLudendorff, Erich, 54\n\nLueger, Karl, 31\n\nLustig, Walter, 201\u20132\n\nLuther, Martin, 12\n\nLutz, Carl, 298\u201399\n\nLviv, 131, 185, 200, 228, 288\n\nLyons, Joseph, 109\n\nMadagascar as destination for Jews, 86, 245,\n\nMajdanek concentration camp, 127\u201329, 193, 311, 329\n\nMann, Michael, 148\n\nMantello, George, 298\u201399\n\nMarie-Ben\u00f4it, Father, 286\n\nMarr, Wilhelm, 4, 31, 43, 47\n\nMarrus, Michael, 209\n\nMarx, Karl, 61\n\nMauthausen concentration camp, 120, 130, 163, 172, 174, 187, 210, 307, 309, 315, 331\n\nMcCloy, John, 293\u201394\n\nMcKale, Donald, _Nazis after Hitler_ , 306\n\n_Mein Kampf_ (Adolf Hitler), 54\n\nMengele, Joseph, 147, 310\u201311\n\nMiddle Ages, 11\u201312\n\nMiddle Eastern politics\n\nand Israel, 334\u201336\n\nin prewar period, 264\n\nand wartime aid from general public, 283\u201385\n\nMildner, Rudolf, 237\n\nmilitarization, of German life, 94\u201395\n\nMilgram, Stanley, 138\n\nminority groups\n\nand bigotry, 336\u201339\n\nand liberal politics, 333\n\nself-reliance vs. isolationism for, 339\n\nMinsk, 120\u201321, 185, 194\n\n_Mischlinge_ (partial Jewish ancestry), 101\u20132, 159\n\n_Mit brennender Sorge_ (With Burning Sorrow), 274\u201376\n\nMitchell, George, 339\n\nmodernization, 329\u201330\n\nMoll, Otto, 307\n\nMontagu, Edwin, 264\n\nMontini, Giovanni (Pope Paul VI), 312\n\nmorality, 341\u201343; _See also_ Nazi morality\n\nMorgenthau, Henry, 292\n\nmortality rates\n\nin concentration camps, 203\n\nin Polish ghettos, 182\u201383\n\nfor slave laborers, 169\u201370\n\nMuench, Aloisius, 314\n\nM\u00fcller-Oerlinghausen, Georg von, 343\n\nmunitions, 167\u201369\n\nMushkin, Eliyahu, 194\n\n_Musselm\u00e4nner_ , 211\u201312\n\nMussolini, 238\n\nNapoleon, 22\n\nnationalism\n\nin Hitler's political platform, 61\n\nin Imperial Germany, 38\u201340\n\nNational Representation of German Jews, 106, 112\n\nNational Socialist German Workers' Party (NSDAP), _See_ Nazi Party\n\nNational Union of Jews in Germany, 107\u20138\n\nNazi morality\n\nand antinomianism, 341\u201343\n\ndefining, 62\n\npromotion of, 7, 9\n\nand willingness to kill, 140\u201341\n\nNazi Party\n\nbehavior of public and policies of, 97\u201398\n\ncampaigning of, 68\u201370\n\nideology of, 62\u201365\n\nand Pope Pius XII, 285\u201387\n\npopular support for, 65\u201371\n\nNazis\n\ncollaboration in Eastern Europe with, 228\u201329\n\ncontrol in concentration camps by, 211\u201312\n\ndeportation of Jews by, 100\u2013101\n\nmanipulation of sense of duty by, 93\u201395\n\ntreatment of Jews in Poland by, 85\u201386\n\n_Nazis after Hitler_ (Donald McKale), 306\n\nNazis and Nazi Collaborators Law (Israel), 202\n\n_Neighbors_ (Jan Gross), 240\n\nNetherlands\n\nimmigration to, 261\u201362\n\nlack of resistance to deportations from, 196\n\nrestitution by, 320\n\nsurvival rates in, 236\n\nwar criminals tried by, 308\n\nNeuengamme concentration camp, 172, 173\n\nNeumann, Franz, 341\u201342\n\nNeuser, Richard, 142\n\nNirenberg, David, 12\n\nNisko, 86\n\nnon-Jewish victims\n\nof concentration camps, 204\u20138\n\nin Poland, 242\u201344\n\nNortheim, 69\n\nNorthwestern University, 175, 268\u201370, 324\n\nNorway, 220, 224, 297, 309\n\nNSDAP, _See_ Nazi Party\n\n_ODESSA (Organisation der ehemaligen SS-Angh\u00f6rigen)_ , 314\u201315\n\n_Odessa File, The_ (Frederick Forsyth), 314\n\nOliner, Samuel and Pearl, _The Altruistic Personality_ , 221\n\n\"On the Streets of Truth,\" 332\n\nOperation Harvest Festival, 192\n\nOperation Reinhard death camps\n\ndeath toll of, 126\u201327, 281\n\nplunder from, 131\n\nstaff of, 239, 311\n\n_Ordinary Men_ (Christopher Browning), 137\n\n_Organisation der ehemaligen SS-Angh\u00f6rigen_ (ODESSA), 314\u201315\n\nOrganization of Ukrainian Nationalists (OUN), 228\n\nOrthodox Jews, 103, 184\n\nOyneg Shabes, 193, 256\n\nPacelli, Eugenio, _See_ Pius XII, Pope\n\nPalatucci, Giovanni, 239\n\nPale of Settlement, 23, 125, 228\n\nPalestine\n\nunder British rule, 263\u201364\n\nimmigration to, 104\u20135, 265, 303\u20134\n\nPalmnicken, 171\u201372\n\nPanama Scandal, 30, 337\n\nPapen, Franz von, 71, 340\n\nParnes, Joseph, 187\n\n_Partisanenbek\u00e4mpfung_ , 89\n\nPasher, Yaron, _Holocaust vs. Wehrmacht_ , 136\n\npassivity\n\nAllied, 278\u201382\n\ndangers of, 340\n\nof non-Jews, 71\u201372, 91\n\nby Pope Pius XII, 289\u201390\n\nPatents of Toleration, 21\n\nPatton, George, 301\n\nPavelic, Ante, 313\n\nPehle, John, 293\u201394\n\n_People of Auschwitz_ (Hermann Langbein), 204\n\nPerechodnik, Calel, 185\u201386, 191, 249\n\nPerlasca, Giorgio, 299\n\nP\u00e9tain, Philippe, 225, 286, 288, 309\n\nPetri, Erna, 145\n\nPeukert, Detlef, 329\n\nphilology, 17\n\nphrenology, 17\n\nphysiognomy, 17\n\nPitt, William, 342\n\nPius XI, Pope, 275\u201376\n\nPius XII, Pope, 276\u201377\n\non clemency for war criminals, 313\u201314\n\nlack of resistance to Nazi regime by, 285\u201387\n\nreasons for passivity of, 289\u201390\n\n\" _Summi Pontificatus:_ On the Unity of Human Society,\" 291\n\nPlaszow concentraton camp, 202, 307\n\nPloetz, Alfred, 19\n\nplunder, from concentration camps, 131\u201332\n\npogroms, 255\n\nPohl, Oswald, 149, 154, 307\n\nPoland, 240\u201358\n\naid to Jews from general public in, 256\n\nantisemitism in, 244\u201347, 255\u201356\n\ndeath camps in, 125\n\nghettoization in, 181\u201382\n\nJewish citizenship in, 82\n\nJewish segregation in, 245, 247\u201348\n\nNazi treatment of Jews in, 85\u201386\n\nand political views of Jews and Poles, 249\u201350\n\nviolence toward Jews in, 250\u201355\n\nwar criminals tried by, 307\u20138\n\nwartime conditions in, 240\u201344\n\nPolice Battalion 101, 138\u201340\n\nPolish People's Army, 250\n\npolitical evolution, of annihilation, 121\u201325\n\npolitics\n\nantisemitism in Imperial Germany, 31\u201335\n\nexpulsion of Jews from, 76\u201377\n\nof Jews in Imperial Germany, 51\n\nliberal, 23\u201324, 333\n\nMiddle Eastern, _See_ Middle Eastern politics\n\nin nineteenth-century Europe, 26\n\nviews of Jews vs. Poles about, 249\u201350\n\nPoniatowa concentration camp, 193\n\nPope, Alexander, \"An Essay on Man,\" 13\n\npopulation density, of ghettos, 191\n\npopulation growth\n\nand German expansion, 84\n\nin Imperial Germany, 48\u201349\n\nin nineteenth-century Europe, 24\u201325\n\npostwar period, 300\u2013323\n\nescapes by war criminals in, 311\u201315\n\ngeneral restitution in, 319\u201323\n\nGerman restitution in, 316\u201319\n\nJewish refugees in, 300\u2013305\n\nrebuilding of Germany in, 315\u201316\n\nRoman Catholic Church in, 311\u201314\n\nwar crime punishments in, 305\u201311\n\n_Power and the Glory, The_ (Graham Greene), 277\u201378\n\nPrekerowa, Teresa, 221\n\nPretzel, Raimund, 94\n\nprewar aid to Jews from general public, 259\u201378\n\nAmerican immigration, 265\u201372\n\nEuropean immigration, 260\u201365\n\nand immigration difficulties of Jews, 272\u201373\n\nPalestinian immigration, 265\n\nand Roman Catholic Church, 273\u201378\n\nPreysing, Konrad von, 277\n\nPriebke, Erich, 312\n\nPrittwitz und Gaffron, Friedrich von, 92\n\nProdolliet, Ernest, 222\n\n_Protocols of the Elders of Zion_ , 56\u201357, 247, 269\n\nPr\u00fcfer, Curt, 155\n\npsychological explanations\n\nfor aid from general public, 220\u201322\n\nof German compliance, 137\u201342\n\npunishment(s)\n\nfor aid to Jews, 218\u201319\n\ncollective, 209\n\nfor Jewish resistance, 108, 192\u201393\n\nfor war crimes, 305\u201311\n\nQuisling, Vidkun, 309\n\nracial hygiene, 19\n\nRaczkiewicz, Wladislaw, 287\n\nRathenau, Walther, 53\n\nratlines, 312\n\nRauff, Walter, 122, 313\n\nRavensbr\u00fcck concentration camp, 161, 174, 203, 293, 309\n\nRecherchegruppe Henneicke, 225\n\nRed Cross, International Committee of, 101, 260, 281, 293, 312\n\nReder, Rudolf, 210\n\nReformation, 12\u201313\n\nReform Judaism, 49\n\nrefugees, 300\u2013305, 317\n\n_Reich, Das_ , 156\n\nReichenau, Walter von, 89\n\nReich Security Main Office (RSHA), 85, 146\u201348, 179\u201380\n\nReichstag, 37\n\nantisemites and elections to, 44\u201348, 54\u201355\n\nReichsvereinigung der Juden in Deutschland, _See_ National Union of Jews in Germany\n\nReichsvertretung der deutschen Juden, _See_ National Representation of German Jews\n\nrelationships, as survival tactic, 217\n\nreligion\n\nand aid from general public, 219\u201320\n\nantisemitism based on, 9\u201313\n\nresistance; _See also_ Jewish resistance\n\nto annihilation, 142\u201346\n\nin concentration camps, 210\u201311\n\nindividual, 341\n\nby public, 196\u201398\n\nrestitution, in postwar period, 319\u201323\n\nRetzius, Anders, 17\n\nRiegner, Gerhart, 280\n\nRiga, 121, 185, 228, 307, 312\n\nRingelblum, Emanuel, 256\n\nRoessler, Fritz, 93\n\nRoma and Holocaust, 205\u201306\n\nRoman Catholic Church, 10\u201311, 14, 27, 42, 260, 319\u201320\n\nand escape of war criminals, 311\u201314\n\nand euthanasia, 120\u201321, 286\n\nGerman massacre of Polish priests, 241\n\nin Poland, 241, 246\u201347, 253, 257\n\nand prewar aid from general public, 269, 273\u201378\n\nprotests by bishops, 220\n\nand wartime aid from general public, 219\u201320, 236, 285\u201391\n\nRomania, 239, 264\u201365, 283, 285, 303, 309\u201310, 319, 322\n\nlate emancipation in, 23\n\nmurders in or by, 224\u201326, 230, 234\u201336\n\nterritorial gains and losses, 231, 233\u201334\n\nRome, ancient, 5\u20136\n\nR\u00f6mer, Felix, 140\u201341\n\nRoosevelt, Franklin Delano\n\nand American immigration, 265\u201368, 270\u201371\n\nand Breckenridge Long, 291, 292\n\nRoschmann, Eduard, 312, 314\n\nRosenberg, Alfred, 124\n\nRosenberg, G\u00f6ran, 214\n\nRosenblatt, Leon, 188\n\nRosenman, Samuel, 268\n\nRosenstrasse protest, 158\u201359\n\nRossner, Alfred, 223\n\nRothmund, Heinrich, 262\n\nRowecki, Stefan, 249\u201350, 253\n\nRSHA (Reich Security Main Office), 85, 146\u201348, 179\u201380\n\nRumkowski, Chaim, 181, 189\u201390, 194, 198\n\nRussian empire, 23\n\nRust, Bernhard, 95\n\nSachsenhausen concentration camp, 83, 108, 119, 122, 161, 172, 174, 203, 295\n\nsacraments, of Catholic Church, 277\u201378\n\nsatellite concentration camps, 165\n\nSauckel, Fritz, 160\n\nSaxony, 46\u201348\n\nScavizzi, Pirro, 279\n\nSchacht, Hjalmar, 80\n\nSchindler, Oskar, 222\u201323\n\n_Schindler's List_ , 202, 307\n\nSchlegel, Friedrich, 17\n\nSchmelt, Albrecht, 164, 309\n\nSchmidt, Anton, 145\u201346\n\nSchulte, Eduard, 280\n\nSchumpeter, Joseph, 24\n\n_Schutzmannschaften_ , 89\n\n_Schwarze Korps, Das_ , 84\u201385\n\nsecularization, 26\u201327\n\nSegev, Tom ( _Soldiers of Evil_ ), 146\n\nsegregation, _See_ Jewish segregation\n\nself-delusion\n\nabout Holocaust, 280\n\nand lack of Jewish resistance, 185\u201387\n\nself-dignity, in concentration camps, 214\u201315\n\nself-interest\n\nof German public, 95\u201396\n\nof Jews in ghettos, 184\u201385\n\nself-reliance, 339\n\nsenior officers, roles of, 146\u201354\n\nSerbia, 75, 87, 90, 205, 224\n\nSeyss-Inquart, Arthur, 308\n\nShanghai, China, 272\n\nSheptytsky, Andrey, 228, 288\n\n_Shoah_ (documentary), 240\n\nshock of arrival, at concentration camps, 215\n\nSiemens, Carl Friedrich von, 92\n\nSierakowiak, Dawid, 182\n\nSilberklang, David, 194\u201395\n\nSinclair, Sir Archibald, 283\n\nSinti and Holocaust 205\u20136\n\nSiri, Giuseppi, 312\n\nsituational explanations\n\nof the Holocaust, 339\u201340\n\nof perpetrator behavior, 137\u201338\n\nSkarzysko-Kamienna labor camp, 166, 167, 250\n\nskin color, 16\u201317\n\nslave labor system, 160\u201375\n\ndevelopment of, 161\u201363\n\nand evacuation of labor camps, 170\u201375\n\nexpansion of, 164\u201366\n\nand forced vs. slave labor, 160\u201361\n\nmyths about, 329\n\nPolish labor camps in, 166\u201370\n\nrestitution for, 318\n\nSlavs, 208\n\nSlovakia, 224, 226, 231, 279, 285, 288\u201389, 309\n\nsmuggling, in concentration camps, 215\u201316\n\nSobibor concentration camp, 134, 253, 307, 311\u201313\n\ndeath toll of, 126\u201327, 281\n\nescapes from, 211\n\nuprising at, 192, 250\n\nsocial class, in ghettos, 184\u201385\n\nsocial groups, Jews banned from, 78\n\n_Sonderkommando_ 1005, 307\n\nSontag, Susan, 339\n\nSousa Mendes, Aristides de, 221\u201322\n\nSouth America, 312\u201315\n\nSoviet prisoners of war\n\nescaped from Mauthausen concentration camp, 210\n\nfood for, 90\n\nlack of resistance among, 196\n\nas volunteer guards at concentration camps, 134\n\nSoviet Union, _See_ USSR\n\nSpellman, Francis, 312\n\nspies\n\nin concentration camps, 210\n\nfear of, 270, 271\n\n_St. Louis_ (ship), 273\n\nStab in the back legend, 60, 79\n\nStalin, Joseph, 282\n\nStangl, Franz, 312\u201313\n\nStangneth, Bettina, _Eichmann Before Jerusalem_ , 152, 332\n\nStarachowice labor camp, 166\u201367\n\nStepinac, Aloysius, 288\n\nStern, Samu, 195\n\nStoecker, Adolf, 43\n\nStone, Dan, 330\n\nStrasser, Gregor, 66\n\nStreicher, Julius, 99\n\n_Stroop Report, The_ , 198\u2013200\n\nStroop, J\u00fcrgen, 307\n\nStrousberg, Bethel Henry, 42, 337\n\n_St\u00fcrmer, Der_ , 99\n\nSugihara, Chiune, 222\n\nSuhard, Emmanuel Celestin, 288\n\n\" _Summi Pontificatus:_ On the Unity of Human Society\" (Pope Pius XII), 291\n\nsurvival\n\nin concentration camps, 212\u201317\n\nas Jewish resistance, 193\u201395\n\nsurvival rates, 218\u201339\n\nand aid from general public, 218\u201324\n\nin Baltic states and Ukraine, 227\u201329\n\nin Denmark, 236\u201338\n\nin Hungary, 231\u201334\n\nin Italy, 236\u201339\n\nfor native vs. foreign-born Jews, 229\u201331\n\nby region, 224\u201327\n\nin Romania, 234\u201336\n\n_Survivor, The_ (Terrence Des Pres), 214\n\nSweden, 23, 237\u201338, 296\u201399\n\nSwitzerland\n\nemancipation in, 23\n\nimmigration to, 262, 296\n\nrestitution by, 320\u201322\n\nSzalasi, Ferenc, 309\u201310\n\nSzerynski, Joseph, 190\n\nTacitus, 5\n\nTec, Nechama\n\n_Dry Tears_ , 255\n\n_When Light Pierced the Darkness_ , 220\n\nTheresienstadt concentration camp, 101\u20132, 108, 136, 158\u201359, 196, 200, 203, 309\n\nTiso, Jozef, 289, 309\n\nT4 program, 117\u201321, 134\n\npersonnel in, 142, 147\u201348, 309, 311\u201312\n\ntrain traffic, 134\u201336\n\nTransfer Agreement, 104\u20135\n\ntransit camps, 130\n\nTransnistria, 235\u201336\n\ntransportation, 26\n\nTrawniki concentration camp, 134\n\nTreblinka concentration camp\n\ndeath toll of, 126\u201327\n\nescapes from, 210\u201311\n\nJewish resistance in, 177, 192\n\nas labor camp, 163\n\nPolish communities profiting from, 254\n\nTreitschke, Heinrich von, 43\u201344\n\nTrieste, 239\n\nTrocm\u00e9, Andr\u00e9, 341\n\nTruman, Harry S., 302\n\nTucholsky, Kurt, 155\n\nTwenty-five Point Program, 63\u201364\n\nU-boats (underground Jews), 156\u201357\n\nUkraine, 128, 219\u201320\n\ncollaboration in, 227\u201329, 303, 330\n\nJews in, 89, 197, 239\n\nkilling in, 122, 224, 230\n\n_Uncompromising Generation, An_ (Michael Wildt), 146\n\nunification, of Germany, 36\u201338\n\nUnited Nations Relief and Rehabilitation Administration (UNRRA), 300\u2013303\n\nUnited States\n\nantisemitism in wartime, 291\u201392\n\nimmigration policy of, 266\n\npostwar immigration to, 304\n\nprewar immigration to, 265\u201372\n\nwar criminals tried by, 307\n\nwartime aid to Jews , 291\u201395\n\nunity, 70\n\nurbanization, 25\n\nurban migration, of German Jews, 49\u201350\n\nUris, Leon, _Exodus_ , 305\n\nUSSR\n\nimmigration to, 263\n\nwar criminals tried in, 307\n\nwartime aid to Jews , 282\u201383\n\nValeri, Valerio, 288\n\nvan Tijn, Gertrude, 222\n\nVazsonyi, Adam, 31\n\nVersailles Treaty, 57\n\nVichy France, 206, 225, 229\u201330, 286, 288, 309\n\nVilna, 145, 186, 191\u201392, 194, 228\u201329\n\nVinnytsia, 89\n\nviolence\n\nescalation of, _See_ escalation of violence\n\nin Nazi platform, 64\u201365\n\nvolitional explanations, of perpetrator behavior, 137\u201338\n\n_Volk_ , 38\u201340\n\n_V\u00f6lkischer Beobachter_ , 156\n\n_Volksdeutsche_ , 87, 116, 143, 304\n\n_Volksgemeinschaft_ , 70, 95\n\nVolkswagen, 164\u201365, 318\n\nVoltaire, 14\n\nvolunteer guards, at concentration camps, 134\n\nvom Rath, Ernst, 82\n\nVrba, Rudolf, 213\n\nWachsmann, Nikolaus, 309\n\nWagner, Gustav, 313\n\nWagner, Richard, \"Jewishness in Music,\" 40\n\nWagner-Rogers Bill, 268, 271\n\nWalesa, Lech, 256\n\nWallenberg, Raoul, 292\u201393, 298\n\nWannsee Conference, 115, 119, 124-25, 164, 331\n\nwar crimes, punishments for, 305\u201311\n\nwar criminals, escapes by, 311\u201315, 329\n\nwar effort\n\neffect of annihilation, on, 131\u201336, 328\u201329\n\nGerman women in, 144\u201345\n\nWar Refugee Board, 292\u201393\n\nWarsaw ghetto, 182, 188, 193, 307\n\nchildren in, 198\u2013200\n\nconsequences of uprising in, 192, 195, 310\n\neventual fate of, 194\n\nghetto police in, 190\n\nhistorical narratives compiled at, 193\n\nmortality rates in, 191\n\nPolish aid to, 253\n\nsealing of, 181\n\nsurvival in, 243, 248\n\nWarsaw Rising, 243, 253\n\nWarthegau (annexed Poland), 122, 181, 241, 307\n\nwartime aid to Jews from general public, 278\u201399\n\nand Allied passivity, 278\u201382\n\nInternational Jewish organizations, 295\u201396\n\nand Middle Eastern politics, 283\u201385\n\nand Roman Catholic Church, 285\u201391\n\nin Sweden, 296\u201399\n\nin Switzerland, 296\n\nin United States, 291\u201395\n\nin USSR, 282\u201383\n\nWasserstein, Bernard, 273\n\nwealth, Jewish immigration and, 105\n\nWeidt, Otto, 223\u201324\n\nWeimar Republic, 59\n\nWeiss, Theodore Zev, 175, 213\u201314\n\nWeizmann, Chaim, 273\n\nWeizs\u00e4cker, Ernst von, 84, 93\n\nwelfare states, 334\n\nWelzer, Harald, 140\u201341\n\nWestermann, Edward, 139\u201340\n\nWestern Europe, 319\u201322\n\nWesterbork transit camp, 132, 187, 203, 262, 308\n\n_When Light Pierced the Darkness_ (Nechama Tec), 220\n\nWildt, Michael, _An Uncompromising Generation_ , 146\u201347\n\nWilhelm II, Kaiser, 54\n\nWilhelmina, queen of Netherlands, 290\n\nWilmanns, Carl, 43\n\nWinstone, Martin, 242\n\nWirth, Christian, 121\u201322\n\nWise, Stephen, 271, 295, 363\n\nWistrich, Robert, _The Longest Hatred_ , 4\n\nwith-and-against behavior, 215\u201317\n\nWolski, Mieczyslaw, 256\n\nWorld War I, 53\u201354\n\n_World Without Jews, A_ (Alon Confino), 7, 9\n\nxenophobic antisemitism, 5\u20136\n\nYad Vashem, 219, 256\n\nYaffe, Moshe, 194\n\n_Yishuv_ , 104, 295\u201396\n\nZegota, 253\u201354\n\nZiimbardo, Philip, 138\n\nZionism, 34\u201335, 264, 292, 304\n\nZionist Jews, 103\u20134, 184\n\nZola, \u00c9mile, 33\n\nZwartendijk, Jan, 222\n\nZyklon, 93, 122\u201323, 127, 130, 133, 172, 280, 307, 308, 331\nALSO BY PETER HAYES\n\n_How Was It Possible? A Holocaust Reader_ (editor)\n\n_Frankreichforum XI: Universit\u00e4tskulturen\/L'Universit\u00e9  \nen perspective\/The Future of the University_ (coeditor)\n\n_The Oxford Handbook of Holocaust Studies_ (coeditor)\n\n_Das Amt und die Vergangenheit: Deutsche Diplomaten im  \nDritten Reich und in der Bundesrepublik_ (coauthor)\n\n_From Cooperation to Complicity: Degussa in the Third Reich_\n\n_The Last Expression: Art and Auschwitz_ (coeditor)\n\n_\"Arisierung\" im Nationalsozialismus: Volksgemeinschaft,  \nRaub und Ged\u00e4chtnis_ (coeditor)\n\n_Lessons and Legacies III: Memory, Memorialization,  \nand Denial_ (editor)\n\n_Lessons and Legacies I: The Meaning of the Holocaust  \nin a Changing World_ (editor)\n\n_Industry and Ideology: IG Farben in the Nazi Era_\n\n_Imperial Germany_ (coeditor)\nCopyright \u00a9 2017 by Peter Hayes\n\nAll rights reserved\n\nFirst Edition\n\nFor information about permission to reproduce selections from this book,  \nwrite to Permissions, W. W. Norton & Company, Inc.,  \n500 Fifth Avenue, New York, NY 10110\n\nFor information about special discounts for bulk purchases, please contact  \nW. W. Norton Special Sales at specialsales@wwnorton.com or 800-233-4830\n\nBook design by Marysarah Quinn\n\nJacket design by Evan Gaffney\n\nJacket photograph by Paula Salischiker \/ Millenium Images, UK\n\nDescription: Young girl reading list of names of Holocaust victims inscribed on wall. Shoah Memorial, Paris, France\n\nProduction manager: Anna Oler\n\nThe Library of Congress has cataloged the printed edition as follows:\n\nNames: Hayes, Peter, 1946 September 7\u2013 author  \nTitle: Why? : explaining the Holocaust \/ Peter Hayes.  \nDescription: First edition. | New York ; London : W. W. Norton & Company,  \nindependent publishers since 1923, [2017] | Includes bibliographical  \nreferences and index.  \nIdentifiers: LCCN 2016031588 | ISBN 9780393254365 (hardcover)  \nSubjects: LCSH: Holocaust, Jewish (1939\u20131945) | Holocaust, Jewish  \n(1939-1945)\u2014Causes. | Antisemitism\u2014Germany\u2014History\u201420th century. |  \nJews\u2014Germany\u2014History\u201420th century. | Jews\u2014Persecutions\u2014  \nEurope\u2014History\u201420th century. | Germany\u2014History\u20141933\u20131945. |   \nGermany\u2014Ethnic relations.  \nClassification: LCC D804.3 .H387 2017 | DDC 940.53\/1811\u2014dc23 LC  \nrecord available at https:\/\/lccn.loc.gov\/2016031588\n\nISBN 978-0-393-25437-2 (e-book)\n\nW. W. Norton & Company, Inc.\n\n500 Fifth Avenue, New York, N.Y. 10110\n\nwww.wwnorton.com\n\nW. W. Norton & Company Ltd.\n\n15 Carlisle Street, London W1D 3BS\n","meta":{"redpajama_set_name":"RedPajamaBook"}}
+{"text":" \nTHE NEW QUISLINGS\n\nHow the International Left Used the Oslo Massacre to Silence Debate About Islam\n\nBruce Bawer\n\nContents\n\nThe New Quislings\n\nAbout the Author\n\nCopyright\n\nAbout the Publisher\nThe New Quislings\n\nI\n\nOn the morning of Friday, July 22, 2011, I was in a friend's house in the United States chatting on Skype with my partner in Norway. \"Oh my God,\" he suddenly said. \"There's been an explosion in Oslo.\"\n\nHe had a newspaper website open. I went at once to the same site and saw a giant headline and a horrific picture. I immediately opened the website of Norwegian state television, NRK, and began to watch its live coverage online.\n\nThe images of devastation were staggering. A government building, one of the tallest structures in Oslo, had sustained major damage, and the streets around it were filled with debris. There were reports of casualties, though the numbers were, as yet, unknown. The explosion had been so powerful that windows had been blown out of stores and offices blocks away.\n\nI was stunned. The government building that had been damaged was right down the street from where I had, until recently, lived. I had passed it almost every day for years, either on foot or on a bus. It was numbing to see Oslo, my longtime home, suffering a fate so similar to that which my native city, New York, had suffered in 2001.\n\nThe first thing I did was to contact my friends in Oslo, to ensure they were all okay. They were, although a couple of them had been very close to the explosion when it took place, and several of them had felt the power of the blast, even from some distance away.\n\nThen I began to look at every Norwegian news website I could think of, and watched NRK, Norwegian TV2, CNN, and Al Jazeera online. (I didn't have a TV at hand.) Within an hour, it was confirmed that the explosion had been the result of a bombing. Initial reports said that it bore all the earmarks of a jihadist attack. Nobody publicly disputed this conclusion.\n\nThen, suddenly, came reports of another event. Shots had been fired a half hour or so west of Oslo, on an island called Ut\u00f8ya, where the annual summer camp for Workers Youth League\u2014the Labor Party youth organization\u2014was under way. The first details were sketchy. Young campers on the island, apparently, were telephoning their parents and begging them frantically to call the police. A gunman, they said, was shooting their friends down in cold blood. When he had first come ashore, wielding a huge gun, he had pretended to be a cop, come to safeguard them in the wake of the explosion in Oslo. Then he had started firing at unarmed teenagers. According to an article by \u00c5sne Seierstad published weeks later in Newsweek, he \"shout[ed] 'Hurray!' 'Bull's-eye!' or 'Got you!' as he slew his victims.\" Kids were running, hiding in the woods, hysterical, in shock. There was nobody there with a gun to protect them, and no easy means of getting off the island. One minute they had been living in a pastoral idyll: the next minute they had been plunged into a nightmare. And they had no idea why it was happening.\n\nSince I had lived in Norway for many years and had written a great deal about Islam, my inbox soon began to fill with emails from editors asking me to write about this atrocity. I agreed to submit pieces both to the Pajamas Media (now PJMedia) website and to the Wall Street Journal opinion page. I began working on the Pajamas piece while listening to the Norwegian news and crying incessantly.\n\nI had already finished a draft when the news came that the attacks were not, after all, the work of jihadists. Instead, the perpetrator was an ethnic Norwegian named Anders Behring Breivik, who claimed that his actions were motivated by anti-jihadist sentiment.\n\nIn the piece I ended up sending to Pajamas Media I noted that one Norwegian newspaper had observed that the July 22 death toll was higher than at Columbine and Virginia Tech combined. \"The Norwegian media,\" I pointed out,\n\nhave always reported on mass murders by lone gunmen in the U.S. as if they were things that could never happen in Norway: rather, they were symptoms of a sick society that Norwegians could never possibly understand. In Norway, they use the term \"amerikanske tilstander\"\u2014American conditions. It never means anything good. Yesterday's nightmare, from a Norwegian perspective, was the most American of American conditions.\n\nI also wrote that while virtually everybody had assumed at first that the attacks in Oslo were the work of jihadists, \"it would've been just plain dumb for Islamists to make an enemy of Norway,\" given that the Norwegian government and cultural elite had been making friendly gestures for years to even the most extreme elements of Islam: they'd treated their Jews shabbily, coddled resident terrorist Mullah Krekar, squelched domestic criticism of Islam, dropped Muslim riots down the memory hole, and openly supported terrorist groups. I concluded the piece as follows:\n\n. . . it is deeply depressing to see this evil, twisted creature become the face of Islam criticism in Norway. Norwegian television journalists who in the first hours of the crisis were palpably uncomfortable about the prospect of having to talk about Islamic terrorism are now eagerly discussing the dangers of \"Islamophobia\" and \"conservative ideology\" and are drawing connections between the madness and fanaticism of Breivik and the platform of the Progress Party. Yesterday's events, then, represent a double tragedy for Norway. Not only has it lost almost one hundred people, including dozens of young people, in a senseless rampage of violence. But I fear that legitimate criticism of Islam, which remains a very real threat to freedom in Norway and the West, has been profoundly discredited, in the eyes of many Norwegians, by association with this murderous lunatic.\n\nAs the day wore on, it quickly emerged that Breivik had been an avid reader of a website called document.no, where he had posted a number of comments.\n\nThere are a couple of major websites that regularly address Norway's immigration and integration policy and its attendant problems. One of them is rights.no, the site of Human Rights Service, a small Oslo-based think tank for which I have worked on and off for several years as a writer, editor, translator, and consultant. Their focus is on the rights of women and girls in Norway and Europe, especially in Muslim communities, and their mission is to develop proposals for new laws and government programs. HRS's information director, Hege Storhaug, has appeared countless times on Norwegian TV debate programs, and has become a very familiar\u2014and polarizing\u2014figure; while many ordinary citizens have relished her bluntness about the failures of Norwegian immigration and integration policies, members of the cultural elite have tended to balk at her blithe violation of long-standing boundaries as to what can and cannot be said. For years, multiculturalists who frown on any mention of Muslim community problems have savaged HRS as racist and \"Islamophobic\" and have battled to remove its government funding. HRS's website features regular news commentaries in Norwegian and English by Hege and managing director Rita Karlsen; it has also published original articles about Islam, immigration, and integration by contributors from around the world, such as Robert Redeker in France and Henryk Broder in Germany.\n\nAnother website that addresses immigration and related issues is document.no, edited by my friend Hans Rustad. Unlike HRS's website, document.no is not connected to any larger organization, and its focus is not on the rights of Muslim women and girls (although this is certainly among its concerns) but on the threat that unreconstructed Islam and failed immigration and integration policies pose to the West. Like rights.no, it is a serious, intelligent, and respectable site that respects the facts and has never dealt in vulgar Muslim-bashing. Unlike HRS's website, it allows readers to post comments on its articles.\n\nWhen I looked at document.no, I found that Hans, in reaction to the atrocities, had already compiled all of the comments Breivik had ever posted on the site, forming a useful package for the edification of journalists and anyone else who was interested. The first thing I did was to search Breivik's comments, which had been posted between 2007 and 2009, for my name. It came up three times.\n\nOn September 14, 2009, apropos of the need to form an alliance between anti-jihadists and cultural conservatives, Breivik had written: \"Bawer is probably not the right person to work as a bridge-builder. He is a liberal anti-jihadist and not a cultural conservative in many areas. I have my suspicions that he is TOO paranoid (I am thinking of his homosexual orientation). It can seem that he fears that 'cultural conservatives' will become a threat to homosexuals in the future. He refuses therefore to take the opportunity to influence this in a positive direction. This seems entirely irrational.\"\n\nOn October 31, 2009, Breivik wrote that several things needed to be done in the next twenty years to prevent the Islamization of Norway, among them: \"Initiate a collaboration with the conservative forces in the Norwegian church. I know that the libertarian forces in the European anti-jihad movement (Bruce Bawer among others, and some other libertarians) will have a problem with this, but conservative forces in the church are in fact one of our best allies. Our main opponents must not be jihadists but the jihadists' facilitators\u2014namely the multiculturalists.\" And on November 6, 2009, he wrote: \"It is tragicomic that an important NGO like Human-Etisk Forbund [the Norwegian Humanist Association] has been taken over by a cultural Marxist when it should be run by a liberal anti-jihadist like Bruce Bawer.\"\n\nTo discover that this murderer knew who I was and had read my work filled me with a feeling that is hard to describe. As a professional writer for almost three decades, I have met or received communications from hundreds if not thousands of my readers, and while most of them have been very nice, there has always been a sprinkling of nuts. When you're a writer you never know who may be reading you. You get used to the idea. But this was new territory for me. I was chilled\u2014sickened.\n\nIt was interesting to note that, while Breivik preferred me to a \"cultural Marxist,\" he still found me too liberal for his tastes.\n\nAs many people on the left don't realize, there is a very broad range of views among the critics of Islam.\n\nStill, until Breivik came along, it had all been about debate. The violence had all been on the side of the jihadists\u2014the major right-wing extremists of our time\u2014and guilt had stained their apologists on the left. Now the tables were turned. Someone who claimed to be, broadly speaking, on my side\u2014the anti-jihadist side\u2014had committed a massive atrocity.\n\nThen it emerged that Breivik had written a 1,500-page manifesto which he had e-mailed to hundreds of recipients only moments before setting out on his murder spree. It was online. I found it easily. At the outset, Breivik summed up his argument:\n\n. . . the root of Europe's problems is the lack of cultural self-confidence (nationalism). Most people are still terrified of nationalistic political doctrines thinking that if we ever embrace these principles again, new \"Hitler's\" will suddenly pop up and initiate global Armageddon. . . . Needless to say; the growing numbers of nationalists in W. Europe are systematically being ridiculed, silenced and persecuted by the current cultural Marxist\/multiculturalist political establishments. This has been a continuous ongoing process which started in 1945. This irrational fear of nationalistic doctrines is preventing us from stopping our own national\/cultural suicide as the Islamic colonization is increasing annually. This book presents the only solutions to our current problems.\n\nThe book made for exceedingly creepy reading. Well, not the first half\u2014the first half was, in large part, a surprisingly sane-sounding take on modern society and politics. Had the killer actually written this? If so, I thought after skimming through it, he was a very well-read and thoughtful mass murderer indeed. Later, a closer perusal revealed that much of the book consisted of texts that Breivik had borrowed from various writers. Indeed, in a passage I had missed on my first read-through, Breivik acknowledged that he had \"written approximately half of the compendium myself\" and that the rest was \"a compilation of works from several courageous individuals throughout the world.\" Many of these borrowed works were credited to their authors; others were not.\n\nThe book's first few pages, for example, which linked political correctness to \"cultural Marxism,\" turned out to be the text of a 2004 Free Congress Foundation pamphlet titled Political Correctness: A Short History of an Ideology, by William Lind. This led off an introductory section in which Breivik went on to discuss the domination of Western Europe by political correctness; trace the development of PC to the rise of critical theory and the Frankfurt School of philosophers (each of whom he profiled at some length); and describe the assault on Western values by Jacques Derrida and radical feminism.\n\nThen came Book One, about \"our falsified history.\" He covered the current whitewashing of the history of Islam, served up some of the basics of Islam (sharia law, jihad, al-taqiyya, Koranic abrogation, dhimmitude), and quoted passages about Islamic history and theology from Robert Spencer, Walid Shoebat, Serge Trifkovic, and Bat Ye'or. He recounted the history of the Hindu Kush; the Crusades; the Ottoman Empire and the Armenian genocide (here he included an article by Andrew G. Bostom); the fall of Christian Lebanon; the defeat of the \"first Islamic wave\" by Charles Martel at the Battle of Tours in 732 (here he quoted dozens of historians); and the defeat of the \"second Islamic wave\" at the Battle of Vienna in 1683. He cut-and-pasted an article by Baron Bodissey about Crusader heroes and one by the pseudonymous Norwegian essayist \"Fjordman\" on Western versus Islamic science; wrote about Bosnian history (quoting at length from the Encyclopaedia Britannica, a Time-Life book about the Balkans, and other sources); and reprinted a speech by Bat Ye'or about Yugoslavia and an article by Daniel Pipes titled \"Palestine for the Syrians?\"\n\nIn Book Two, about \"Europe's current problems,\" Breivik moved from history to the present day. He wrote about jihad in today's Muslim and Western world. The section included many complete essays by \"Fjordman\" about such topics as media bias, the relative birthrates of native Europeans and Muslims, the role of the European Union, the United Nations, and feminism in aiding the Islamization of the West, the unreliability of moderate Muslims, Europe's demographic crisis, the capitulation of Europe to sharia law, and Norway's anti-discrimination act.\n\nWhich brought us to the halfway point of the manifesto\u2014and to Book Three, \"A Declaration of Pre-Emptive War.\" It was thoroughly, and stunningly, different from everything that had preceded it. It was, quite explicitly, the work of a madman. There was no smooth transition, either. One minute Breivik was writing seriously\u2014or cobbling together the work of other people who had written seriously\u2014about various strains of modern Western thought and their consequences for liberal democracy and individual freedom.\n\nThe next minute he was talking about killing people.\n\nYes, that was what the second half was about. Killing people. Where to get weapons and ammo. Where to acquire body armor. How to commit acts of terrorism. How many people to kill.\n\nBreivik claimed to be part of a movement\u2014a revival of the medieval Knights Templar\u2014that had re-formed that band of brothers with the goal of saving Europe from its fate. And how would they save it? By killing\u2014killing on a massive scale. And not by killing Muslims, but by killing the members of Norway's left-wing political class and, even more monstrously, their children. For his chief enemy was not Muslims themselves\u2014it was the socialist politicians whose multiculturalism had shaped the immigration and integration policies of modern Norway (and of modern Western Europe as a whole) and their comrades-in-arms, the left-wing academics, journalists, authors, and others who had abetted what he saw as their treason.\n\nThis second half of his manifesto, then, was addressed in particular to his fellow Knights, with an eye to preparing them to commit violence against the multiculturalist enemy.\n\nTo this end, he listed the preferred \"equipment for urban operations,\" including \"HK416 assault rifle with 'redpoint' optics (4 extra long clips),\" a \"Glock handgun with silencer and laser (2\u20134 extra long clips),\" \"3 splint grenades,\" \"1\u20132 shock grenade,\" \"2 x arm defensive devices (knives),\" a \"Gas mask,\" and \"Ammo (clip administration).\" He went into great detail about the different kinds of body armor, which provide various levels of protection against different types of ammunition. He recommended \"a small police version shield. . . . An optimal size for our purpose (and provided you have leg armour) would be any size from 50 x 50 to 70 x 70 cm, although most shields on the market are larger. You may have to re-equip with handles, a carrying strap (so you may carry it on your back), police insignia, one or two 10 cm spikes and\/or razorblades on the front of the shield (primarily as a deterrent to prevent people from jumping you from behind).\"\n\nIn later passages, he explained in great detail how to make bombs, how to obtain and deploy weapons of mass destruction, and how to acquire anthrax. He listed the nuclear reactors in Europe, all of them potential targets for the Knights' operations. And he offered strategic advice, which he himself would follow on July 22: \"Make a sound in the east, then strike in the west.\" (Ut\u00f8ya is west of Oslo.) He elaborated: \"In any battle the element of surprise can provide an overwhelming advantage. Even when face to face with an enemy, surprise can still be employed by attacking where he least expects it. To do this you must create an expectation in the enemy's mind through the use of a feint.\" In short: \"get the enemy to focus his forces in a location, and then attack elsewhere which would be weakly defended.\"\n\nHe also offered advice on how to choose targets. He divided the multiculturalist \"traitors\" into three categories, A, B, and C, noting that such traitors could be found in heavy concentrations at \"[a]nnual gatherings for journalists\" and at \"[l]iterature conferences and festivals.\" He did not mention the Labor Party summer camp at Ut\u00f8ya.\n\nIn the first part of his book, then, Breivik presented himself as a man concerned about the survival of Western civilization. It was, essentially, a thumbs-up to much of the best that has been thought and said, from the Enlightenment on, about the nature of freedom and of tyranny. The Breivik of these pages would have the reader believe that he was a true disciple of those great men and women who stood for liberal values against the encroachments of totalitarianism, religious or otherwise.\n\nThe second half of his book was an utter betrayal of the first\u2014a leap from civilized reason into the depths of barbarism, from logical sanity into pure madness.\n\nMuch has since been made of Breivik's references to this or that writer. In fact, his manifesto is a veritable phone book of names. Among the hundreds of people whom he mentions or quotes are Mark Twain, George Orwell, John Stuart Mill, John Locke, Henry David Thoreau, Bernard de Clairvaux, Bernard Lewis, Ayaan Hirsi Ali, Christopher Caldwell, Samuel P. Huntington, and Mohandas Gandhi. He quotes Andrew Jackson: \"One man with courage makes a majority.\" Winston Churchill: \"A man does what he must\u2014in spite of personal consequences, in spite of obstacles and dangers and pressures\u2014and that is the basis of all human morality.\" Thomas Jefferson: \"The tree of liberty must be refreshed from time to time with the blood of patriots and Tyrants.\" Robert Frost: \"Don't ever take a fence down until you know why it was put up.\" Winston Churchill again: \"An appeaser is one who feeds a crocodile, hoping it will eat him last.\" Hillel the Elder: \"If not us, who? If not now, when?\" He quotes the opening sentences of the Declaration of Independence and a couple of dozen militaristic verses from the Old Testament. Apropos of his need for prayer on the fast-approaching day of his \"mission,\" he cites the Twenty-Third Psalm (\"Though I walk through the valley of the shadow of death, thou art with me\") and the gospels (\"I am the resurrection and the life. He that believeth in me though he were dead, yet shall he live\"). And he lists his favorite books: Nineteen Eighty-Four, Leviathan, On Liberty, Essay Concerning Human Understanding, The Wealth of Nations, Reflections on the Revolution in France, Atlas Shrugged, The Fountainhead, Pragmatism, On War, and Fjordman's own immense, self-published manifesto Defeating Eurabia.\n\nTo this list one might add the manifesto of the Unabomber, Ted Kaczynski\u2014for, as it turned out, much of Breivik's book was in fact lifted from the Unabomber's. (Indeed, given that Kaczynski alone, of all the people whose writings are quoted by Breivik, actually came anywhere near to proposing or executing the kind of \"solution\" Breivik carried out on July 22, it would seem reasonable to suggest that Kaczynski was the only one of the hundreds of people mentioned in Breivik's text who can truly be considered an influence on his actions.)\n\nAnd what about me? The first thing I did when I found Breivik's manifesto online was to search for my name. I got twenty-two hits, and though I saw that some of these hits were accounted for by appearances of my name in essays lifted from \"Fjordman,\" I spent the next several weeks under the impression that Breivik himself had also quoted me a number of times. As we shall see, many members of the Norwegian cultural elite quickly embraced the idea that Breivik had quoted me frequently in his book, and that I therefore loomed large among his supposed influences\u2014for which, they made clear, I deserved contempt and condemnation.\n\nWhen I went carefully through Breivik's manifesto at the end of August, however, I discovered that every time my name appears in his book, it is in one or another of the essays by \"Fjordman.\" \"Fjordman\" quoted me on multiculturalism and its consequences, on Pim Fortuyn and Theo van Gogh, on jizya (the tax levied on infidels living in Muslim countries), the fact that some immigration-related issues are not open to debate in Sweden, on editor Vebj\u00f8rn Selbekk's apology for reprinting the Muhammad cartoons in his tiny Christian newspaper Magazinet, on a bombing outside the Danish embassy in Islamabad in retaliation for the Muhammad cartoons, on Norwegian novelist Dag Solstad's distaste for free speech, on the targeting by left-wing thugs of members of the Sweden Democrats Party, on Danish author Lars Hedegaard's grim prediction of Europe's future, and on the censorship of European media. But Breivik himself, it turned out, never once mentioned me in his manifesto.\n\nWho is Anders Behring Breivik? What makes him tick? His manifesto includes a Q&A in which he discusses his childhood and family. His father, a diplomat in London (and, later, Paris) \"had three children from a former marriage\"; his mother had \"a daughter from a past relationship.\" They divorced when he was a year old, and he moved back with his mother and stepsister to Oslo, where she married an army captain. \"My parents,\" he writes, \"were not politically active but supported the policies of the Norwegian Labour Party which was common for most individuals working in the public sector.\" His father broke off contact with him when Anders was fifteen because the boy had become involved with kids who were into hip-hop music and who committed graffiti vandalism. Anders tried to contact him five years ago but \"he said he was not mentally prepared for a reunion due to various factors, his poor health being one.\" Despite this nonrelationship with his father, Breivik writes,\n\nI feel I have had a privileged upbringing with responsible and intelligent people around me. I do not approve of the super-liberal, matriarchal upbringing though as it completely lacked discipline and has contributed to feminise me to a certain degree.\n\nBreivik had many Muslim friends growing up. In his Q&A, he asks himself: \"Why did you have so many non-ethnic Norwegian friends?\" The answer: \"pride and certain moral codexes\/principles have always been very important to me\"; in times of trouble, \"I expected my friends to back me up 100% without submitting or running away. . . . Very few ethnic Norwegians shared these principles. They would either 'sissy out,' allow themselves to be subdued or run away when facing a threat.\" So he hung around with Muslim kids who \"shared these principles of pride.\"\n\nNot that having Muslim friends saved Breivik from run-ins with Muslims. He recalls a dozen or so occasions on which he was the target of Muslim aggressiveness during his youth and young manhood in Oslo. And he writes about forming tactical alliances with Muslim gangs in secondary school:\n\nIn Oslo, as an ethnic Norwegian youth aged 14\u201318 you were restricted if you didn't have affiliations to the Muslim gangs. Your travel was restricted to your own neighbourhoods in Oslo West and certain central points in the city. Unless you had Muslim contacts you could easily be subject to harassment, beatings and robbery. Our alliances with the Muslim gangs were strictly seen as a necessity for us, at least for me . . . As a result of our alliances we were allowed to have a relaxing and secure position on the West side of Oslo among our age group.\n\nAfter graduating from school, Breivik became an entrepreneur. But then, in 2006, having decided to become a Knight Templar and to dedicate his time to preparing for armed action and to writing his manifesto, he moved back home with his mother:\n\nThis wouldn't have worked in my old life, when I was an egotistical career cynic as it would devastate my social image. However, individuals who choose to become a Justiciar Knight cares [sic] little about image. . . . Sure, some people will think you are a freak for living with your parents at the age of 31 but this is irrelevant for a Justiciar Knight.\n\nBreivik writes affectionately and at length about his four best friends, \"all of whom are now in the process of settling down\" with wives or girlfriends, but never mentions having any special someone in his own life. (He does record spending much of a year playing the computer game World of Warcraft.) And he mentions plans \"to meet my stepmom, Tove \u00d8vermo,\" a former director at UDI (Utlendingsdirektoratet, the Norwegian Directorate of Immigration), noting the irony that \"UDI is a highly valued target for Knights Templar in Norway as it is an essential tool and facilitator for the Norwegian multiculturalist regime. . . . Although I care for her a great deal, I wouldn't hold it against the KT if she was executed during an attack against UDI, as she used to be a primary tool and category B traitor for the multiculturalist regime of Norway.\"\n\nOther parts of the manifesto also shed light on Breivik's personality. In one passage, for example, he recalls \"mandatory knitting and sewing courses\" in primary school, the goal of which, in his view, was \"to feminise European boys\" and thus serve the cause of \"Marxist utopia\" and \"true equality between the sexes.\" Now, however, \"I am grateful for having received this insight into sewing and stitching as this knowledge is an essential skill when constructing and assembling modern ballistic armour. . . . It is quite ironic and even hilarious when reflecting on the fact that a skill which was intended to feminise European boys can and will in fact be used to re-implement the patriarchy by overthrowing the Western European cultural Marxist\/multiculturalist regimes.\"\n\nAt one point, apropos of the dilution of the Nordic gene pool, Breivik maintains that \"Nordic entertainment super-stars like Scarlett Johansson (60\u201370% Nordic purity), Gwyneth Paltrow (70\u201380%), Pamela Anderson (90\u201395%), Paris Hilton (70\u201380%), Taylor Swift (80\u201390%) would have never been where they are today hadn't it been for their distinct Nordic physical characteristics.\" And then there is a curious passage in which he advises potential Knights Templar on how to prepare for a photo shoot. \"As a Justiciar Knight you will go into history as one of the most influential individuals of your time. So you need to look your absolute best and ensure that you produce quality marketing material prior to operation.\" Therefore:\n\n\u2022 Take a few hours in a solarium to look fresher.\n\n\u2022 Train hard (work out) at least 7 days prior to photo session\n\n\u2022 Cut your hair [and] shave\u2014Visit a male salon if possible and apply light makeup. Yes, I know\u2014this might sound repulsive to big badass warriors like us, but we must look our best for the shoot.\n\n\u2022 Use your best clothing\u2014you can f[or] example bring 3 different sets of clothing to the sho[o]t location\u20141. Dress, tie etc. 2. Casual wear 3. Sporty wear 4. Militaristic wear (obviously, you can't bring your guns or anything indicating that you are a resistance fighter).\n\nHe even recommends musical artists whose work he considers suitable listening for Knights Templar.\n\nAnd he advises his fellow Knights on how to prevent friends and family \"from digging too much or ask too many questions\" while you are planning a secret military operation. His suggestions:\n\n\u2022 Say you play WoW (World of Warcraft) or another MMO and have developed an addiction for it. Say that are going to play hardcore for the rest of the year and it is no point trying to convince you otherwise. . . .\n\n\u2022 Say you think you are gay and are in the process of discovering your new self and that you don't want to talk any more about this issue. . . . Make them swear to not tell anyone!\n\nBreivik notes that he bought \"three bottles of Ch\u00e2teau Kirwan 1979 . . . at an auction 10 years ago\" and is saving the last remaining bottle \"for my last martyrdom celebration,\" during which he plans to \"enjoy it with the two high class model whores I intend to rent prior to the mission.\" He explains that in his view, the concept of the \"Perfect Knight\" \"should not include celibacy, although some of my KT peers might disagree with me on this point. . . . A pragmatic approach, which involves acknowledging the primal aspects of man for the purpose of preparing him for a martyrdom operation, should always take precedence over misguided piety, which only increases the chance of jeopardizing the execution of the operation. And I believe the majority of war strategy analysts will agree with me on this.\"\n\nBreivik also wonders what will happen if \"I survive a successful mission and live to stand a multiculturalist trial.\" He takes stock of himself: \"I have an extremely strong psyche (stronger than anyone I have ever known) but I am seriously contemplating that it is perhaps biologically impossible to survive the mental, perhaps coupled with physical torture, I will be facing without completely breaking down on a psychological level. I guess I will have to wait and find out.\" Yet whatever happens,\n\nI will always know that I am perhaps the biggest champion of cultural conservatism, Europe has ever witnessed since 1950. I am one of many destroyers of cultural Marxism and as such; a hero of Europe, a savior of our people and of European Christendom\u2014by default. A perfect example which should be copied, applauded and celebrated. The Perfect Knight I have always strived to be. A Justiciar Knight is a destroyer of multiculturalism, and as such; a destroyer of evil and a bringer of light. I will know that I did everything I could to stop and reverse the European cultural and demographical genocide and end and reverse the Islamisation of Europe.\n\nIt is perhaps appropriate here to say a few words about my own introduction to European Islam. In 1998 I moved to Amsterdam\u2014a beautiful, civilized city with which I had fallen in love. But after living there for a while I discovered a side of it I'd never heard about. The city center\u2014the part the tourists see\u2014was liberalism, or libertarianism, itself: a place of real diversity, tolerance, and freedom. But just outside it was another Amsterdam\u2014a parallel society, insular and Islamic.\n\nThis, I soon learned, was not unique to the Netherlands. In cities across Western Europe, Muslims inhabited isolated, intolerant enclaves, living in extended patriarchal families governed by sharia law. In countries whose residents were supposedly free, children were growing up in communities where the very idea of an individual's right to shape his or her destiny was alien and anathema. All too many of these kids were being brought up to disdain the countries they lived in, the values on which those countries were founded, and those countries' non-Muslim natives. And to disdain, especially, people whose identity or behavior was seen as specially offensive to Islam\u2014among them gays, Jews, and women who dressed \"immodestly.\" In many cities, as a result, rapes, gay-bashings, and attacks on Jews were on the rise.\n\nSome observers took it for granted that the children of Muslim immigrants would grow up to be more integrated into European society and values than their parents, and that the grandchildren would be even more integrated. But over the years evidence mounted that things were going the other way\u2014that the children of immigrants were more hostile to their surroundings than their parents had been. And the larger their enclaves grew, the less they felt any need to relate to European culture and values.\n\nWorst of all, the governments of these countries either didn't see what was going on or didn't want to. They'd based their immigration and integration policies on the idea of multiculturalism\u2014which is another way of saying that they didn't really have immigration and integration policies. Not only didn't they encourage newcomers to adopt liberal democratic values and become full, free members of their societies\u2014they actively discouraged it. Why? Part of the reason was a contempt for their own societies, founded in a multicultural guilt over the Western heritage of colonialism and imperialism. Part was a misguided, romantic notion that everything about the cultures that Muslim immigrants brought with them was colorful and enriching. And part was a deep-seated, unacknowledged, and largely unconscious unwillingness to see these newcomers become full members of their societies.\n\nIt was one thing to have, say, Pakistanis in one's capital city, sporting exotic costumes and serving exotic dishes at restaurants. It was another thing to think of these aliens as, say, Dutchmen or Norwegians. Better to let them marry one another and stay put in their own neighborhoods\u2014veritable outposts of their home countries\u2014than to let them blend in; better to encourage them to live indefinitely on welfare, supported by the state, than to welcome them into the workforce, where they might take jobs from natives.\n\nThe multicultural mentality of many elite Europeans was epitomized by a 2001 remark by Norwegian cultural anthropologist Unni Wikan. When informed that a colossal percentage of rapes in Norway were committed by \"non-Western\" men (Norwegian code for Muslims), and that almost all the victims were ethnic Norwegians, Wikan placed blame largely on the victims. These women, she insisted, must realize that theirs was now a multicultural society. Their new Muslim countrymen considered their attire provocative; if only they'd dress more conservatively, they'd be less likely to be raped. (In the United States, such comments would be roundly denounced as blaming the victim; among the Norwegian cultural elite, they were taken as sage guidance on how to achieve intercultural harmony.)\n\nIt is important to underscore here that while multiculturalism may seem to be rooted in respect for other cultures, it in fact often masks a distaste for the idea of sharing one's culture and national identity with foreigners. After I moved to Norway in 1999, I soon lost count of the number of times I heard ethnic Norwegians, in barroom conversations with the Norwegian-born children of immigrants (who spoke Norwegian just as well as they did), ask: \"No, but where are you really from?\"\n\nNorway has, after all, historically been an ethnically homogeneous society. Cultural elite types are very aware of that fact\u2014and are, consequently, desperately eager to show they are not racists and to advertise their love for people of different races. They often do this in artificial ways that can seem positively antiquated. After the atrocities of July 22, for example, several newspapers in Norway reported on an ethnic Norwegian woman who had been wounded in the explosion in Oslo and had received help from one Christian Armando Clementsen. Though born in Colombia, Clementsen had been raised in Norway from infancy as the adopted son of ethnic Norwegians. The media instantly declared a picture of him helping the woman \"iconic,\" and hailed his act as a triumph of common humanity over xenophobia. \"People were surprised that a dark-skinned person managed to show compassion,\" said Clementsen.\n\nConsider, too, the following passage from a Dagbladet piece published on July 30 by columnist Marte Michelet:\n\nHere in Gr\u00f8nland [a largely Muslim neighborhood in Oslo], where we live, it is as if a heavy and long-lasting air pressure has disappeared, dissolved by the 200,000 people who filled Oslo with love and roses held high. The Somalis walk a little more lightly. The hijab girls no longer look nervously up at passersby. The Pakistani shopkeepers smile a bit more broadly. A feeling of being encamped and of constant criticism has been replaced with a new sense of security. They don't hate us after all, these Norwegians. The fantastic celebration of community, solidarity, and tolerance that has manifested itself from one end of the country to another will have a long-lasting effect on the life of people with minority backgrounds in this country.\n\nReading this girlish drivel, all one could think was how remote Michelet was from the reality surrounding her. Did she really believe for one instant that her Muslim neighbors had been sitting around worrying all these years about what ethnic Norwegians think of them? (And notice how it didn't even occur to her to think of them as Norwegians; no, to her, she's the Norwegian\u2014they're still Somalis and Pakistanis.) She seemed barely aware that Norway, compared to the places they came from, is a playground. They may have feared Saddam Hussein, or Pervez Musharraf, or some local chieftain or warlord back in the old country. They most assuredly do not fear Norway's prime minister, Jens Stoltenberg, and they certainly don't tremble with worry about the opinion of some bubbleheaded columnist who is impressed with herself because she lives in a largely Muslim part of town.\n\nHow far has multiculturalism gone in Europe? So far that Muslim leaders who call for the execution of homosexuals are not considered to have overstepped the bounds of decency. At a 2007 debate, the deputy chairman of Norway's Islamic Council, who was also a high-ranking official in both the Labor Party in Oslo and the nation's leading trade union as well as an advisor to the government's Equality and Anti-Discrimination Ombud, refused to reject the death penalty for gays. Mohammed Usman Rana, then head of the Muslim Student Association, now a physician and a prize-winning columnist for Norway's leading newspaper, would not say whether he supported or opposed executing homosexuals.\n\nThe hostility toward gays in the Muslim community is so intense that until recently there was not a single publicly gay Muslim in all of Norway. When I did finally meet the country's first openly gay male and lesbian Muslims, they proved to be two of the most emotionally battered people I've ever encountered. Not only were they despised by their communities, but the institutions of mainstream Norwegian society that should have been giving them support had turned their backs on them, afraid to offend Muslim leaders. This, too, is the result of multicultural thinking on the part of the European establishment: all too often, gay Muslims, apostate Muslims, and Muslim women who've divorced their husbands are left to fend for themselves.\n\nIn the last few years, I've written regularly about such issues for the website of HRS, whose feminist founders, Hege Storhaug and Rita Karlsen, established it because they were outraged by the deprivation of women's and girls' rights in Norwegian Muslim communities. When they started HRS in 2001, it was still highly taboo in the Norwegian media to criticize Islam, multiculturalism, or Norway's immigration and integration policies. Criticizing Islam, it should be emphasized, is not about putting down Muslims as people\u2014it is about recognizing Islam as a severe, totalizing ideology of which Muslims are the first and greatest victims. It is about acknowledging that imams lauded as \"moderate\" by multiculturalists are in fact supporters of forced marriage, female genital mutilation, the execution of homosexuals, and the systematic subordination of women. Yes, there are liberal and kind-hearted Muslims\u2014but they are liberal and kind-hearted precisely to the degree that they reject the counsel of their religion's leading theologians, such as Yusuf al-Qaradawi, and choose instead to embrace the image of peaceful, loving deity.\n\nWhile Norway's multicultural media, politicians, and academics were systematically ignoring or explaining away or quite simply lying about various uncomfortable developments related to Islam, immigration, and multiculturalism, Hege and Rita, along with a number of others, were doing their best to speak the truth about such issues and to put them on the Norwegian national agenda. In doing so, they endured a great deal of abuse by the political and media establishment. I played my own small part in their effort, and received my share of unfair abuse.\n\nBut it paid off. Over the years, Norwegians became less uneasy about airing their concerns. Public support for the upstart Progress Party, with its vocal criticism of multiculturalism, climbed steadily. Islam and immigration became acceptable topics of discussion in newspaper opinion pages and on prime-time debate programs. In 2006, most Norwegians told pollsters that they opposed Selbekk's republication of the Danish cartoons; in early 2011, a majority took the opposite view.\n\nNot all critics of Islam in Europe, alas, oppose it in the name of tolerant, pluralist democracy. Soon after I became aware of Islam in Europe, I became aware too that there were far-right parties, groups, and individuals across the continent that opposed Islam in the name of narrow religious, ethnic, and\/or nativist values. From the time I first began writing about these issues, I warned that if Europe's cultural elites did not address them responsibly, they'd face an increasing danger of right-wing extremists taking matters into their own hands. The terrible events of July 22 only confirmed the Norwegian establishment's failure in this regard.\n\nThose events shocked Norwegians to the depths of their being.\n\nThe national display of grief was unlike anything I had ever seen. On 9\/11 the United States had been attacked by foreigners; on June 22, Norwegians had been victimized by one of their own. This fact shattered many Norwegians' sense of themselves as a homogeneous, peaceful, virtuous people who had nothing to fear from one another.\n\nA larger country\u2014a different country\u2014would not have responded to the massacres by Breivik in the way Norway did. The Oklahoma City bombing in 1995, which killed 168 people, including nineteen children under six, and injured 680, caused shock and horror around the world, but it did not engender anything remotely like the national existential crisis that the July 22 atrocities led to in Norway.\n\nAt the bottom of this existential crisis were two questions: How can anybody do this to us? and even more, How can one of us do this to us?\n\nAll their lives, Norwegians had been taught to think of their country as a virtuous actor on the international stage. A terrorist attack against Norway was unthinkable\u2014though such attacks against other countries, above all the United States, were thoroughly understandable. After 9\/11, Norwegian newspapers, like those in other Western countries, ran articles gleefully explaining why the United States had had it coming; after atrocities like Columbine, the reflexive response in the Norwegian media has been to attribute them to something unhealthy in the American soul. Yet many of the same people whose instinct, in the face of American national tragedies, has been to sneer at the Great Satan, haughtily condemned as tasteless any expressions of concern, after July 22, about the potential impact of Breivik's actions on Norwegian multiculturalism, immigration policy, and criticism of Islam. Few seemed to notice the inconsistency: it's perfectly fine to blame Americans and their culture for atrocious acts that have caused them to suffer; but when Norwegians are suffering, even to express legitimate concerns while one is patently hurting for the victims is considered an act of sacrilege. Underlying this moral contradiction is a belief, encouraged by the left-wing cultural elite, in Norway's unique virtue and innocence\u2014in the idea that it exists on a somewhat higher moral plane than the rest of the world, certainly the United States.\n\nThe reality of Norway, to be sure, differs considerably from its official self-image. Norway belongs to NATO; it has troops in Afghanistan and Libya. There's something else, too. On weekdays Norwegians present an exceedingly peaceable and sober image, but on weekends (as Norwegians themselves acknowledge) an extraordinary number of them drink to excess and\u2014well\u2014misbehave. It is as if they are letting out all the emotion they have repressed all week; it is as if, possessed all week by their overly self-disciplined inner Lutherans, they have been repressing their inner Vikings. Since July 22 I have wondered whether some Norwegians have seen in their homegrown terrorist a nightmare image of that inner Viking writ large\u2014and I have wondered whether the country's reaction to Breivik's acts\u2014a reaction that, viewed from abroad, may seem, in many ways, bizarre\u2014can be explained by many Norwegian's deep sense of guilt about their own inner Vikings.\n\nThe thrust of all this is that many Norwegians, in response to Breivik's atrocities, plainly felt a desperate need to restore their sense of themselves as a peaceable people. In the days after July 22, they held one memorial tribute after another. The streets of Oslo were filled with flowers and candles. Norwegian TV endlessly repeated something a girl belonging to Workers Youth League had said in a CNN interview: \"If one man can show so much hate, think of how much love we can share together.\" Somebody else said: \"This will make us be nicer to each other.\" The message sent out by official Norway was that \"all Norway is one\" and that the country was being \"united in love.\" A picture on one of the major newspaper's websites showed a string of Norwegians of various colors holding hands.\n\nYou have to be familiar with Norwegians to know how odd all this was. Norwegians never talk about love. On English-language TV shows, the subtitles typically water down expressions of emotion to make them sound more naturally Norwegian, so that \"I love . . .\" almost invariably becomes \"I like . . .\"\n\nYet the massive display of love clearly didn't fill the void inside. Norwegians wanted desperately to find some meaning in what had happened. That was, in large part, why they amassed so many flowers and lit so many candles\u2014as if they hoped that the scale of the tribute alone could somehow overcome the senselessness and evil of the whole terrible thing. But of course it couldn't. For however peaceable they liked to think of themselves as being, they were human. They wanted a sense of meaning, wanted something to do. And, last but not least, they wanted revenge.\n\nAfter 9\/11, Americans could at least look forward to sending soldiers to Afghanistan to take out the terrorists who had ordered the hit on their country. But the arrest of Breivik\u2014one solitary lunatic\u2014provided precious little revenge. Norwegian justice being what it is, the man had been put in a very comfortable cell. The law, needless to say, didn't permit the possibility of execution\u2014indeed, given current sentencing guidelines, it was entirely possible he would one day be released. It is only normal for the human mind to rebel at such facts, to long for proportionate justice.\n\nBreivik's atrocities, then, left Norwegians in a complicated and intensely emotional state of mind. And the country's left-wing cultural elite\u2014that grab bag of professors, authors, journalists, bureaucrats, and politicians, all too many of them pompous, self-regarding mediocrities who share essentially the same lockstep politics\u2014exploited it with breathtaking cynicism.\n\nFirst, they seized on a single detail in Breivik's Facebook profile\u2014he had put himself down as a Christian\u2014and suggested that his rampage had been carried out in the name of religion. On July 23, document.no noted that the assistant police chief of Oslo, Roger Andresen, had called Breivik a \"Christian fundamentalist,\" and that journalists had eagerly embraced this description. (This in a country where the media are at pains to avoid identifying evildoers as Muslims.) On August 2, NRK's website ran a long article coauthored by an American \"terrorist expert,\" Mark Juergensmeyer, affirming that Breivik was a \"Christian terrorist.\" The purpose here was obvious: to play down the threat of Islamic jihad by pretending that Breivik's actions had amounted to a kind of Christian jihad, and had proven that terrorism in the name of Christianity is at least as serious a menace as terrorism in the name of Allah. (Another approach was taken by Thorbj\u00f8rn Jagland, head of the Norwegian Nobel Committee, who wrote in a July 29 Aftenposten op-ed: \"After this . . . there should be a complete end to calling terrorism committed by Muslims 'Islamic terrorism.' No one would think of calling Anders Behring Breivik a Christian terrorist just because he has described himself as a Christian.\")\n\nTo anyone who had actually read Breivik's manifesto, this thesis was transparent hogwash: his book makes it clear that he is not a religious man in the slightest and that he views Christianity in an entirely abstract way, as a foundation of the Western civilization that he purported to be trying to rescue. \"I'm not going to pretend I'm a very religious person,\" Breivik wrote,\n\nas that would be a lie. I've always been very pragmatic and influenced by my secular surroundings and environment. . . . Religion is a crutch for many weak people and many embrace religion for self serving reasons as a source for drawing mental strength. . . . Since I am not a hypocrite, I'll say directly that this is my agenda as well. . . . I'm pretty sure I will pray to God as I'm rushing through my city, guns blazing, with 100 armed system protectors pursuing me with the intention to stop and\/or kill.\n\nElsewhere in the manifesto he declared: \"European Christendom isn't just about having a personal relationship with Jesus or God. It is so much more. Christendom is identity, moral, laws and codexes which has produced the greatest civilisation the world has ever witnessed.\" And, apropos of the rules for being one of his fellow Knights:\n\nIt is not required that you have a personal relationship with God or Jesus in order to fight for our Christian cultural heritage and the European way. In many ways, our modern societies and European secularism is a result of European Christendom and the enlightenment. It is therefore essential to understand the difference between a \"Christian fundamentalist theocracy\" (everything we do not want) and a secular European society based on our Christian cultural heritage (what we do want).\n\nFinally, Breivik declared emphatically that \"it is essential that science takes an undisputed precedence over biblical teachings. Europe has always been the cradle of science and it must always continue to be that way.\"\n\nBreivik is a Christian, in short, in much the same way that most other Norwegians are Christians\u2014purely nominally. It was easy for non-Norwegians, especially Americans, to fail to understand this, especially when members of the Norwegian cultural elite were telling them (with an air of absolute authority) that the murderer was, indeed, a Christian jihadist\u2014a theme that was quickly picked up by American leftists.\n\nNorway's cultural elites didn't stop at identifying Breivik with Christianity. They also strove to suggest that his atrocities had been motivated in large part by a fanatical devotion to Israel and identification with Jews. Among Breivik's \"core values,\" reported a Dagbladet article on July 23, was his \"Pro-Israel\" stance. On the same day, the Swedish newspaper Nationell referred darkly to his \"extreme Zionist sympathies.\" In a July 26 Dagbladet article about Breivik's manifesto, Andreas Malm (a supporter of Hamas and Hezbollah) zeroed in on the murderer's complaint \"that our leaders, instead of supporting 'our cultural cousin' Israel, which is only defending itself against the jihadists, side with the Palestinians\"\u2014and identified this view of Israel as one of \"the standard elements of Islamophobic ideology.\"\n\nThis effort to link Breivik with Israel and the Jews was a natural outgrowth of many Scandinavian leftists' pathological anti-Semitism and loathing of Israel, which they consider the modern-day equivalent of Nazi Germany. Norway is, alas, a country that has never been kind to Jews. Its 1814 constitution explicitly denied Jews entry into the realm. During the Nazi occupation, Norway (unlike all other Nordic countries) readily handed its Jews over to the Nazis\u2014and when some of those Jews returned after the war, Norway refused to restore to some of them their homes and property, while charging others an exorbitant \"administration fee\" to recover what was rightly theirs. In recent years there has been no Western nation in which editorial cartoons in the mainstream media have consistently gone as far in depicting Jews and Israelis in ways that bring to mind the virulent propaganda of Der St\u00fcrmer. The most familiar premise in these cartoons is that Israelis are today's Nazis, and Muslims are today's Jews.\n\nOnly days before the atrocities of July 22, it was reported that Norway was planning to support the Palestinian bid to be recognized as a separate state by the UN; and on the very day before the attacks, the young people at Ut\u00f8ya, as Alex Weisler of the Jewish Telegraph Agency pointed out on July 26, had discussed \"the organization of a boycott against Israel\" and pressed Norway's foreign minister \"to recognize a Palestinian state.\" A picture was widely circulated on the Internet (but not in the mainstream Norwegian media) of Ut\u00f8ya campgoers hoisting a huge \"Boycott Israel\" banner.\n\nAs it turns out, Israel-bashing at Ut\u00f8ya has a long history. In 2007, Stoltenberg gave a speech on the island praising Workers Youth League for their campaign to win the release of Palestinian prisoners in Israel; among the prisoners of special concern to the youth at Ut\u00f8ya, he noted, was Hussam Shaheen of Fatah Youth, \"who has been here at Ut\u00f8ya several times and who has many friends in Workers Youth League.\"\n\nA year earlier, on July 15, 2006, a local Norwegian newspaper, Adresseavisen, reported from Ut\u00f8ya that Workers Youth League had demanded Stoltenberg take \"a tougher line on Israel\" following that country's actions in Gaza and Lebanon. One campgoer, who accused the party of cowardice for failing to come down harder on Israel, \"gave Stoltenberg a Palestine scarf and a T-shirt reading 'free Palestine,' and encouraged Jens to become 'Palestine Jens.' \" Stoltenberg defended his government by pointing out that Norway had \"gone further than other countries in letting Hamas have contact\" with its political officials. That year, according to Adresseavisen, Palestinian scarves and flags were \"a conspicuous element of camp life,\" and guests on the island included Hassan Faraj of Fatah Youth, who handed Stoltenberg a T-shirt reading \"Tear down the wall.\"\n\nApparently the tone at the 2011 camp did not differ greatly from that in earlier years. Indeed the tragic irony of Ut\u00f8ya may be that before the slaughter started, the island was the setting for speeches in which politicians, and aspiring politicians among the campers, encouraged participants to give their heart and soul to groups that engage in exactly the kind of monstrous terrorism that would mow dozens of them down before the week was out. They were, in short, urged to support groups that are internationally recognized as terrorists\u2014and, therefore, to embrace the idea that the cold-blooded murder of innocent men, women, and children is a legitimate means of achieving an ideological end. As one Facebook user put it: \"Before the terrorist murdered the kids at the camp, the kids at the camp were lending their support to terrorists who murder kids.\"\n\nThe attempt to associate Breivik with Israel and the Jews, then, was just the latest chapter in a long history of Norwegian establishment anti-Semitism and hostility to Israel. In fact, Breivik had no special devotion to Jews (he described the United States as having a \"Jewish problem\") and supported Israel principally because it is a victim of and ally against jihad; in his manifesto he expresses admiration for Jews who shared his anti-jihadist sentiments, but denounces Jewish multiculturalists, imploring his readers to \"learn the difference between a nation-wrecking multiculturalist Jew and a conservative Jew.\"\n\nSo intense was the effort by the Norwegian cultural elite to link Breivik with Jews and with Israel, however, that Norwegian Jews were seriously concerned about blowback. \"If the Norwegian public is looking for a larger villain than Breivik,\" reported Weisler, \"Jews here [in Norway] are worried that Zionism and pro-Israel organizations may be singled out.\" Weisler quoted a chemistry professor who noted that in Norway, supporters of Israel are demonized: \"The Jews . . . have a lot of friends in Norway, but the Norwegian politicians are not our friends.\"\n\nAs if to underscore this point, the news came on July 26 that Norway's ambassador to Israel, Svein Sevje, had chosen to draw a distinction between the massacres in Norway and terrorist attacks by Palestinians in Israel. In an interview with the Israeli newspaper Maariv, Sevje said that while Breivik \"had an ideology that says that Norway, particularly the Labor Party, is forgoing Norwegian culture\"\u2014an ideology that Sevje plainly considered absurd\u2014terrorist attacks by Palestinians in Israel were caused by Israel's occupation of Palestinian land. In other words, Israelis were responsible for the terrorism inflicted upon them; Norwegians weren't.\n\nThree days later, Michal Rachel Suissa of Norway's Center against Anti-Semitism sent out an alarming bulletin that began: \"We are experiencing a macabre attempt to gag the opposition and a uniformity of debate by means of a tendentious representation of a person whose mental illness, directly or implicitly, is claimed to be the responsibility of the 'right.' \" After the atrocities of July 22, she noted, NRK and other media had lost no time in \"identify[ing] the political opposition in this country as both direct and indirect accomplices in terror and mass murder\"\u2014and in the days that followed had intensified this effort.\n\nThe message we others have received is clear: in the name of the new free speech, no one in Norway from now on will be able to dare to remind anyone that since September 11, 2001, the world has been subjected to more than 17,000 terrorist attacks, almost all carried out in Allah's name. This fact is no longer a part of the politically correct \"truth.\"\n\nSuissa expressed concern that if the media succeeded in their effort to impose this new \"politically correct 'truth' \" and to make the murderer the face of the Norwegian political opposition, \"Norway will emerge as the one-party state that some of the participants in the debate have shown that they admire.\" This state of affairs, Suissa enjoined her readers, obliged Norwegian Jews \"to be on guard against all tendencies to engage in the 'blame game' and in the apportioning of guilt. We know all too well that when the game is over, we Jews can risk being blamed for this, too.\" (Indeed, by the time Suissa voiced her concern, Ellie Merton, the chair of the Waltham Forest Palestinian Solidarity Campaign in Britain, had already publicly called Breivik's massacre \"an Israeli government-sponsored operation.\")\n\nEven as the Norwegian cultural elite strove to link Breivik to Christianity and Israel, it sought as well to use his atrocities to reimpose the ideological control that had lately been slipping away from them. Politicians, authors, academics, and journalists alike put forth the idea\u2014unargued, as if it were self-evident\u2014that the proper way to respond to the atrocities of July 22 was to drop all of the problems with current Norwegian immigration and integration policies down the memory hole and embrace Islam without qualification.\n\nDuring the days after the atrocities, the Norwegian TV news showed leading politicians and other prominent figures making pilgrimages to mosques and hugging imams. On July 26, for example, Crown Prince Haakon, the heir to the throne, participated in a memorial service for Breivik's victims at the World Islamic Mission, along with Oslo bishop Ole Christian Kvarme, Oslo mayor Fabian Stang, Minister of Children, Equality and Social Inclusion Audun Lysbakken, U.S. ambassador Barry White, and Foreign Minister Jonas Gahr St\u00f8re, who recited from the Koran. The message clearly being conveyed by this display was that any concerns about the loyalty of some Muslim leaders to Norway\u2014however much evidence there might be to back up those concerns\u2014were now inoperative, and to fail to abide by this new order of things would be received as a betrayal of the memory of all those young people who had died on July 22.\n\nWhile they were being cozy with imams, moreover, Norway's cultural-elite types were simultaneously encouraging their countrymen to turn on the critics of Islam. In other words, even as a sermon of universal love, harmony, and solidarity was being preached in the Norwegian media, the message was being sent out that certain persons\u2014namely, all those who had ever dared to criticize Islam\u2014were henceforth to be excluded from this glorious new circle of love. Imams, whatever their positions on forced marriage, female genital mutilation, the execution of homosexuals, and the systematic subordination of women, were now officially considered to have been washed clean in the blood of the victims of July 22.\n\nMeanwhile those who had criticized Islam, however legitimately concerned they might be with the denial of basic human rights and individual liberties within Muslim communities, had been deemed officially anathema. They were Islamophobes\u2014racists, bigots, extremists. They were the danger. They were the threat. They had fertilized the soil in which the mass murderer had grown.\n\nIn short, because one maniac had gone on a murderous rampage, Norwegians were expected to forget everything they knew about their country's immigration and integration fiascoes, and to drown all the facts in a sea of love\u2014and retribution. The premise was entirely illogical\u2014it was, in fact, sheer madness. But such was the atmosphere of intimidation that hardly anybody in a position to be heard dared challenge it openly.\n\nMost foreign observers, not being fluent in Norwegian, missed this story entirely. \"Even in their deepest sorrow,\" wrote Anna Reimann in Der Spiegel, \"the Norwegians don't get hysterical. They resist hate. It is amazing to see how politicians and the whole country react. They are sad to the deepest thread of their souls. They cry in dignity. But nobody swears to take revenge. Instead they want even more humanity and democracy. That is one of the most remarkable strengths of that little country.\"\n\nI have no trouble believing this to be essentially true of the Norwegian people as a whole, for whom I have a great deal of affection and respect. But the political leaders? The national media? The professoriat? In the wake of the murders of July 22, as we shall see, all too many members of the Norwegian cultural elite made use of this atrocity as an opportunity to launch personal attacks against their longtime ideological adversaries\u2014whom they unhesitatingly linked to the perpetrator of these unspeakable crimes.\n\nOf course it is a common practice on the far left, not only in Norway but elsewhere, to use guilt by association to smear one's opponents and delegitimize their views, even as one hypocritically refuses to \"jump to conclusions\" in obvious cases of Muslim fanaticism. For years one element of politically correct leftist orthodoxy has been that it is unfair to suggest that the \"root cause\" of acts of jihadist terrorism has anything to do with Islam or the contents of the Koran. Such argumentation is simply not permissible in politically correct circles\u2014not even if a terrorist shouts \"Allahu akbar\" as he shoves a knife into someone's throat, sets off explosives, or drives a plane into a building.\n\nNo, one must never connect such acts to Islam; if one dares to mention Islam at all, one must be sure to echo the mantra that the terrorist has \"misinterpreted\" his religion\u2014even if thousands upon thousands of other terrorists have \"misinterpreted\" it in precisely the same way, and even if untold numbers of their co-believers around the world have taken to the streets to cheer their terrorist acts because they, too, are guilty of theological \"misinterpretation.\" No matter that the Koran, a book presented to the world by Muhammad\u2014a warrior who created the Muslim world through brutal armed conquest\u2014actually does call on believers to use violence to expand the rule of Islam.\n\nFor an example of this stubborn refusal to connect the dots, consider the aftermath of the 2009 killing spree at Fort Hood, Texas. A Muslim U.S. Army major and psychiatrist, Nidal Malik Hasan, shouted \"Allahu akbar\" as he gunned down people at the military base, killing thirteen and wounding thirty-two. Evidence abounded that Hasan was a devout Muslim and that this had been an act of jihad: he had written about martyrdom and jihad on an Islamist website; he had posted a Muslim prayer on his apartment door; in conversations, he had expressed sympathy for suicide bombers and complained that the United States was making war on his faith; hours before the massacre, he had given his neighbors copies of the Koran. Yet the media refused to look these facts in the eye. Instead they attributed Hasan's actions to his colleagues' Islamophobia or to fear of deployment in a war zone, or acted as if his motives were utterly inscrutable. Months later an army major suggested in all seriousness that \"we may never know\" why Hasan did what he did.\n\nThen there was Faisal Shahzad, who attempted a car bombing in Times Square in 2010. Though he admitted he had been inspired by al-Qaeda operative Anwar al-Awlaki, New York mayor Michael Bloomberg suggested he may have been motivated by anxiety about the economy.\n\nBut let an Anders Behring Breivik cobble together a \"manifesto\" in which he approvingly quotes innumerable writers, thinkers, and politicians from across the generations who are advocates of peace and freedom and enemies of violence\u2014and then proceed to commit unspeakable atrocities in the name of opposition to jihad\u2014and suddenly a small army of left-wing multiculturalists start arguing that everyone the murderer has ever read shares responsibility for his actions.\n\nSuch irresponsible \"analysis\" is entirely of a piece with the left-wing tendency to jump to conclusions about the supposed propensity for violence on the right and to assume that any domestic American terrorist must by definition be motivated by racism, bigotry, or Christian fanaticism. The shooting in Arizona in which six people were killed and thirteen wounded, including Representative Gabrielle Giffords, was immediately ascribed\u2014by former MSNBC host Keith Olbermann, among others\u2014to Tea Party rhetoric. Sarah Palin was also apportioned a degree of the blame for having published an electoral map with targets placed on certain districts, including Giffords's own in Arizona. It quickly turned out that the perpetrator, Jared Loughner, was a crazed loner who had no politics to speak of and no affiliation with the Tea Party; nor was he a reader of Palin's website. (Needless to say, no apology was forthcoming from Olbermann or his allies on the left.)\n\nTo understand the vehemence with which Norway's left-wing cultural elite, headquartered in the Labor Party, sought to crush its enemies after July 22, it will help to go over a bit of history.\n\nThe Labor Party, it should be mentioned at once, is not just Norway's largest party. Ever since World War II, it has been first among equals\u2014primus inter pares. During its golden age in the immediate postwar years, it stood alone as the single dominant force in Norwegian politics. It is only a slight exaggeration to say that the Labor Party created postwar Norway\u2014the welfare state par excellence, with extraordinarily high taxes and an extraordinarily large government bureaucracy. (In few other countries does the public sector account for as large a percentage of the national economy as in Norway.) Labor instituted a political system in which the government has, by American standards, a mind-blowing degree of involvement and intrusiveness in virtually every aspect of every individual's life.\n\nToday, though it is no longer the unconquerable colossus it was during the decades after World War II, when Labor prime minister Einar Gerhardsen became known as \"the father of his country,\" and though actual workers (as opposed to public-sector paper-pushers) now tend to prefer the Progress Party, Labor remains unique. It's more than just a party. Government bureaucrats are overwhelmingly Laborites, as are the country's most prominent academics. Under the guise of supporting \"media diversity,\" the government, following a policy set down long ago when Labor reigned supreme, subsidizes a number of left-wing newspapers, including the Communist daily Klassekampen. There is no major conservative daily in the country, and the evangelical Christian paper that comes closest to being one lost its subsidy in 2008. The state television network, NRK, to which every owner of a TV set in the country must pay a license fee (now $460 a year), is widely recognized as a vehicle for Labor Party propaganda.\n\nThen there's LO (Landsorganisasjon i Norge, or Confederation of Trade Unions), Norway's answer to the AFL-CIO, with just under nine hundred thousand members in a country of fewer than five million. Though LO is officially nonpartisan, and though Norway's working class has increasingly recognized over the years that Labor's policies are not necessarily in its best interests, LO is intimately tied to the Labor Party\u2014an alliance that affords the party an immense advantage, pecuniary and otherwise, over its competitors. (The island of Ut\u00f8ya was, in fact, a gift from LO to the Workers Youth League. I do not know of any other islands given to political parties or their youth groups by LO.)\n\nThe attitude of many Labor loyalists toward their party is demonstrated by an exchange I had with a friend of mine one day when I'd been living in Norway for about a year. I ventured a mild criticism of the Labor Party; he was outraged. \"The Labor Party built this country after the war!\" he exclaimed angrily. \"We owe everything to the Labor Party!\" I was stunned: I'd known a lot of fervent political types back in the United States but had never heard any American talk this way about any political party. This wasn't the way people in a democracy talked about political parties; this was Soviet-style thinking.\n\nMany people outside of Norway have been puzzled, even shocked, by the very idea of a Labor Party youth camp. It should perhaps be explained that all of the political parties in Norway have youth divisions. They're not like the Young Republicans or Young Democrats. No, this is more like being a Cub Scout before you're old enough to be a Boy Scout. Or perhaps it makes more sense to compare the youth divisions to farm teams. In any case, these groups are very closely tied to their respective parties, and their members come into frequent and close contact with party leaders. Indeed, the leaders of these youth divisions are already active in real party politics: the head of a party's youth division at the county level, for example, automatically receives a seat on the party's county board. Thus a kid who joins the Workers Youth League, say, at age fourteen can make a smooth transition into a political career without any experience whatsoever of any kind of adult life other than politics. One of the things that make American politics look so alien to Norwegians is that people who have spent most of their adult lives in business or banking (or the movies) can become governors and presidents. Instead of finding this an admirable example, they mock it as typical of American unseriousness and fatuity.\n\nThere are other radical differences between American and Norwegian politics. In the United States, the two major political parties have their platforms and daily \"talking points,\" but at bottom (as the presidential primary campaigns demonstrate every four years) they're grab bags of individuals with a range of opinions and ideas; in Norway, with the conspicuous exception of the Progress Party, each of the seven or eight major parties is a group of people who are expected to be exceedingly loyal to the party line. In the United States, voters can choose among their parties' candidates in primary elections; in Norway, each party draws up its list of candidates, and you can either vote for the names listed on your party's slate or go elsewhere. No wonder, then, that meetings of Norwegian party youth groups are essentially indoctrination sessions: here's the party line, kid; if you want to become a successful politician in our ranks, learn to argue for it effectively. The aspiring politico who has fresh ideas and thinks for herself is not especially welcome.\n\nBreivik's targeting of Ut\u00f8ya was no accident, of course. He sees the Labor Party as the national headquarters for \"cultural Marxism,\" multiculturalist thinking, and the appeasement of Islam. In his manifesto he complained particularly about Labor's protective stance toward \"extreme Marxist movements\" such as Blitz, which has committed acts of vandalism at the Norwegian Parliament and at the government office building that Breivik bombed, but which still receives government support. Breivik recalls \"crackdowns on right-wing youth movements\" when he was young: \"The police raided them several times, called their parents and invested a lot of resources on [sic] squashing the right-wing movement all over Norway.\" Yet a far-left group like Blitz, which is \"often referred to as the 'storm troops' of the Norwegian Labour Party,\" receives public funds: the government subsidy for the building in which Blitz has been squatting for years amounts to \"more than 3 million USD per year alone. The violent Marxist group 'SOS Rasisme' receives 2\u20133 million NOK annually.\" That Breivik is a mass murderer does not make these facts any less true, or any less deplorable.\n\nLabor, to be sure, is not Norway's only major party of the left. Many Laborites, who were fonder of the Soviet Union than of the United States, opposed Norwegian NATO membership so strongly that, in 1961, they formed the Socialist People's Party, the forerunner of today's Socialist Left Party (which is part of Norway's current ruling coalition, and which still despises NATO and the United States). Others who also considered Labor insufficiently radical established the Arbeidernes Kommunistparti (marxist-leninistene), a Maoist party that promoted communist dictatorship, in 1972. This party, known familiarly as AKP (m-l), fielded candidates in elections via the R\u00f8d Valgallianse (Communist Party), which was formed in 1973 and was the forerunner of today's R\u00f8dt (Red) party.\n\nThough AKP (m-l) and the R\u00f8d Valgallianse were small parties, they included among their members many men and women who were, or who would become, influential writers, academics, journalists, and politicians. One former head of AKP (m-l) is Aslak Sira Myhre, who now runs Litteraturhuset, a major institution in Oslo that hosts lectures and other cultural and political events. Another former party head is Sigurd Allern, who went on to become Norway's first professor of journalism. A previous leader of the R\u00f8d Valgallianse, Hilde Haugsgjerd, is Allern's ex-wife and is now editor in chief of Aftenposten, which is generally regarded as Norway's newspaper of record and has traditionally been considered its most conservative major national daily. Kjersti Ericsson, head of the AKP (m-l) from 1984 to 1988, is now a professor of criminology at the University of Oslo and the author of dozens of books. Celebrated novelist Jon Michelet is a card-carrying communist, as is his daughter, Dagbladet columnist Marte Michelet, who once ran the youth division of the R\u00f8dt (Communist) party and whose Iranian-born fianc\u00e9, Ali Esbati, works for Manifest, a far-left think tank.\n\nAnd let's not forget revered \"peace researcher\" and founder of the discipline of peace studies Johan Galtung, a passionate admirer of Mao and booster of the Cultural Revolution. (When Galtung was presented with a prestigious award in early September, he delivered an acceptance speech in which he compared Norwegian soldiers in Afghanistan to Anders Behring Breivik.)\n\nThe list goes on. In Norway, in short, being an ardent supporter of left-wing totalitarianism is no impediment to becoming a respected and powerful member of the cultural elite.\n\nWhat of Norway's purportedly non-socialist mainstream parties? They differ with the socialists on some issues\u2014the Conservatives represent big business, the Christian People's Party advocates for churchgoers, the Liberals are green, the Center Party speaks for farmers and the provinces. But none of them opposes the welfare state and big, intrusive government in any serious way, and none of them makes any serious effort to exclude out-and-out totalitarians from public debate. And for a very long time, none of them challenged the government's disastrous multicultural approach to immigration from the Muslim world.\n\nFor years, then, multiculturalism reigned unquestioned in Norway. The situation was essentially the same, of course, throughout most of Western Europe. Immigration from the Muslim world proceeded apace, and though it became increasingly clear that integration was not taking place as expected, the pressure not to say anything was overwhelming. In 1968, British Conservative MP Enoch Powell became anathema overnight after giving his \"Rivers of Blood\" speech. He was a distinguished classical scholar who had once been the youngest professor in the Commonwealth, and an honored military man who during the war rose from private to become the youngest brigadier in the British Army; yet after his speech, in which he cited the concerns of a great many ordinary British citizens about the influx into their country of immigrants who did not share and did not want to share their values, his name became synonymous with racist hatred, and he was ejected from the Shadow Cabinet. (It was, admittedly, misguided of him to focus in his rhetoric on race rather than on the differences in culture and values that, as the substance of his speech makes clear, were plainly his real concern.)\n\nFor decades, hardly anyone in Europe dared follow in Powell's footsteps. Immigration was debated, if at all, in the most careful and euphemistic ways; it was de rigueur to refer to Muslim immigrants in an enthusiastic tone as \"our new countrymen\" (even if they despised the values of their new country) and to congratulate them for having enriched Europe by their presence (even if they had, in fact, been bleeding it dry by collecting massive welfare payments ever since their arrival).\n\nThe advent of the Progress Party changed all that. Founded in the 1970s by people fed up with sky-high taxation and devoted to individual rights, it is a classical liberal party that questions some of the fundamental assumptions of the social-democratic welfare state. It calls for lower taxes, a smaller government bureaucracy, stronger U.S. ties, support for NATO and Israel, reduced payments to the UN, and a more responsible approach to foreign aid (much of which currently goes into the pockets of African autocrats).\n\nIt also supports major immigration and integration policy reform. Though it believes in easing restraints on labor immigration, it does not support immigration by persons who are obviously going to go immediately onto Norway's welfare rolls. It also calls for a halt to the notorious \"fetching marriages\" whereby Norwegian Muslims wed their cousins abroad so as to provide the latter with Norwegian visas\u2014a practice that has crushed hopes of integration and also robbed so many individuals in the Muslim community of their freedom.\n\nIt is, in short, the only party that considers individual liberty more important than welfare state solidarity, and its positions have struck a chord with many ordinary Norwegians, who turned this once-small and isolated group into a major party. (For some years it was the second largest in parliament; in the days before July 22, it was third.) Many of its rank-and-file supporters are former members of Labor\u2014once the party of industrial workers, now largely a party of government bureaucrats whose main interest is in preserving the sprawling bureaucracy on which they thrive.\n\nHow did Norway's cultural elite respond to Progress Party's rise to power? Two words: sheer panic. Though perfectly willing to welcome into its ranks supporters of Mao and Stalin, the cultural elite consistently attempted to paint the Progress Party as a gang of dangerous extremists. All the major mainstream parties went along with this effort and joined in vilifying the Progress Party as unserious, irresponsible, \"populist,\" far right, and racist. This rhetoric, moreover, was picked up around the world by journalists who, utterly ignorant of Norwegian language and politics, simply echoed their sources in the Labor, Conservative, and other parties. (Not long ago, for instance, the Daily Telegraph labeled the Progress Party a \"fringe group\" and suggested its platforms were \"neo-Nazi.\") The fact is that on the American political spectrum the Progress Party would fall somewhere to the left of the Republican center. In any event, for all the vilification and demonization over the years, the party's enemies failed to vanquish it.\n\nNor could they silence a new willingness by many Norwegians, both in and outside the Progress Party, to speak home truths about Islam and multiculturalism. Over the last decade or so, as 9\/11 and later acts of jihad served as reminders that Islam was not all sweetness and light, and as the baleful consequences of multicultural policy in Europe reached such critical proportions that they could no longer be denied, the critics of Islam and of multiculturalism found their voices\u2014and found an audience. Parties that questioned the multicultural experiment won voters. In the months before July 22, the leaders of Western Europe's three largest countries, Angela Merkel, Nicolas Sarkozy, and David Cameron, pronounced the failure of multiculturalism. The multiculturalists, who a decade ago had held total sway over public opinion, were now on the defensive, the tide turning against them.\n\nAnd they were livid. In recent years, as they saw it, too many flowers had bloomed. Voices that dissented from the official consensus\u2014a consensus long set by them\u2014had multiplied. And this, as they saw it, was dangerous. It was sheer \"populism\"\u2014a phenomenon that in the view of elite Norwegian circles is a very, very bad thing. Part of the job of a left-wing cultural elite, they believed, was to protect a country from the boneheaded beliefs, attitudes, and prejudices of many members of the general public. In their view, America's whole problem was that the opinions of ordinary people were given too much weight.\n\nThat's not all. In disdaining \"populism,\" Norway's left-wing elite exhibits not only its class prejudice but its fear that the danger of a fascist resurgence is always lying just below the surface of the civilized, orderly society it has created. What today's left, not just in Norway but all over Western Europe, actually wants is to separate the socialist and nationalist aspects of fascist ideology, salvaging the one and jettisoning or suppressing the other.\n\nNorway's cultural elite, in short, didn't see the rise of the Progress Party as a positive, democratic development, a case of a party gaining power because it honestly and effectively represented the views of its supporters. No, they saw the Progress Party as a group of protofascists who were cynically exploiting fear and prejudice to gain power. Implicit in the elite view of these matters, obviously, is that ordinary people are too stupid to be trusted with democracy. Of course, in its contempt for the idea of government of the people\u2014as well as its distaste for American-style liberty\u2014the European elite is very much in sync with the Islamists, just as it was, before the fall of the Berlin Wall, very much in sync with Soviet communism.\n\nSo things stood as of July 21, 2011. And then along came Anders Behring Breivik. After countless acts of terror in the name of Allah, one Norwegian man had taken violent action against multiculturalism\u2014and thereby handed the multiculturalists a remarkable opportunity to regain the power that had slipped away from them in recent years and to vanquish those who had eroded their authority. With a single day's evil work, Breivik provided the multicultural left with the means to wrest back their power\u2014by linking their political opponents to the mass murderer.\n\nThe world has rarely seen such callousness so cynically disguised as a sensitive concern for social harmony.\n\nThe multiculturalists acted\u2014and with lightning speed. They lost no time in turning Breivik's actions to their advantage, brazenly maintaining that because he had opposed multiculturalism and the Islamization of Europe, everyone else who held such views also bore a share of the responsibility for his monstrous actions\u2014unless they repented now. The only proper response to Breivik, the Norwegian people were told in TV interviews and newspaper op-eds, was to reject criticism of Islam and accept multiculturalism wholeheartedly. Only in that way could they truly defeat Breivik\u2014and only in that way could they remove any suspicion that they, too, harbored the ugly prejudices that infected the murderer's soul.\n\nIt was an absurd line of argument, but\u2014to an amazing extent\u2014it worked. To understand why, we need to look at the kinds of ideas on which Norwegians have been nurtured throughout the modern era.\n\nThree weeks after Breivik's atrocities, on August 12, an article in Dagsavisen paid tribute to the Norwegian philosopher Arne N\u00e6ss, who died in 2009 at age ninety-six. N\u00e6ss was a rarity among philosophers, in that his was, during his lifetime, a household name in his own country. More than that, he was widely beloved (or at least was represented in the media as being widely beloved), for he was seen as having articulated the authentically Norwegian view of life\u2014good-hearted, great-spirited, nature-loving, and supremely unpretentious (and proud of it). It would not be unfair to call him \"the philosopher of niceness.\" In the Dagsavisen article in question, Truls Gjefsen recalled with admiration that during the Nazi occupation, N\u00e6ss had publicly criticized the Norwegian Resistance for stirring up hatred against Germans. Instead of treating the enemy as, um, the enemy, N\u00e6ss insisted, resistance fighters should be \"polite,\" \"friendly,\" and \"respectful\" to the occupiers, and should try to put themselves in the Nazis' shoes. After all, Nazis were people, too.\n\nAs Gjefsen summed it up, N\u00e6ss believed in \"the good in people.\" Gjefsen (who didn't explain how to reconcile N\u00e6ss's wisdom with the deportation of Norwegian Jews to death camps) proposed that Norwegians today, in the wake of July 22, should learn from N\u00e6ss's attitude toward the Nazis. Gjefsen didn't mean\u2014heavens, no\u2014that the left should stop demonizing the Progress Party and critics of Islam. What he meant was that everyone should shut up about Islam, link arms with people who, if given the power, would oppress or even kill them, and join in choruses of \"Kumbaya.\" (Gjefsen didn't seem to realize that he was implicitly accepting the idea, ordinarily anathema in the pages of Dagsavisen, that Islam can indeed legitimately be compared to Nazism, and that some Muslim leaders in Norway share certain traits with German officers who were stationed in Norway during the occupation.)\n\nGjefsen's article underscored a salient fact: that all too many members of the Norwegian cultural elite are inclined, like Arne N\u00e6ss, to be passive in the face of totalitarian tactics, and to attack those who dare to stand up to them. These multicultural elitists, who have elevated being \"nice\" to the status of an absolute moral principle, feel perversely compelled to befriend terrorist groups that target civilians and children and to give Nobel Peace Prizes to murderers. Also like N\u00e6ss, they tend to confuse this cowardice with a virtuous love for their fellowman.\n\nOnly to the untutored eye do these seem like contradictions. As we shall see, these and certain other ideas form the core of an ideology of politically correct leftism that appears to have first taken root in Norway in the years after the war, and that has now, mainly through the medium of universities and elite communications media, spread throughout the educated classes of Western Europe and North America.\n\nOne of this movement's core ideals is the exaltation of \"peace\" over all other values\u2014including freedom, which Americans consider the core ideal of their own political philosophy.\n\nTo live in Norway is to constantly hear Norway referred to as the \"peace nation.\" The country's cultural elite encourages Norwegians to be proud of the Nobel Peace Prize and of their country's role in international peace negotiations. And it has sought to foster a national self-image founded in the idea that, as former prime minister Gro Harlem Brundtland once famously put it, \"It is typically Norwegian to be good.\" Though most Norwegians have long since given up religious belief, deep down inside many of them, especially in the cultural elite, is, as I have suggested, an inner Lutheran\u2014a stiff-necked, holier-than-thou moralist missionary imbued with an overweening, unconscious condescension toward members of the lesser races, whom they are eager to help \"save\" in order to revel in their own virtue. (A leading embodiment of this principle is the insufferably pietistic and self-righteous Kjell Magne Bondevik of the Christian People's Party, an ordained minister who served two terms as prime minister between 1997 and 2005.)\n\nI have never seen a country's elite make more of a spectacle out of its foreign aid and charity efforts. Polls have shown that no people in the world have more faith in the United Nations as a promoter of international peace and goodwill than Norwegians do. (I blame this less on the Norwegian public, however, than on their media, which present them with an absurdly glowing picture of the UN.) Nowhere in the world, moreover, is peace studies taken more seriously than in Norway, where Johan Galtung, the aforementioned Maoist \"father of peace studies,\" is a veritable secular saint. This is, note well, a man who has said that the destruction of Washington, D.C., would be fair payback for American arrogance, who has praised Castro's Cuba for \"break[ing] free of imperialism's iron grip,\" who has mocked the West's preoccupation with \"persecuted elite personages\" such as Solzhenitsyn and Sakharov, and who has argued that while Mao's China was \"repressive in a certain liberal sense,\" it was \"endlessly liberating when seen from many other perspectives.\" In a commentary posted on August 29, French blogger Diane Berbain described an initiative that Norway's Anti-Racist Center had begun some months earlier and that (as I can attest) had been promoted ever since in splashy ads all over the public transit system in Oslo. The idea was simple: in order to overcome intercultural friction, non-Muslims should meet their Muslim neighbors over a cup of tea. \"After the murders of July,\" wrote Berbain, \"the 'Tea Time' crystallized all of the Norwegians' desires for harmony and for redemption.\" In her view, this harebrained scheme was a typical example of \"the cheerful nihilism of Norwegians\"\u2014a \"nihilism lite\" whose adherents, uneasy with social friction or debates about values, prefer to go with the politically correct flow, seeking only comfort, convenience, and unity (or a pretty illusion thereof).\n\nThis doesn't describe all Norwegians\u2014far from it\u2014but Berbain was on to something. America is a country of people from wildly different backgrounds\u2014E pluribus unum; Norway, until recently, was extraordinarily homogeneous ethnically, culturally, and religiously. Norwegians were like each other\u2014and they liked being alike. (One of the many strange things that I noticed during my first months in Norway was that when Norwegian audiences applaud, they applaud in unison: the sound of a Norwegian audience clapping is utterly unlike the sound of an American audience clapping.) Being different was not encouraged\u2014and being better at anything other than sports not only went unrewarded; it was often actively punished. (In 1933, this national pressure for conformity was given a name\u2014the \"Jante Law\"\u2014by novelist Aksel Sandemose, who codified it, in part, as follows: \"Don't think you're anything special. . . . Don't think you're smarter than us. . . . Don't think you are more important than us.\")\n\nHow to respond, then, to an influx into Norway of people so different from Norwegians in so many ways? On the one hand, Norwegians are not, by nature, comfortable with difference; on the other hand, they're also deeply uneasy about serious conflict. For years, while immigration proceeded apace, they chose conflict avoidance, keeping their heads down while the multiculturalists called the shots. Gradually, though, as I've noted, they began to stand up against looming differences they perceived as dangerous. The events of July 22 unsettled them profoundly, however, and when the cultural elite decreed that the appropriate Norwegian response\u2014the \"nice\" response\u2014to these atrocities would be a return to good old Norwegian unity and a papering over of differences, many were quick to acquiesce.\n\nTo a great extent, this response seems to have reflected a deep-seated need to believe, with Gro Harlem Brundtland, that \"it is typically Norwegian to be good.\" Earlier incidents had shown that when something happens to shake Norwegians' sense of their own virtue, the result is an earthshaking display of \"love\" and togetherness\u2014and uniformity\u2014by a constitutionally aloof people ordinarily not inclined even to smile at one another on the street or to say \"please\" when ordering a drink.\n\nCase in point: in 2001, not long after I moved to Norway, a neo-Nazi killed a Muslim teenager named Benjamin Hermansen in the Oslo neighborhood of Holmlia. Over the years a number of Norwegian teenagers have been killed by Muslims, but none of these murders has occasioned the kind of seismic reaction that Hermansen's death did\u2014for none of them made Norwegians feel as if their own goodness as a people had been called into question. After Hermansen's murder, massive candlelight processions were held across the country; the one in Oslo drew forty thousand people. The motive of these demonstrations was not only to express sympathy with the victim and hostility to the murderer, but to reassert Norwegian virtue, to make the statement: \"See? The murderer was Norwegian, but he didn't act in our names! We're good!\"\n\nNorway wasn't the only Western European country to lurch to the left after World War II. But in Norway the shaping of the \"peace country\" image, the notion of intrinsic Norwegian goodness promoted by the likes of Arne N\u00e6ss and Gro Harlem Brundtland, can be understood as a reaction not just against the wartime collaboration with Nazi brutality but against the inner Viking. What was so threatening to many left-wing Norwegians about the killing of Benjamin Hermansen, and what was many times more threatening about the atrocities of Breivik, is that these murderers seemed like the very personification of the inner Viking, that creature who would seem, in the view of many of them, to have always been threatening to arise out of the evil depths of \"nice\" Norway's national soul. To the collective-minded Norwegian, Breivik was a disconcerting phenomenon not only because he managed to do so much harm, but because his very existence seemed to give the lie to the myth of distinctive Norwegian goodness. And indeed that was how he presented himself in his manifesto\u2014as a rebel against the Labor Party image of what it means to be a Norwegian. He was a knight, resurrected out of the mists of the past, to lead a new generation of Viking warriors in a crusade against everything Gro and Arne stood for.\n\nRather than facing this challenge squarely and honestly, however, the multicultural left chose to account for Breivik in other terms: as the carrier\u2014and victim\u2014of a foreign infection, an ideological bacillus from without, imported by reactionaries, populists, conspiracy theorists\u2014and Jews.\n\nII\n\nThus far I have spoken a good deal about the cultural elite\u2014the left-wingers, the multiculturalists. But a better name for them\u2014especially in Norway\u2014would be Quislings. I am aware that this term is likely to strike the members of the Norwegian governing and media elite as highly insulting. That is precisely how I mean them to take it. And I will prove my case in the pages that follow.\n\nThe original Quisling was a Norwegian official who welcomed the Nazi occupiers during World War II and whose name, after the war, became synonymous with treason, collaboration, and appeasement. The New Quislings similarly welcome a new breed of totalitarian occupiers\u2014and seek to impose their own regime of ideological orthodoxy, ruthlessly using every tool at their disposal to silence their critics. What's more, they are in many cases the direct descendants of the ruling elite that followed Quisling during the war.\n\nWho was Vidkun Quisling?\n\nBorn on July 18, 1887, into an old and distinguished family in the county of Telemark, the son of a Church of Norway pastor, Quisling spent his teens in Skien (famous as the hometown of Henrik Ibsen). An exceptional student, he earned the top score on the entrance examination for the Norwegian Military Academy and graduated with unprecedentedly high scores from the Norwegian Military College. Joining the General Staff of the Norwegian Army at twenty, he was dispatched after the Bolshevik Revolution to Russia, where he admired the new rulers' control over their subjects, comparing Lenin's regime favorably with the more democratic government of Alexander Kerensky, which the Bolsheviks had so handily dispatched.\n\nLike many members of today's Norwegian elite, Quisling was, in a seeming paradox, a sincere humanitarian who at the same time admired autocracy and disdained individual liberty. In the 1920s he worked closely with Fridtjof Nansen, one of the true Norwegian heroes of the twentieth century, to try to ease the impact of the famine in the Ukraine. (Nansen considered Quisling's contribution vital to his efforts.) After living for a while in Paris\u2014where he developed a political philosophy, drawing on both Christianity and modern science, that he called Universism\u2014Quisling, who by now had left the army as a major, returned to Norway and joined the communist movement. Largely owing to his intense nationalism, his sympathies for communism soon soured, and in 1929 he founded a quasi-militaristic political organization, Norsk Aktion (Norwegian Action), modeled on the French fascist group Action Fran\u00e7aise. When Nansen died in 1930, Quisling suggested that Norway would best honor Nansen's legacy by focusing more on racial identity and instituting a strong government; not long after, serving as defense minister in an Agrarian Party cabinet (1931\u201333), the now firmly anti-Soviet Quisling called for war against the communists and for a ban on left-wing parties. And on Constitution Day 1933 (May 17), Quisling and a colleague formed a national-socialist party, Nasjonal Samling (National Unity), or NS, which was notable not only for its Nazi-like focus on the importance of a strong leader but also for its heavy emphasis on propaganda and for the strong support given to it by many members of the Oslo upper classes\u2014the denizens of the capital's posh west side.\n\nThis is a detail worth pausing over, because if one were to accept the received wisdom in Norway\u2014namely that the country's current left-wing elite is ideologically the polar opposite of Quisling and his NS\u2014it would seem more than a little puzzling that the leading lights of the present elite hail disproportionately from that same neighborhood. How, one might ask, could it be possible that the children, grandchildren, and great-grandchildren of people who may have supported Quisling during the war went on to fill the ranks of their country's postwar\u2014and very left-wing\u2014cultural establishment, the power base for the Labor Party and its multiculturalist agenda? Remember that Norway is a traditionally agricultural country whose politics, major media, and intellectual and cultural circles alike have been heavily dominated by a relatively small group of people who grew up on the same streets and went to the same handful of schools. To an American, any party called the Labor Party naturally sounds as if its power base lies in the working class; in today's Norway, however, Labor is the party of the chattering classes and power brokers. In the same way, while one would think that something calling itself the Progress Party would be a vehicle of the left-wing elite, it's in fact a party of the kind of people a certain U.S. president was referring to when he coined the term \"silent majority.\"\n\nAll of which is by way of pointing out that at least one curious aspect of the history of postwar Norway is the fact that many members of the country's contemporary cultural elite were raised in the same neighborhoods that once cheered Quisling. And this, in turn, is perhaps not unconnected to the fact\u2014also often obscured\u2014that Quisling was as much a socialist as he was a nationalist (Nazi, after all, is short for National Socialist), with a political philosophy that drew on both Hitler and Mussolini. Like many members of today's Norwegian elite, moreover, he held Jews in contempt and saw a baleful Jewish influence everywhere. While his effort to compel children to join the party's youth organization intensified public hostility toward him, he met with little resistance when he restored the constitutional ban on Jews in Norway that had been lifted in 1851, and, not long after, in quick succession, ordered the registration, rounding up, confinement in concentration camps, and, finally, deportation of Norwegian Jews.\n\nThe story of Quisling's path to power can be briefly told. When war broke out in September 1939, he and the Nasjonal Samling had already established very firm ties with the German regime. While the Nazis provided the NS with generous subsidies, Quisling provided the Nazis with information on Norwegian defenses. On April 9, 1940, the day the Germans invaded, Quisling became the first person in history to announce a coup on the radio. Hitler waffled, first recognizing his government, then (days later) withdrawing support and appointing a German Reichskommissar, then (two months on) naming Quisling head of government. (In 1942 he was granted even more power and the title of minister-president.) While the monarchy was officially abolished and all parties other than the Nasjonal Samling banned, party membership increased only minimally (indeed, it never exceeded forty thousand), suggesting that Quisling's ruling elite was, like today's, not necessarily representative of the Norwegian people at large.\n\n(It must be added, however, that in Norway, as in other European countries, the extent of wartime collaboration has long been downplayed; a rare honest look at this topic is Jo Nesb\u00f8's recent thriller, Redbreast, a story of elderly Norwegians who fought alongside the Germans and who resent the postwar cultural elite's denigration of what they still regard as having been a patriotic effort.)\n\nQuisling's regime was brutal. Striking workers and communist leaders were arrested, a Gestapo-like national police established, radios confiscated, and opponents of the regime executed. Though he pressed for greater Norwegian independence from Germany, the Germans exercised increasing authority as the war wound down, practicing greater brutality and causing resistance ranks to swell. At his war crimes trial in August 1945, Quisling argued that he had acted in his country's best interests and had fought to keep occupied Norway as independent as possible; but in the end he was sentenced to death (the government-in-exile having instituted the death penalty precisely for this purpose). He was executed by firing squad that October.\n\nQuisling was, naturally, often compared to Hitler, but personally and professionally he seems to have resembled, in many ways, some of the more typical members of today's political establishment in Norway\u2014which is to say that he came off (to many if not all observers) as civilized, dignified, sanguine, moderate, personable, hardworking, and modest and undemanding in his lifestyle. Though the New Quislings do not share his nationalism and his love of Norwegian mythology (while Hitler thought Germans were the master race, Quisling had similar ideas about Norwegians), they do share with him a belief in a strong state and a respect for the power of propaganda\u2014as well as a readiness to demonize Jews. And their apparently sincere tenderness for those they regard as helpless victims (in Quisling's case, the starving Ukrainians; in today's world, the starving Africans and put-upon Muslims) coexists with a pitiless readiness to crush all those whom they perceive as standing in the way of their efforts to translate ideology into reality.\n\nIt is important to note that while most Norwegians out in the hinterlands had little affection for Quisling, many members of the country's wartime establishment were ready enough to fall into line when it suited them. More than a few exulted, in particular, in the Nasjonal Samling's anti-American, anti-British, pro-Nazi posture. Among them was Nobel Prize\u2013winning novelist Knut Hamsun, who shared with a considerable number of his fellow Norwegian writers and intellectuals a contempt for the United States based entirely on reactionary grounds: in his eyes, America was a mongrel country and the wellspring of modern technology, and thus a threat to Norway's ethnic purity and traditional values. During the occupation, the octogenarian author publicly praised the Nazis, sent Goebbels his Nobel Prize medal as a gift, and had an audience with Hitler. (After the F\u00fchrer's death, Hamsun eulogized him as \"a warrior for mankind, and a prophet of the gospel of justice for all nations.\") Hamsun was far from alone. To read wartime issues of Aftenposten and other newspapers is to see politicians, professors, and journalists eager to praise their Nazi overlords, to echo the Germans' poisonous anti-Allied and anti-Semitic propaganda, and to convey the idea that Norwegian culture not only could continue to exist but could thrive under the benign oversight of the occupiers.\n\nYes, there were heroic Norwegian writers and intellectuals such as Sigrid Undset, who had always been a gutsy contrarian and who during the occupation, true to form, traveled around the United States as an eloquent spokeswoman for all of her fellow Norwegians who yearned to breathe free again. And there was a real Norwegian Resistance, whose valiant members deserve to be remembered forever. Indeed, the most successful Norwegian film ever made, Max Manus (2008), celebrates Norway's most famous resistance hero, and its popularity would appear to reflect Norwegians' pride in, and eagerness to identify with, those who stood up to Hitler. But to reside in Oslo during the war was to live in the midst of a cultural and political elite that showed few outward signs of resistance to Nazi tyranny.\n\nThe war's end marked an end to the Nasjonal Samling. Quisling's admirers disappeared quickly into the woodwork; today no name brings more shame to Norwegians than his. He is viewed as the country's single great historical embarrassment. But not everything associated with him and his party disappeared from the scene. Among the nation's cultural elite, the fondness for ideological conformity, the weakness for totalitarianism, and the belief that it is not only necessary but virtuous, in the name of national identity and social harmony, to destroy those who dissent from the party line\u2014which is to say, those who threaten peace and harmony\u2014all this endured, though in a somewhat muted form. Though ordinary Norwegians were, overwhelmingly, genuine lovers of freedom who would always remain grateful to the Allies for having made possible their liberation from Nazi tyranny, the people who came to form the country's postwar cultural elite were disproportionately enemies of America and romantic admirers of tyranny\u2014fans of Mao and Stalin, of Castro and Che, cheerleaders for communism, devotees of a lockstep, severely enforced \"solidarity\" that had little tolerance for independent thought or serious dissent. And those who did not sincerely admire tyranny were feckless appeasers of it.\n\nYet because they were of the left and not the right (though it has always been highly arguable whether a philosophy called National Socialism can be considered strictly a phenomenon of the right), the members of this new elite were viewed\u2014especially once the leftist propaganda had begun to be spread in the schools and official media\u2014as a triumphant rejection of everything Quisling had stood for. Similar political shifts took place across postwar Europe. The right had been discredited; the left was now in power\u2014except that many of the new leaders who presented themselves as heroes of anti-fascism had rather shaky credentials. (Kurt Waldheim, anyone?) In Norway many politically ambitious individuals who had, during the war, been cheerleaders for Quisling found a new and rewarding home on the left. Some may have been driven by shame over their parents' wartime histories and by a sincere need to redeem themselves, their families, and their class\u2014even if not all of them, perhaps, had shaken off all the beliefs and values that had driven their parents to support Quisling in the first place.\n\nThe result of all this is that the leading lights of the postwar Norwegian left, the stars of its cultural elite, proved in their own way to be Quislings, too\u2014only Quislings of the left, not the right. They were the bearers of a new ideology of politically correct leftism that bore significant earmarks of the fascist outlook and its propaganda methods. And the schools and universities, the rhetoric of politicians and the news media (hardly any less slanted, it could sometimes seem, than in Nazi times) passed on this Quisling-like mentality to the children and grandchildren of the nation's elite. The result: a governing class capable of giving a peace prize to Yasir Arafat and of embracing Hamas as a friend and partner.\n\nYes, there were always Norwegians\u2014many of them far from the corridors of power in Oslo, living in remote valleys and on rugged mountain farms where their ancestors had tilled the land from time immemorial\u2014who looked upon such activities with deep suspicion. But they had a long cultural history of shyness and aloofness, of provincial awkwardness, of deference to the educated and supposedly intelligent urban elites who shaped their country's fortunes. Not until the Progress Party came along and spoke for many of them did they find their voices, embrace their power as citizens of a free country, and pose a real challenge to their left-wing leaders in Oslo.\n\nBut then came July 22, 2011. And in the days and weeks that followed, those leaders\u2014the New Quislings\u2014saw their chance to retake the reins of power from people they saw as rubes and yokels, as provincial bigots and the ignorant pawns of \"populists.\" And they acted with a vengeance. In the electronic media and the pages of the newspapers, this was anything but a beautiful new era of love and harmony; it was an inquisition\u2014a time of brutal repudiations and denunciations, of ritual confession and capitulation. People who had been treated as respectable citizens a few days earlier were now being savaged as mentors to a murderer.\n\nIt was a classic example of what might be called the \"germ theory\" of ideological transference, straight out of the old fascist playbook. Unable to rebut opposing arguments using facts and logic, the multiculturalist left stigmatizes its ideological opponents by warning darkly that those opponents' views are \"extreme\" and \"dangerous\" and lead to violence. Such rhetoric, in the days after July 22, seemed to be applied disproportionately to foreigners, to people like me who lived in Norway but had come from somewhere else, and most especially, to Jews and their ideological sympathizers. We \"foreigners\" had introduced a deadly bacillus into pure, good Norway. It was all unsettlingly reminiscent of the anti-Semitic propaganda of the Nazis. The multiculturalists' highly disciplined prosecution of this theory\u2014as well as their effortless mastery of Goebbels-like propaganda techniques\u2014were on full display in the wake of the massacre. Watching Norwegian TV and reading Norwegian newspapers in the first days and weeks after the events of July 22 was a chilling experience for anyone who cherished freedom of speech. Opposition writers, politicians, and editors were now being portrayed by the media essentially as accomplices in the murders in Oslo and at Ut\u00f8ya, and \"interviews\" with them were not really interviews at all. These people were being called on the carpet to account for themselves\u2014to show contrition and to promise to reform. It was like something out of Stalinist Russia\u2014which was no surprise, given that many of the people who were running this inquisition were indeed communists.\n\nSo it was that in the days after July 22, Norway's newspapers and TV and radio news programs rang with mea culpas. Men and women who had criticized Islam or expressed doubts about Norwegian immigration policy or questioned multiculturalism now \"crept to the cross,\" to use a Norwegian expression\u2014meaning that they fell into line, writing articles to indicate that they were on the \"right side,\" and insisting that if they had ever written or said anything to indicate otherwise, they now repudiated it. It was clear that many people in the public eye felt pressured to make a great show, as it was repeatedly said, of \"looking into their hearts\" and \"examining their souls,\" and of admitting to what George Orwell would have called Thoughtcrimes.\n\nIn a piece that was typical of the kind of journalism that filled the Norwegian newspapers in the days after July 22, Roar Helgheim, a journalist for Dag og Tid, recalled on August 12 that when the attacks first took place, he had written that if the perpetrator turned out to be an immigrant or a Muslim, it would be devastating to those in Norway who had been too na\u00efve about the dangers of Islamic terrorism. But the fact that the perpetrator turned out to be \"one of 'us,' \" he wrote, made him think again. Now his view was that the warmth and love that had blossomed in Norway in the days after July 22 had dealt \"a crushing blow to the perpetrator who wanted to destroy diversity and the multicultural Norway.\"\n\nThis was the new meme. But there was no logic in it. To suggest that Breivik could have destroyed \"diversity and the multicultural Norway\" is to make him into something larger than he was. People wrote about Norway's response to Breivik's actions\u2014the flowers and candles, the crowds in the streets\u2014as if it were a calculated political statement. No, it was anything but political: it was a very natural, human, and (as I have suggested) psychologically complex and culturally rooted outpouring of sympathy and solidarity\u2014which certain people then began to exploit politically by carrying out a witch hunt.\n\nLike everyone else, needless to say, I was crushed at the news of the attacks of July 22. But when I learned that they were the work of a native Norwegian who claimed to have acted in opposition to his country's multicultural policies, I was even more devastated because I saw at once what this would mean. Norway, I knew, was now in an even greater danger than before\u2014in danger of losing its chance at a free, secure, and prosperous future. As I wrote in my Wall Street Journal piece, \"to speak negatively about any aspect of the Muslim faith has always been a touchy matter [in Norway], inviting charges of 'Islamophobia' and racism.\" But it would, I feared, \"be a great deal more difficult . . . now that this murderous madman has become the poster boy for the criticism of Islam.\"\n\nThis statement would later come in for harsh criticism from the multicultural left in Norway and elsewhere: how dare anyone speak of such issues at a time like this! But this was not an abstract consideration. This, like the atrocities in Oslo and at Ut\u00f8ya, was a matter of real human lives\u2014perhaps millions of them. For Breivik had committed acts that, thanks to the cultural elite's cynical efforts, would indeed come to be widely seen as discrediting honest and open discussion of Islam, immigration, integration, and multiculturalism\u2014a discussion whose whole point was to ensure that young Norwegians like those kids at Ut\u00f8ya, and even younger Norwegians like my two-year-old nephew in a small town in Telemark, would live their lives in freedom and prosperity.\n\nAnd if those critics protested against the witch hunt, then they were further accused of dishonestly representing themselves as victims of a witch hunt. And, moreover, of rank insensitivity: how dare they represent themselves as being victims, when the real victims were those poor kids at Ut\u00f8ya\u2014and, of course, the Muslims? Instead of representing themselves as victims, the critics of Islam and of multiculturalism were told, they should be looking into their hearts, doing some serious self-searching. (This Stalinist formulation appeared again and again.) How dare they take up such divisive issues as multiculturalism and Islam, thundered the scolds of the left, when the country was so beautifully united in grief? Thus did the New Quislings cynically use the image of a country \"united in grief\" as a pretext to attack and destroy their ideological opponents.\n\nWho, exactly, are the New Quislings?\n\nWell, one of them is a young Dagbladet opinion editor, Simen Ekern, who during the week after the murders wrote a piece headlined \"We can't ignore the ideological mudbath from which this murderer emerged.\" In his piece, Ekern dragged readers into his own slimy mudbath of scurrilous accusation and innuendo. The murderer, he wrote, \"has several role models.\" My name came first; it was followed by several others. Ekern summed us up as \"the new extreme European right.\" He cited, as if in approval, the official government directive that nobody should \"make political hay\" out of the events of July 22\u2014and then proceeded to do precisely that. He claimed that he intended \"to avoid demonizing all criticism of immigration and multicultural challenges\"\u2014then demonized away.\n\nIt was necessary, Ekern argued, \"to take the clear ideological elements of the killer's disgusting project seriously\" and \"to warn against the tendencies to turn the mass murderer into a lone wolf.\" Well, of course\u2014if he's a lone wolf, he's no use as a club with which to batter one's ideological opponents. Ekern proceeded to question freedom of speech\u2014or, as he put it, the \"instinct, in a free society, to air all views.\" Such an \"instinct,\" he declared, \"is a nice thought,\" but a dangerous one, for \"our society is not improved by cultivating ever more 'honest' and 'brave' warlike Crusader rhetoric directed against Islam. . . . Much 'Islam criticism' is . . . screaming dressed up as debate. . . . It is dangerous to spread fear.\"\n\nI would say in response to this slick formulation that it is not dangerous, but salutary, to spread correct information about a genuinely fearful enemy\u2014and that it is evil to demonize people who have done good and important work in the cause of freedom, and to try to exploit the murders of young people to silence debate about an issue of national importance. As a rule, moreover, it is not the Norwegian critics of Islam and of multicultural immigration policies who are engaged in \"screaming dressed up as debate.\" It is Ekern and his ilk who routinely reply to the cogent arguments of their opponents not with serious arguments of their own but with personal attacks (\"warlike Crusader rhetoric\").\n\nBy accusing his ideological opponents of wallowing in an \"ideological mudbath,\" even as he himself proffered nothing but character assassination, Ekern established himself as a worthy member of the New Quisling crowd.\n\nNot content to restrict their efforts to Norway itself, some of the New Quislings exported their scapegoating. Petter Nome, a longtime journalist and host on Norwegian national television who is now (oddly enough) head of the Norwegian Brewers' Association, chose to focus on the fact that Breivik, from 1997 to 2007, had been a member of the youth movement of the Progress Party. In an article charmingly titled \"To You Who Nourished the Killer,\" published on July 25 in the Spanish daily El Mundo, of all places, Nome, like Ekern, refused to dismiss the murderer as a lunatic, purportedly because \"making this a mental issue is a dangerous dead end road\" (yes, a dead end\u2014once again\u2014for those out to make political hay of Breivik's actions).\n\nThough the murderer's views were \"obviously extreme and pervaded with hate,\" Nome maintained, they were \"not obscure nonsense in the mind of a freak. They are all too well present in everyday conversations in streets and pubs\u2014and mainstream politics.\" He then listed several of the murderer's political views, none of which I have ever heard anyone express in a Norwegian street or pub: a desire to \"[r]eplace western democracies with administrative monarchies or republics,\" to \"increase the birth rate in western countries by banning abortion,\" to give \"[m]ore cultural power to the church,\" to put criminals to death \"after three criminal convictions,\" to put drug addicts in concentration camps, and to carry out \"[f]orced reeducation of Marxists.\"\n\nNome noted that Breivik had belonged to the Progress Party and had said that he \"identifies himself with Christian fundamentalism and strongly supports the state of Israel\"\u2014all of which, in official Norway, are of course highly suspicious associations. Nome further observed that Progress Party leader Siv Jensen \"claims she was shocked\" that Breivik had been a party member. \"But,\" asked Nome, \"did she ever carry one single brick to the bridge most of us are trying to build between people and cultures?\" To which I would say: the Progress Party has encouraged immigration by individuals who want to come to Norway to enjoy its freedoms and contribute to its economy; it opposes immigration by people who are hostile to Western values and seek to exploit the welfare state. The Progress Party recognizes that there are certain aspects of certain cultures to which one should not want to build bridges.\n\n(In a magnificent piece of reportage for the Weekly Standard that went online on July 30, James Kirchick exposed the outright lies told by Nome and others about the Progress Party. Kirchick talked with several Muslim members of the party, including Farida Amin, a Norwegian-Pakistani who was drawn to the party by, in her words, \"[i]ts emphasis on assimilation, and its concern for the harsh treatment that many Muslim women in Norway receive at the hands of their male relatives.\" This is the Progress Party I know, and that Nome and other Norwegian socialists have labored so hard to misrepresent and demonize.)\n\n\"Did she ever try,\" Nome thundered, referring to Siv Jensen, \"to make electoral catches [sic; I am quoting Nome's official English version of his text] with her talk about 'islamisation' and 'national' and 'Christian' values?\" Jensen has indeed talked unapologetically about Norwegian values\u2014by which she means things like individual liberty and sexual equality\u2014and about the danger posed to them by cultures in which women are systematically treated as inferiors and threatened with abuse or worse if they get out of line.\n\nThough Nome acknowledged that Jensen and \"most of her colleagues in populist and right wing parties in Europe\" are not supporters of violence, they \"carry profound responsibility for actively creating a climate where hate and violence appear as options for their most impatient followers.\" The Progress Party has not \"creat[ed] a climate,\" however much that may seem to be the case in the eyes of cultural elite types like Nome, who still cannot figure out how the Progress Party has managed to gain so much support and mount a challenge to their power. Rather than \"creat[e] a climate,\" the party has listened to, and articulated, the concerns of very many Norwegian people about a range of issues that the cultural elite long refused to address.\n\nAfter taking a break from his nasty screed to paint a pretty picture of how Norway was, at the moment, \"united in grief and sorrow,\" the streets filled with flowers and candles, Nome added darkly that \"a tomorrow must also come, for the vital questions of responsibility and lessons learned.\" This rhetoric was not only ugly but more than vaguely threatening: today we mourn together\u2014tomorrow comes the reckoning. Wait for the knock at the door\u2014we'll be there soon.\n\nNome's readiness to accuse his ideological opponents of creating an atmosphere of hatred and thereby \"nourishing\" a killer\u2014when in fact they had done no such thing\u2014and to hint at future retribution certainly recalls the kind of rhetoric once served up by the head of the Nasjonal Samling.\n\nOn July 28, two men who are very famous in Norway, novelist Jostein Gaarder and professor Thomas Hylland Eriksen, contributed an op-ed to the New York Times titled \"A Blogosphere of Bigots.\" Rejecting the idea that Breivik was \"an isolated case of pure evil,\" they wrote that \"the hatred and contempt from which he drew his deranged determination were shared with many others throughout the international right-wing blogosphere,\" which they described as consisting of \"loosely connected networks of people\u2014including students, civil servants, capitalists, and neo-Nazis,\" many of whom \"do not even see themselves as 'right-wing,' but as defenders of enlightened values, including feminism.\"\n\nBut those who see themselves as defending enlightened values are wrong, according to Gaarder and Hylland Eriksen. The authors did not take the trouble to explain how this curious business works psychologically\u2014how does it happen that we benighted souls think we are actually liberals concerned about things like human rights, sexual equality, and individual liberty, when in fact we are loathsome far-right bigots? Oh well. The first writer they named as an example of this execrable \"right-wing blogosphere\" phenomenon was me. Saying that the murderer \"has praised writers like Bruce Bawer,\" they characterized me and others as consisting of a \"new right\" in Europe that \"has swapped anti-Semitism for Islamophobia. . . . Traditional racism may actually be waning in several European countries, but hostility toward Islam and animosity toward Muslim immigrants and their children is on the rise.\"\n\nIn a masterpiece of understatement, Gaarder and Hylland Eriksen wrote that \"Norwegian society is changing, and rapid immigration has no doubt led to tensions.\" And in a statement that in any other context would be laughable, and that provides a useful example of the Norwegian habit of using \"immigrant\" as a synonym for \"Muslim,\" they referred to \"[t]he perception that immigrants are patriarchal and insular\"\u2014a \"perception,\" they went on to say, that \"has sparked controversies over everything from school excursions to swimming lessons to disrespect for female teachers.\"\n\nAn interesting sentence, in which the authors, in deft multicultural fashion, neatly avoided explaining what they were actually referring to. For example, \"disrespect for female teachers\" refers to the fact that all too many Muslim boys are taught at home to show no respect for non-Muslim adults, especially women\u2014a state of affairs that results in a great deal of unpleasantness for their female teachers. These \"controversies\" have nothing to do with \"perception\"\u2014they're about hard realities that many Norwegian schoolteachers (unlike, say, celebrity professors) have to deal with every day.\n\n\"Conceding that a culturally diverse society raises knotty and complex social and political questions is one thing,\" wrote Gaarder and Hylland Eriksen in a sentence rife with euphemistic abstraction. \"It is quite another to state that a multicultural society is impossible, or that Islam is incompatible with democracy.\" Tell that to Angela Merkel, David Cameron, and Nicolas Sarkozy, all of whom have declared the failure of multiculturalism. Are they far-right bigots, too?\n\n\"We hope,\" Gaarder and Hylland Eriksen went on to say, \"that Norway's longstanding consensus about immigration and integration policies will not be eroded.\" Consensus? There has been no such consensus for many years, except among elites like Gaarder and Hylland Eriksen. This is precisely why these men were exploiting July 22 to the hilt: it provided a wonderful opportunity to bring the country back into line and take back their power.\n\n\"Until last week,\" Gaarder and Hylland Eriksen concluded, \"Norwegian authorities did not see the far right as a security threat. Mr. Breivik has now shown that those who claim to protect the next generation of Norwegians against Islamist extremism are, in fact, the greater menace.\" This breathtaking last line pointed directly at these men's dark agenda: to convince as many people as possible, not only in Norway but internationally, that the real danger to Norway and other Western countries comes not from jihadists of the sort that carried out 9\/11, London, Madrid, Bali, Mumbai, and innumerable other terrorist attacks in the name of their faith\u2014or from the expansion in Western cities of communities of people whose imams preach the oppression of women, equate Jews with pigs and dogs, and call for the execution of gays\u2014but from writers who dare to warn of these terrible things.\n\nWho exactly, you might ask, are Jostein Gaarder and Thomas Hylland Eriksen? The contributor's note to the Times op-ed identifies the former as \"the author of 'Sophie's World' and many other books\" and the latter as \"a professor of social anthropology at the University of Oslo.\" In fact, these men who are so eager to push the meme that Muslims are Europe's new Jews happen to be two of the vilest anti-Semites in Norway.\n\nIn a now-famous 2006 op-ed for Aftenposten, sarcastically titled \"God's Chosen People,\" Gaarder, writing in the royal \"we,\" consigned Israel to the dustbin of history. Through its actions, he insisted, it had lost its right to exist: \"We no longer recognize the state of Israel. . . . The state of Israel in its current form is history. We don't believe in the idea of God's chosen people. . . . To present oneself as God's chosen people is not just stupid and arrogant, but a crime against humanity. We call it racism.\"\n\nGaarder went on: \"There are limits to our patience and there are limits to our tolerance. We do not believe in divine promises as a justification for occupation and apartheid. We have placed the Middle Ages behind us. We laugh uneasily at those who still believe that the God of the flora, the fauna, and the galaxies has chosen a certain people as his favorites and given them funny stone tablets, burning bushes, and a license to kill.\" (In the Norwegian original, those last three words are in English.) \"We laugh at this people's caprices and weep over their misdeeds,\" he wrote, and suggested that many Israelis celebrate the deaths of Lebanese children just \"as they once cheered the plagues of the Lord as 'fitting punishment' for the Egyptian people.\" He further envisioned \"little Israeli girls writing hateful greetings on the bombs to be dropped on civilian populations in Lebanon and Palestine\" and \"strut[ting] with glee over the death and torment.\" As if it were Israelis who were putting guns into the hands of children!\n\nThere was much more in this vein. To see such a screed in the pages of Norway's newspaper of record\u2014even after decades of Nazi-style Jew-baiting cartoons\u2014was jaw-dropping. Author Mona Levin, perhaps the best-known member of Norway's small Jewish community, wrote that Gaarder's piece was \"the ugliest thing I have read since Mein Kampf.\" But Hylland Eriksen, along with several other high-profile Norwegian writers and intellectuals, rushed to second Gaarder's twisted remarks. Gaarder suffered no negative repercussions for his op-ed; on the contrary, a year or so later I saw his bearded face, two or three feet high, beaming out at me from the side of a bus stop shelter. It was an ad for a children's book club.\n\nGaarder and Hylland Eriksen, in short, are Quislings of the first order, soft-pedaling the menace of Islamic totalitarianism while casting its opponents, liberal and otherwise, as the real threat.\n\nThere was more. On August 1, the Norwegian newspaper VG published an interview with Lars Gule, the former head of the Norwegian Humanist Association and a very high-profile figure in Norway. The headline: \"We need an oppgj\u00f8r with Breivik's 'heroes.' \" I have not translated oppgj\u00f8r because in this context the word can mean anything from \"We need to have a sharp talk with Breivik's 'heroes' \" to \"We need to do something about Breivik's 'heroes.' \" In other words, it can have a very dark meaning\u2014it can conjure images of the Gestapo knocking on one's door in the middle of the night. \"It is obvious,\" said Gule, \"that certain groups, persons, and communities have contributed to Breivik's warped view of reality, and these people need to take a good look at themselves. If not, others must help them.\"\n\nOthers must help them. This sentence immediately summoned visions of Maoist reeducation camps, and its sinister invocation is an authentic mark of the New Quisling. \"For they have contributed,\" Gule went on, \"to an extreme world view that has led this particular person to an extreme act. No one other than Breivik has any criminal responsibility for his actions. But if you run, in a cowardly and pathetic way, from the moral responsibility of having contributed to Breivik's world view, you're out of touch with reality.\"\n\nVG identified Gule as a \"professor and expert on multiculturalism.\" In fact, Gule (born in 1955) is a considerably more colorful figure than that description would suggest, and a man whose career is one that could hardly have happened anywhere but in Norway. In 1977, in his early twenties, he joined the Democratic Front for the Liberation of Palestine, a terrorist group responsible for the 1974 Maalot massacre in which more than one hundred Israeli children were taken hostage and twenty-two of them killed. Gule was delegated to set off a bomb in Israel on the tenth anniversary of the Six-Day War. At the Beirut airport, however, he was caught with 750 grams of explosives hidden in books in his backpack.\n\nHe was imprisoned for six months in Lebanon, then returned to Norway\u2014where he proceeded to enjoy an illustrious career, holding prominent positions at the Centre for the Study of the Sciences and Humanities, in the human rights program of the Christian Michelsen Institute, and at the Centre for Development Studies at the University of Bergen. In 2000, he was appointed general secretary of the Norwegian Humanist Society. During his years in that post he was, not surprisingly, a harsh critic of Israel (which he called a racist state) and a staunch defender of Muslims' right to discriminate against women and gays\u2014this at a time when he was his nation's leading official spokesman for secular values.\n\nOn August 16, another high-profile Oslo figure had his say. Anders Heger is the longtime head of Cappelen, one of Norway's three major publishing houses. He is also a columnist for Dagsavisen, where he described Breivik's rampage as an act of \"violence from the extreme right\" and expressed astonishment that while this violence \"has killed 77 people . . . what people are upset about is that they can't criticize Islam the way they did before.\" He assured readers that \"the political debate will continue\" but added that it would not be the same debate as it had been: \"Nothing will be entirely as before. The debate will be more open and inclusive, and less judgmental.\"\n\nWhy? Heger didn't say. He acted as if this new style of debate were a foregone conclusion, a natural consequence of what had happened on July 22. In fact, this new style of debate was plainly a new Norwegian order that the political and media establishment, led by the Labor Party, was trying to ram down the country's throat in the wake of the atrocities. It was also clear that while the new debate would indeed be \"more open and inclusive, and less judgmental\" of Islamists, it would be decidedly less open and inclusive, and more judgmental, when it came to critics of Islam. Indeed, it was now open season on Islam critics.\n\nHeger noted the calls by Stoltenberg and other political leaders in the wake of July 22 for civility\u2014no one, they decreed, should try to exploit Breivik's actions to score political points or carry out witch hunts. Heger said that this sounded good yet he complained that this enforced civility would make it harder to address xenophobia and intolerance. In other words, should we be civil to bigots, too? His unspoken assumption here was that criticism of Islamic theology amounts to bigotry, to \"hate rhetoric,\" to \"xenophobia,\" to \"contempt for human beings\"\u2014all of which, he said, must not be treated with civility but must rather \"be confronted and fought against.\"\n\nHe made no mention of the fact that it is the theology being criticized by these so-called bigots that is, in fact, rife with bigotry\u2014bigotry toward women, bigotry toward Jews, bigotry toward gays, and others. It has always been a cornerstone of cultural-elite Norwegian thinking to turn a blind eye to the monstrous bigotry that is part and parcel of orthodox Islamic theology; now the cultural elite was seeking to impose this willful blindness upon the entire country\u2014using the events of July 22 as a stick with which to pummel Progress Party supporters, among others, into an ideological retreat.\n\nHeger said that those on the \"extreme right\"\u2014meaning critics of Islam and of current Norwegian immigration policies\u2014viewed themselves as being \"forced into silence\" by the standard-bearers of \"political correctness\" who label all \"legitimate skepticism about immigration\" as racist. Heger dismissed this view even as he confirmed it by his own action of calling these critics \"extreme right.\" As for being \"forced into silence\"\u2014yes, a few years ago it was almost impossible for dissenters from official policy on Islam and immigration to be heard in Norway's mainstream media. More recently\u2014at least until July 22\u2014it was more possible, though in order to be heard, those critics had to deal with abuse by people like Heger, who instead of answering their reasonable arguments with reasonable arguments of their own, chose to demonize them and to depict their concern about real threats to liberal values (such as the equality of women) as far-right racism.\n\nHeger then brought me into the picture\u2014\"[t]he chronically Islam-hating American Bruce Bawer, who for unclear reasons is viewed as an important social critic in large areas of the Norwegian commentariat\"\u2014and quoted from my Wall Street Journal piece: \"It was immediately clear to me that [Breivik's] violence will deal a heavy blow to an urgent cause.\" Heger agreed that Breivik's actions had threatened \"an urgent cause,\" but he claimed that the \"urgent cause\" being threatened was, in fact, \"the open society, a democratic sense of community, social democracy, or diversity.\"\n\nNote how Heger praised \"the open society\" and \"diversity\" even as he was busy dismissing and demonizing an ideological opponent. This is Quisling thinking in a nutshell: they claim to believe, and many of them actually appear to think they believe, in an \"open society\" and \"diversity\"\u2014but it is clear that by these things they mean, in a profoundly Orwellian sense, a society of lockstep support for Norwegian-style social democracy (which they regard as goodness set in system) and a readiness to crush any opposition thereto. Heger sneered when he quoted my prediction that it would be harder to discuss Islam and immigration after July 22, but his entire article only proved me right; his whole point was that if people like me could not be ridiculed and intimidated into staying silent in the wake of July 22, then Norwegians as a whole needed to take action to silence us, in the name of Norwegian virtue and social harmony.\n\nOne of the New Quislings' chief targets was my friend Hege Storhaug of Human Rights Service, who has devoted most of her adult life to the struggle to secure greater individual liberty and a higher quality of life for Muslim women and girls in Europe. On July 27 she was invited to call in to the NRK news interview program Dagsnytt, which is broadcast simultaneously on television and radio. Hege's fellow participants, she was told, would be Per Fugelli, who had already blamed the Progress Party in part for the murders, and Magnus Marsdal, a young communist who had written a witheringly snide book about the Progress Party. (Marsdal exemplifies a true only-in-Norway situation: the classical liberal Progress Party receives about twenty to forty times as many votes as his totalitarian party does, but he's treated by the media and the rest of the cultural elite as a respectable mainstream voice while members of the Progress Party are reviled as extremists.)\n\nThe host promised Hege that it would be a decent discussion with no personal attacks. Yet, as she wrote on August 1, it turned out to be \"the worst debate I have ever experienced.\" Marsdal was permitted to \"Nazify HRS and me.\" He had brought along quotations from work by Hege and her HRS colleague Rita Karlsen, which he distorted in good Stalinist fashion: for example, an article in which Rita expressed concern about young girls being forced to wear hijab was twisted, in effect, into a suggestion that the girls were wearing hijab voluntarily in order to serve as \"warriors for Islam.\" We are talking here about two women who have striven most of their adult lives to help ensure that Muslim girls and women can live in the West as freely as their non-Muslim counterparts.\n\nOn August 1, Dagsnytt again welcomed Marsdal, who this time went on the attack against Aftenposten opinion page editor Knut Olav \u00c5m\u00e5s for having published too many articles critical of Islam and immigration\u2014and, in particular, for having praised my book While Europe Slept. \u00c5m\u00e5s, who participated in the discussion on Dagsnytt by telephone (and who has published op-eds by me), defended me, saying that I'm not an \"extreme writer\" but a writer who is concerned about the dangers posed to liberal society by fundamentalist religion. He insisted that all the writers that the Norwegian terrorist happened to read cannot be held responsible for his actions. But \u00c5m\u00e5s was clearly on the defensive\u2014for Norway had entered a new era. The program host had introduced the segment by saying, chillingly: \"Many people have felt that Aftenposten has let a hundred flowers bloom. But some of those flowers will be clipped now.\" Mao, too, one recalled, had let flowers bloom, and then clipped them ruthlessly.\n\nThere are, insisted Marsdal, connections between opinions and actions. So opinions must be confronted. \"Xenophobia and fascism\" must be confronted, he said\u2014and it was clear that by \"xenophobia and fascism\" he meant dissent from the far-left line, and that by \"confronted\" he meant crushed. He savaged me, Hege, and others for creating a picture of Muslims as the enemy; now he was doing his best to try to persuade all of Norway to see critics of Islam as the enemy.\n\nHege came under attack again on August 5, when Jens Brun-Pedersen, press representative for the Humanist Society, wrote a piece in Dagbladet in which he listed quotations from her about Islam\u2014and, instead of disputing what she had written, simply acted as if it were obvious that such outrageous statements could not be true. For example: \"Child marriages happen in Norway, too, in imitation of Muhammed's example.\" And: there are aspects of Muslim congregations that represent \"a threat to human rights and democracy.\"\n\nThese are statements of fact. Yet after July 22, such truths were not to be spoken. Instead, people like Hege were supposed to begin examining their \"use of words and tendency to generalize that may have helped fertilize the soil in which the terrorist was nourished.\" Hege, suggested Brun-Pedersen, should be \"looking into her heart.\" As if she had not been listening to her heart all along!\n\nIn an article published in Dagsavisen on August 8, a young man named Aksel Kj\u00e6r Vidnes, who (as a quick Google search revealed) received a master's degree in sociology in 2008, called Hege \"totalitarian and fanatical,\" attributed to her \"the same attitudes that characterize parts of Breivik's mental universe,\" and accused her of \"spread[ing] one-sided representations of the danger of Islam by presenting the victims of assault as anecdotal evidence.\"\n\nHege, Vidnes wrote, \"criticizes religion and the religious, often justly, but without taking into consideration that the groups she contributes to prejudice against consist of people. Individuals with feelings.\" As if there were any ethnic Norwegian more familiar with those individuals' feelings than Hege! Vidnes thundered that \"Human Rights Service is not about human rights. . . . the organization's primary work is to be critical of immigration and critical of the multicultural society. . . . Hege Storhaug . . . apparently forgets that human rights are not just for her. They're for everybody.\" Vidnes closed by suggesting that Hege \"engage in some self-reflection.\"\n\nThis was elite Norway's new Maoist mantra: \"reflect\"\u2014and reform. Or else.\n\nAlso on August 8, Marte Michelet, appearing on the radio program Radioselskapet on NRK P2, linked Hege to Oriana Fallaci and Ayaan Hirsi Ali, describing all three women as having inspired Breivik. Michelet echoed Marsdal's calumny that Hege \"speaks of all children in hijab as warriors for Islam,\" and the program host, Nina S. Martin, referring to \"Hege Storhaug and that gang,\" described her as part of a faction of people who hate immigrants. (It is perhaps worth noting that many Norwegians refer to NRK as ARK\u2014\"Arbeiderpartiets Rikskringkasting,\" or the Labor Party Broadcasting System.)\n\nA personal note: In the weeks before Breivik's atrocities, I had traveled to Ottawa, Montreal, and Philadelphia to introduce Hege at gatherings where she gave talks about her work in Norway. At these events she had shown pictures of Muslim girls with Norwegian citizenship who, as a consequence of the hands-off, see-no-evil multiculturalism of Norwegian authorities, were being \"educated\" in horrible, warehouse-like Koran schools in Pakistan and living in equally execrable situations in Gambia. The point was that no Norwegian government would ever have allowed ethnic Norwegian girls to suffer such fates: for these girls, multiculturalism was lethal, for it meant that in the eyes of many of the authorities who should be protecting them, their \"cultures\" deserved more respect than they did.\n\nHege's feeling for those girls was palpable. The high and noble purpose of her work, and her life, came through powerfully.\n\nI have known Hege for a decade now, and I know her through and through. Her organization, Human Rights Service, has formulated legislation that has palpably improved the lives of Muslim women and girls in both Norway and Denmark. I know as well as I know anything that Hege's heart bleeds more every day for individual Muslim women and girls than the typical member of Norway's preening, self-righteous cultural elite\u2014so ready to spew out vapid rhetoric about diversity and \"the colorful society\"\u2014could ever imagine.\n\nIn short, I have never known anyone as genuinely and selflessly dedicated as Hege is to securing freedom and human rights for Muslim women and girls. She has put herself in harm's way in some of the diciest places on earth in order to help people whom she did not know personally and who would probably never know what she had done on their behalf. She is extraordinarily strong and courageous, but I have seen her break into tears over the fate of Muslim women and girls who have crossed her path. I know she is haunted by the memory of Anooshe, an extraordinarily young Muslim woman who came to Norway and divorced her husband only to be gunned down by him outside a courthouse, where they had an appointment to discuss child custody.\n\nYet now, in the wake of July 22, the word was being spread that a woman like Hege\u2014a woman of whom Norwegians should be as proud as they are of their resistance heroes\u2014was to be viewed as a heartless monster.\n\nPerhaps it is no coincidence that Hege\u2014who knows what it means to stand up for freedom when so many of those around her seem to have forgotten the meaning of the word\u2014is, in fact, the daughter of a hero of the Norwegian Resistance.\n\nThe New Quislings are not confined to Norway. They are also to be found on the other side of the Atlantic, among some of America's leading journalists and intellectuals.\n\n\"Bawer vs. Bawer\" ran the headline on my old friend Andrew Sullivan's blog on July 25. It was followed by quotations from my Pajamas Media piece, which had appeared on July 23, and my Wall Street Journal piece, which had run two days later. Here are the quotations:\n\nWhen I first heard the news of the explosions at those buildings, my first thought, of course, was that it was a jihadist attack. But it wasn't: it was a right-wing lunatic. It wasn't jihad. It was a meaningless killing spree by a madman, like the ones at Columbine and Virginia Tech.\n\nIn bombing those government buildings and hunting down those campers, Breivik was not taking out people randomly. He considered the Labor Party, Norway's dominant party since World War II, responsible for policies that are leading to the Islamization of Europe\u2014and thus guilty of treason. The Oslo bombing was intended to be an execution of the party's current leaders. The massacre at the camp\u2014where young would-be politicians gathered to hear speeches by Prime Minister Jens Stoltenberg and former Prime Minister Gro Harlem Brundtland\u2014was meant to destroy its next generation of leaders.\n\nAndrew asserted that these quotations contradicted each other. \"How can a mass murder be both right-wing and meaningless?\" he asked, and articulated his main point in his next sentence: \"There you have the cognitive dissonance of someone devoted to stopping terrorism only to find his own rhetoric may have played a part in motivating a terrorist.\"\n\nAndrew quoted from my article, pointed out what he considered a contradiction, then\u2014instead of making an argument for this assertion\u2014proceeded to make a psychological diagnosis to account for my self-contradiction: cognitive dissonance arising from guilt. In his view, the murders by Breivik could not be meaningless because Breivik had a clear rationale: the victims weren't randomly chosen, they were selected because he held them responsible for treason. As I made clear in my articles, I agree that that was his intention. But his acts were nonetheless insane\u2014meaningless, if you will\u2014because it was obvious, as I also made clear, that the result of his atrocities would be the exact opposite of what he wanted.\n\nLike others, Andrew was eager to identify Breivik's atrocities as the work of what he called a \"Christianist terrorist\"\u2014though it seemed that Andrew had, at best, taken only the briefest of looks at Breivik's manifesto (in which Breivik called himself Berwick, a name by which Andrew chose to refer to him). Insisting, for some reason, on calling Breivik by the British-sounding pseudonym under which he wrote his manifesto, Andrew characterized me as acknowledging, in my Journal article, \"that the Christianist terrorist had been deeply influenced by the anti-Jihadist blogosphere and his own work, quoted 22 times by Berwick,\" but condemned me for \"fail[ing] to assess for a second whether the rhetoric used by him and so many others, was an inspiration for this political mass assassination.\" Talk about \"cognitive dissonance\": Andrew said flat-out in one sentence that I acknowledged having inspired this murderer, and a couple of sentences later accused me of not having considered for an instant whether I had done so.\n\nA more careful reading would have revealed (as I mentioned above) that the twenty-two supposed quotes from me were in fact indirect quotes appearing in essays by Fjordman that Breivik reproduced wholesale in his manifesto. I was never quoted directly by Breivik, who, as I also mentioned earlier, considered me too liberal for his tastes. One might think that in a sensitive case such as this, Andrew would have taken the time to ascertain exactly which statements of mine had been quoted approvingly by Breivik before rushing to collapse the ground between us. But this was apparently too much to expect of someone who declared himself my friend and ally.\n\nIt also needs to be pointed out that \"Christianism\" has become one of Andrew's major hobbyhorses. He appears to believe that there is a thing out there called Christianism that is every bit as dangerous as Islamism. Having staked his reputation on this notion, he was therefore quick to seize on the idea that Breivik's actions had proven his case. For Andrew, the need for a moral equivalency between \"Christianism\" and Islamism is obviously a matter of conscience, and for Andrew (a devout Catholic) his own conscience is privileged over everything else. He loves to put his conscience on display, to wrestle with it in a brightly lit ring in view of all his fans. To Andrew, this kind of casuistical wrestling is the epitome of intellectual virtue, embodying the best of the Western tradition. Yet lost in all of this is any notion of a patient and (yes) conscientious study of the evidence. Instead he prefers to play the Grand Inquisitor, appearing before us every day to serve as the Chief Justice of the Blogosphere, rendering moral judgment on every matter big and small. In his mind he is a champion of rectitude and virtue; in reality he is a reckless purveyor of conspiracy theories, drawing moral lines in the sand as fast as Picasso could scribble a profile on a napkin, hysterically jumping to conclusions, compulsively exaggerating arguments for effect, and habitually pretending that the extremists on the other side speak for all his opponents. He is a master of the straw man and slippery-slope fallacies.\n\nSo it was that Andrew, having invented the \"Christianist\" category, leapt at the opportunity when Breivik said he was a defender of Christian values. Unfortunately Andrew didn't bother to read the manifesto with any care before presenting himself as an expert on its author's motivations. Nor did he have the slightest clue what the average Norwegian (as opposed to, say, Jerry Falwell or Pat Robertson) might mean when he speaks of Christianity.\n\nAndrew claimed that I contradicted myself when I called the murderer a \"madman\" yet described him as \"both highly intelligent and very well read in European history and the history of modern ideas.\" Andrew's comment: \"It is precisely this blind spot by the anti-Islamist right that made me and others get off the train.\" In Andrew's view, apparently, if you accept the argument that Europe is endangered by a rapid growth in the Muslim population that is being \"aided and abetted\" by multicultural European leaders, there is no option other than \"the fascist solutions he [the murderer] recommends and the neo-fascist violence he unleashed.\"\n\nWhen an entire population in your midst is the enemy within and your government is acquiescing to it and your entire civilization is thereby doomed, what does Bruce think a blue-eyed patriot like Berwick should do? Is the leap to violence so obviously insane? Or is it actually the only logical conclusion to the tyranny Berwick believed he faced?\n\nYes, the leap to violence is obviously insane\u2014for no sane person would ever have thought such actions would have accomplished what he wanted. Note Andrew's argument here: that Breivik, in terms of his own premises, was behaving rationally. But we don't judge the sanity of an action by its premises but by the actor's expectation of its results. Since Breivik's means would not lead to his desired ends, he was not only a bloodthirsty monster but obviously insane. (The Holocaust is perhaps the best example of a murderous program, based on irrational premises, that was carried out by thoroughly rational people. Creating a world without Jews is an insane goal. The fact that it was rationally pursued\u2014and justified with rational-sounding arguments\u2014doesn't make it any less so.)\n\nMore important, perhaps, Andrew's argument undermines any possibility of a nuanced middle ground in the debate about radical Islam. Since Andrew, by his own account, is a defender of nuance and a partisan of the liberal tradition of free and open debate, one might think that he would see the value in separating Breivik's social diagnosis from his murderous actions. Surely it is possible for people to agree that a problem exists, and yet disagree in the most fundamental way about how to address it. Writers like myself eschew violent solutions and declare our hope for a reasonable approach to the problem within the confines of a healthy liberal-democratic politics. To claim that Breivik's actions were somehow inevitable given his views is to wipe out this hope and to declare, in effect, that there is no reasonable solution to the problem, and therefore no grounds for a rational distinction between those who wish to discuss and debate it politically and those who wish to answer the problem with violence.\n\nThis is what makes Andrew Sullivan a New Quisling of the first order. Today's Quislings insist that \"fighting words\" are dangerous, that criticism of Islam is \"hate speech\" that necessarily incites violence, and that a liberal society therefore has a vital and legitimate interest in stigmatizing, marginalizing, and suppressing it. This is now Andrew's position, and it flies in the face of his supposed commitment to nuance and open debate.\n\nShortly after 9\/11, Andrew had written a stirring essay titled \"This Is a Religious War,\" acknowledging that Islam was indeed at the root of the jihad that had destroyed the Twin Towers. In 2006 I wrote a book called While Europe Slept: How Radical Islam Is Destroying the West from Within, and Andrew wrote about it on his blog:\n\nThere is no more important issue than that of religious fundamentalism's current battle with liberal democracy. And no one has confronted this issue as forthrightly as Bruce Bawer. I re-read his last book, \"Stealing Jesus,\" as essential background for my next book, \"The Conservative Soul,\" and was struck again by its rigor and passion. Now, Bruce, who's an old friend and ally, has written a clarion call for the West to understand the radical threat to our freedoms from politicized fundamentalist Islam. He writes from the belly of the beast, Norway, where he has lived for several years with his husband. I wish he'd toured the U.S., but he's so enmeshed in the fight in Europe that he has stayed put. I know of very few as close up to what we face as Bruce is; and very few as brave and as eloquent on confronting it.\n\nAt that time, Andrew and I seemed to be on the same page when it came to the danger of radical Islam. But over the years, his views underwent a major shift. At first a staunch defender of what was called the \"war on terror,\" he became one of its fiercest critics. In \"This Is a Religious War\" he had pointed out the menacing nature of Islamic ideology; now he soon began to savage many of those who did exactly the same thing. He and I faced the same challenge: how far to go in making alliances with people who share our view that a certain problem exists but whose method of argument or ideology or practical vision of how to deal with it is not entirely congenial. I have to admit that I often had a hard time making such choices myself when it came to the anti-jihadist cause. For me the question was always whether I felt their rhetoric and actions helped or harmed the cause. Only in a handful of cases did I publicly dissociate myself from anyone by name. I might add that some people from whom I distanced myself before 9\/11 over other matters I have since tacitly reconciled with, because we agree about things that now seem more urgent. Such is always the case with profoundly divisive political and moral questions. We cannot always choose our allies\u2014and we cannot afford to make an absolute morality out of our own motives and preferences.\n\nAndrew has taken a different path. He has turned every break with an old friend into an opportunity to showcase his own righteousness. And he has used the issue of torture at Guant\u00e1namo and Abu Ghraib to ply a moral-equivalency line that is frankly obscene. In what twisted moral universe does America's selective and highly restricted use of enhanced interrogation techniques make us the same as people who saw the heads off innocent civilians? Were the values of Jefferson and Madison really threatened more by George W. Bush than by Osama bin Laden? To make such an argument is (as one might put it) to torture logic and morality beyond all recognition.\n\nStill, Andrew continued to link approvingly to my own writings on radical Islam, usually suggesting, when he did so, that I differed from other writers on the subject in a positive way. In 2006, when a Seattle weekly, the Stranger, dared to reprint the Danish Muhammad cartoons, which appeared alongside an article by me, Andrew praised the Stranger for running the cartoons and agreed with me that doing so was a matter of standing up to Muslim bullies: \"Do we need now to be 'sensitive' toward Wahhabist Islam's treatment of women?\" he asked sardonically.\n\nIn 2009, he praised both me and Christopher Caldwell, saying that we were \"not Steynian hysterics [the reference is to Mark Steyn, author of America Alone and far less of a hysteric than Andrew]; and not authoritarian conservatives\" but rather \"liberal-minded conservatives who are deeply alarmed at the enabling of Islamist illiberalism in Europe.\" And in the same year he praised a piece I had written on the Fort Hood shootings, quoting a passage in which I noted that the killer had, among other things, \"repeatedly expressed sympathy for suicide bombers\" and \"handed out copies of the Koran to neighbors.\" Andrew called the piece \"powerful,\" yet he expressed the following concern:\n\nBut what does Bruce want the US to do in response to an incident like this?\n\nScreen all potential Muslim soldiers in future? Have special surveillance of such soldiers? It's easy to see how this might make matters worse just as it might make them better. Michelle Malkin, remember, favored interning Japanese-Americans during the Second World War. Is that what the anti-Jihadists now want for American Muslims? Or what, exactly?\n\nThis was classic straw-man argumentation: Andrew was using the tired old debater's trick of pushing the argument to an extreme, mentioning far-out \"solutions\" and suggesting that his opponent would support them, instead of acknowledging that the Fort Hood massacre could have been avoided if the army simply took action against soldiers who repeatedly express sympathy for suicide bombers. The army's failure to do so reflects the extent to which politically correct sensitivities have permeated the entire military governing structure.\n\nBut it is Andrew's method to hammer a theme into the ground, and so the day after his \"Bawer vs. Bawer\" posting, he was back with more.\n\nBy far the most destructive terrorist attack in Norway was carried out not by Islamists but by a Christianist fanatic. Per capita, it was more destructive of human life in Norway than 9\/11 or 7\/7 in the US and UK. My problem with Bruce Bawer's WSJ piece is that it didn't seem even to reflect on that astonishing fact. When you have been pointing out the danger of terror from Islamism for years, and it turns out that the terror comes from someone who is on the fringe of your side of the debate, I think it's worth taking some stock.\n\nAndrew went on to contrast my Journal piece, with its lack of the kind of self-flagellation he apparently expected, with an essay by Nils August Andresen, the editor of a Norwegian website, Minerva, who, as Andresen himself put it, had \"been forced to confront the fact that . . . the mass murderer of my countrymen, has visited our website and posted comments in our forum. Though it was impossible to detect this extremism in his comments at the time, I have often worried about the increasingly aggressive tone that characterizes too many not only in our forum, but everywhere that the multicultural society is debated.\"\n\nIt is no wonder that Andrew loved Andresen's piece. He loved the self-criticism; he loved the fact that Andresen made himself the bad guy. Andrew is very experienced in this line. Indeed, his ultimate purpose as a writer is apparently to show that he is too pure for any party. Thus he commits himself heart and soul to a position, attacking everyone on the other side with everything he has, then switches sides and sets to work attacking his former allies with equal gusto. Just beneath the surface it is clear that the whole business is really not so much about examining the issues themselves but about showcasing that exquisite thing, Andrew's moral conscience. The more he berates his former self, the more he expects to be admired for the moral honesty and courage that has led him, through immense and extremely dramatic inner struggle, to assume his present position. He may oppose torturing terrorists, but he loves to make a spectacle of torturing himself ethically. Thus it is that the workings of his conscience become elevated to a moral principle in and of themselves. Andrew praised Andresen's piece for its \"nuances\" and for the suggestion that \"extremist rhetoric\" had some responsibility for the murderer's actions. He plainly agreed with Andresen's assertion that many in Norway \"have Islam as their only concern, their only evil\" and that they are therefore \"willing to accept ever more illiberal measures against Muslims.\"\n\n\"This is the Christianist temptation,\" Andrew went on to say: \"to be so convinced of your own good intentions and culture that you become blind to the fact that you too can spawn and enact evil.\"\n\nThat's how the US came to adopt a torture program based on those once used by Nazis and Communists. That's how Israel can look at the dead bodies of children buried in Gaza rubble and accept no blame or responsibility at all. That's how Bill O'Reilly can simply assert that a confessed Christian simply cannot be one because he is a mass-murderer. And that's how some neocons can regard an Iraq invasion based on false premises that resulted in the deaths of tens of thousands of innocents as a success worth repeating.\n\nThis is, of course, an offensive riot of false equivalency. The Israel line is an obscene misrepresentation of an embattled society that nonetheless has a lively capacity for self-criticism\u2014unlike its jihadist enemies. The United States did not base its interrogation practices on those of the Nazis\u2014any more than the internment camps for Japanese Americans resembled those at Dachau and Auschwitz. Apropos of O'Reilly, jihad is enshrined in the Koran; Christians have committed heinous crimes in the name of faith but mass murder violates the essence of the gospel. Moreover there are innumerable Islamist terror organizations around the world; where, exactly, are their Christianist counterparts? Where are the Christians threatening to decapitate artists who create works like Piss Christ or directors who make movies like Life of Brian? This is sheer hyperbole.\n\nThe task for us is to fight extremist terror\u2014Islamist and Christianist\u2014while retaining common decency, the Geneva Conventions, respect for moderate Islam and apolitical Christianity, and bedrock commitments to free speech, however inflammatory.\n\nThis is a set of sentiments with which I agree entirely. But it is clear that the key words here, for Andrew, were \"Islamist and Christianist.\" These three words summed up Andrew's objective in these postings: to make the argument that there really is something that can be called \"Christianist\" terror out there in the world, and that it represents as much of a threat to the free world and democratic values as does the Islamist variety.\n\nAndrew quoted one last line from Andresen: \"Read American counter-jihadi blogger Pamela Geller's comments on the attacks. That attitude must be confronted.\" \"Indeed it must,\" wrote Andrew. \"And I have little doubt that my friend, Bruce Bawer, will do so once the dust settles.\"\n\nWell, as it happens, I have been confronting the rhetoric of Geller and others ever since I started writing about this topic. If you look at the archives of the website Little Green Footballs, for example, you'll discover the chronicles of a major dustup in the blogosphere that took place a few years ago after I publicly made clear my distaste for the far-right, nationalist, and anti-Semitic Vlaams Belang party in Belgium. It began with a blog posting by me about Charles Johnson, a celebrated anti-jihadist blogger who had publicly distanced himself from friends and allies whose embrace of Vlaams Belang and other illiberal groups and individuals troubled him. In my posting I said that I shared Johnson's dismay, noting that people I had thought of as liberals were now opposing jihadism on what sounded to me like not very liberal grounds\u2014or were rallying around others who did. After my comments were reposted at Little Green Footballs, there ensued a ferocious online conversation. Many well-known Islam critics who had forged close ties with Vlaams Belang were incensed by my position.\n\nIt's all there on the Internet, for anyone willing to do the least bit of Google research. To this I will only add that (a) for all my discomfort with certain elements of the anti-jihad movement, I have subordinated my criticisms of them to what I consider to be the far more urgent problem, namely jihadism itself, and (b) I find it offensive to suggest that any honest writer on this subject, however objectionable in his ideas or language, has the slightest responsibility for Breivik's actions.\n\nAs it turned out, Andresen felt the same way. In a passage that Andrew chose not to quote, Andresen wrote:\n\n. . . from what we know today, it appears that he was not a product of the increasingly hostile Internet debate over the last few years. He was a part of the discourse, but it was not what radicalized him. . . . [T]hese atrocities . . . were not caused by the websites or the rhetoric that we have seen in recent years.\n\nIn the end, Andrew's postings on me were all about justifying his change of position in the war on Islamic terror. He came to feel he had defended a bad cause, that the greater threat was from his former allies, and that moral decency required him to attack them as viciously as he had previously attacked the other side. In this regard he expressed not so much his moral rectitude as an extreme and somewhat narcissistic sensitivity about his political and intellectual bedfellows. I have put some distance between myself and some former anti-jihadist allies out of concern that they were fighting for the wrong reasons and alienating people who might be persuaded to fight for the right ones, but I have not made a habit of attacking them. Andrew, on the other hand, has made a morality\u2014a veritable religion\u2014out of his political alignments and realignments, so that his own moral posturing and preening on life-or-death issues, and not the issues themselves, take center stage. In doing this he habitually erases the middle ground, presenting a false moral choice between extremes, in much the way that Quisling picked Hitler as if he were the only alternative to Stalin.\n\nAndrew wasn't the only New Quisling in the American media. Roger Cohen, too, had a hand in. Cohen lives in London and writes columns for the New York Times in which he reliably bashes Israel (he is a British-born Jew of South African extraction). As someone who has spent much of his career in the capitals of Europe, Cohen thoroughly subscribes to the European liberal line and typically exalts the multicultural elite.\n\nOn July 25, Cohen wrote in the Times that Breivik was, on one level, \"just a particularly murderous psychotic loner\"\u2014or, at least, \"that is how Islamophobic right-wingers in Europe and the United States who share his views but not his methods will seek to portray Breivik.\" But Cohen, like so many others, refused to buy the lone-wolf interpretation. Recalling the shooting of Representative Gabrielle Giffords by Jared Loughner, Cohen insisted that Breivik's atrocities were \"brewed in a specific European environment that shares characteristics with the specific American environment of Loughner: relative economic decline, a jobless recovery, middle-class anxiety and high levels of immigration serving as the backdrop for racist Islamophobia and use of the spurious specter of a 'Muslim takeover' as a wedge political issue to channel frustrations rightward.\"\n\nCohen's sentence reflected the orthodox left-wing notion\u2014which began, perhaps, with the cockamamie idea that the JFK assassination was caused by Dallas's \"climate of hate\"\u2014that the environment, particularly the economic environment, is always the \"root cause\" of any malefaction. Not so: people are responsible for what they do. Individuals who share the same environment and economic background take wildly different paths. As we all know, the atrocities of al-Qaeda have been blamed on poverty in the Arab world, despite the wealth of the bin Ladens and the high educational level of many 9\/11 terrorists. And of course if the root cause is economic, then it is always the Western world and predatory, exploitative Western capitalism that are at fault.\n\nThere were, in any case, a couple of slight flaws in Cohen's argument. To begin with, Norway, more than probably any other country in the Western world, had been left unscathed by the economic downturn that had scarred Europe and North America; its people are not afflicted by \"middle-class anxiety\"; unemployment levels there remained extremely low. As for \"racist Islamophobia,\" hostility to Islam is not racism because Islam is not a race\u2014it is a religion, one whose ideology, in a free country, should be subject to legitimate examination and criticism, which is what had finally begun to happen in Norway in recent years. To accuse Islam's critics of racism is the way of the Quisling: it seeks to stigmatize an argument by discrediting its motives. Furthermore, the rise of Islam in Europe, and the creation of increasing numbers of no-go zones, is not a \"spurious specter\" but an objective fact. The amount of sheer disinformation in Cohen's piece was overwhelming.\n\nIt was reprehensible to see an insulated elitist member of the fourth estate depicting millions of people in Europe as mindless pawns who had been fooled into buying \"the spurious specter of a 'Muslim takeover' \" by politicians seeking to \"channel frustrations rightward.\" To the contrary, people who are concerned about Islam are preoccupied with these matters for one reason only: because they have experienced things that Roger Cohen has not. They've witnessed the duplicity of political leaders who have imposed upon them, without ever asking their permission, a mass immigration into their countries that has radically altered their lives and seriously imperiled their futures, and they've experienced the condescension of those politicians (not unlike Cohen's condescension) in the face of their own thoroughly legitimate concerns.\n\n\"What has become clear in Oslo and on Ut\u00f8ya Island,\" Cohen wrote, \"is that delusional anti-Muslim rightist hatred aimed at 'multiculturalist' liberals can be just as dangerous as Al Qaeda's anti-infidel poison.\" Note Cohen's use of language here: in using the word delusional and hatred, he was clearly referring to the delusions and hatreds of the insane Breivik\u2014but he also seemed to be implying that any criticism of Islam is equally delusional and amounts to hatred. As if to confirm this interpretation, Cohen, in his very next sentence, expressly linked Breivik to others:\n\nBreivik has many ideological fellow travelers on both sides of the Atlantic. Theirs is the poison in which he refined his murderous resentment. The enablers include . . .\n\nThere followed a list of people and parties with a range of political stances\u2014Geert Wilders, Marine Le Pen, \"far-rightist parties in Sweden and Denmark and Britain,\" Newt Gingrich and Representative Peter King, \"who have found it politically opportune to target 'creeping Shariah in the United States' at a time when the middle name of the president is Hussein.\" Note the no-holds-barred terminology: \"Fellow travelers.\" \"Poison.\" \"Enablers.\" These are terms that deeply alarmed and offended liberals like Cohen when they were used by the likes of Senator Joseph McCarthy. Yet now they were at the tip of Cohen's tongue.\n\nA sensible response to Cohen's catalogue of suspect political figures might be to wonder: do all these names actually appear in Breivik's manifesto, or was Cohen simply listing people whom he didn't like? Cohen's article was a fine example of how PC works: not through fair argument with respect for the truth, but through moral intimidation, the demonizing of one's opponents, and the characterization of their opinions as dangerous.\n\nNot that I would defend Le Pen or some of the far-right parties of Europe (though I would not tar them with responsibility for Breivik's crimes, either). But it is repulsive to link Breivik with, for example, the courageous congressman Peter King, who, far from doing something \"politically opportune,\" has stepped in where many of his House colleagues have feared to tread. How? By holding hearings to discuss the influence of organizations like the Council on American-Islamic Relations, organizations that, despite their proven terrorist connections, have continued to be treated with respect\u2014by, not least, incidentally, craven newspapers like Cohen's.\n\n(By the way, King's name does not appear anywhere in the manifesto.)\n\n\"Muslims over the past decade,\" continued Cohen, \"have not done enough to denounce those who deformed their religion in the name of jihadist murder. Will the European and U.S. anti-immigrant Islamophobic crowd now denounce what Breivik has done under their ideological banner? I doubt it.\" In fact, everyone whom Cohen smeared in this piece did condemn Breivik's actions.\n\nCohen proceeded to condemn \"the widespread condoning of an anti-Muslim racism once reserved for the Jews of Europe.\" Never mind that in Europe today, the incidence of anti-Jewish aggression (generally by Muslims) far exceeds anti-Muslim aggression, and that, especially in Norway, the kind of \"racism\" most widely condoned by mainstream journalists, politicians, and academics is not targeted at Muslims but at Jews.\n\nIn a single short piece, Cohen managed to throw around a great many ugly labels, apparently hoping that some of them would stick and mark the individuals in question as being beyond the pale. His repeated use of the words Islamophobe and Islamophobia, and of related terms like right-wing and anti-immigrant, was pure name-calling, a matter of hurling invective at everyone he disagreed with about these subjects. Cohen has for some time, it should be recalled, been quick to slap the label Islamophobe on anyone and everyone who dared to criticize Islam. (In April 2011 he described Oklahoma, ridiculously, as \"a state where Islamophobia is rampant.\") He is every bit as quick to smear as bigots people with legitimate concerns about Islam as he is to soft-pedal the open and brutal hostility of many Muslims toward groups of people whom they deem worthy of contempt and even of summary execution.\n\nThe word Islamophobia is, of course, a cant term, invented by the Muslim Brotherhood and now used by Muslims and multiculturalists alike to tar any critic of Islam as a bigot. They analogize Islamophobia and homophobia, but this is a false equivalence. Homosexuality is an orientation; Islam is an ideology. There is no reason to fear homosexuality, but there are very good reasons to fear Islamic ideology. Yet the word carries a powerful heft. Journalist Juan Williams was punished for daring to admit that he was scared of Muslims. The term also came in handy during the Ground Zero mosque controversy in New York. New Quislings, with Mayor Bloomberg in the lead, rushed in to silence legitimate criticism of the mosque plans not through sensible argumentation but simply by charging mosque opponents with Islamophobia.\n\nThis is a favorite term of the New Quislings because it serves to shut down debate on issues where facts and evidence do not support their views.\n\nAnother New Quisling of note is the American writer Chris Hedges, who has been published for years by the Nation and other left-wing organs. He has also been a New York Times reporter, although he left the paper after being censured for antiwar remarks at a college commencement in 2003.\n\nHedges agreed with Sullivan and Cohen about the supposed danger of Christian jihad\u2014only he went even further, indicting \"secular fundamentalists\" as well: \"The gravest threat we face from terrorism . . . comes not from the Islamic world but the radical Christian right and the secular fundamentalists who propagate the bigoted, hateful caricatures of observant Muslims and those defined as our internal enemies.\" Writing at the left-wing Truthdig website on July 26, Hedges went on:\n\nThe caricature and fear [of Islam] are spread as diligently by the Christian right as they are by atheists such as Sam Harris and Christopher Hitchens. Our religious and secular fundamentalists all peddle the same racist filth and intolerance that infected Breivik. This filth has poisoned and degraded our civil discourse. The looming economic and environmental collapse will provide sparks and tinder to transform this coarse language of fundamentalist hatred into, I fear, the murderous rampages experienced by Norway. I worry more about the Anders Breiviks than the Mohammed Attas.\n\nThis was beyond absurd: in the post-9\/11 era, in a time when Islamic terrorists have murdered untold numbers of people around the world\u2014their coreligionists included\u2014in cold blood, Hedges was making the argument that the more sinister threat originates largely in religious groups that have overwhelmingly been victims of terrorism and in the anti-fanatical language of secular critics of religion like Harris and Hitchens. This wasn't Christianist\/Islamist moral equivalence; Hedges was actually saying that we have more to fear from fans of Christopher Hitchens than from the kind of people who brought down the Twin Towers. But one could hardly expect more from the execrable Hedges, an apologist for Hamas whose systematic anti-Israeli distortions are the stuff of legend and who, in 2001, accused the IDF of \"murder[ing]\" children \"for sport.\"\n\nIt did not take long for Norway's New Quislings to rally around a new label for their enemies: \"Eurabia writers,\" \"Eurabia conspiracists,\" \"Eurabia propagandists,\" or some variation thereupon. One of the first to employ this label was Sindre Bangstad, a social anthropologist at the University of Oslo, who in the Danish newspaper Politiken used Breivik's atrocities as a club with which to beat not only a wide range of adversaries. He went, for example, after Walid al-Kubaisi, an Iraqi Norwegian writer whose website is called Opplyste Muslimer (Enlightened Muslims). Walid is one of the bravest people in Norway and one of its most fervent defenders of individual liberty\u2014yet Bangstad smeared him as a \"Eurabia literature propagandist\" and mocked him for having assumed, in the first moments after the explosions in Oslo, that they were the work of Islamic terrorists.\n\nWhat is \"Eurabia\"? The word refers to the book of that title by the scholar Bat Ye'or, who describes how various obscure European commissions, committees, and such have smoothed the way for the Islamization of Europe. Since July 22, the book Eurabia has repeatedly been characterized in the Norwegian media as pure fantasy; on the contrary, it is a sober work of solid documentation, and anyone who wishes to try to refute it should do so by resorting to facts, not by smearing it as baseless propaganda. Ye'or has studied a small library of obscure agreements produced by diplomat meetings, conferences, conventions, and the like over recent decades, and has found what she considers an unsettling pattern of \"informal alliances\" between European officials and their Mediterranean Arab counterparts that take place under the umbrella of something called the Euro-Arab Dialogue, which dates back to 1974. Bat Ye'or considers these alliances to be characterized by a European deference toward Muslim values, sensibilities, and sensitivities, a pattern she likens to the historical subordination of non-Muslims in Islamic countries. These agreements, in her view, have been instrumental in producing an increasingly Islamized Europe in which government leaders are quick to give way to Muslim wishes and demands and loath to defend Western values and principles\u2014thus, Eurabia. Ye'or is no shrill self-promoter, and her books are hardly the punchy screeds they have been made out to be; on the contrary, they are dry, sober, and packed with long, thoroughly footnoted quotations. The serious and responsible way for an opponent to respond to such work is by challenging the facts or the interpretations thereof; it is not to name-call, to describe her as a street-corner hatemonger or a reckless peddler of baseless conspiracy theories.\n\nBangstad also went after the Progress Party and its former head, Carl I. Hagen: \"We don't know when Carl I. Hagen began to read the type of Eurabia literature that Anders Behring Breivik has also read, but it is well documented that he and several of his fellow party members have read precisely that type of literature.\" As in any totalitarian society, it was now apparently an offense in Norway simply to have read certain books that the country's new Public Enemy Number One had also read. (By the same logic\u2014in fact, by far better logic\u2014one would expect that after 9\/11, Madrid, London, Beslan, Bali, Mumbai, and so forth, it would be forbidden to read the Koran.)\n\nBangstad had more to say:\n\nAnders Behring Breivik . . . has read widely in the racist and Islamophobic literature, from the Israeli right-wing extremist Bat Ye'or by way of the American-Norwegian neoconservative Bruce Bawer to the Norwegian professor emeritus in sociology Sigurd Skirbekk. . . . Hereafter it will be difficult for editors and intellectuals to minimize the existence of Islamophobia in Norway, and it will, if possible, be even more difficult to claim that racists' and Islamophobes' words are just words. . . . Anders Behring Breivik has, by his actions, set himself up against history. Multicultural Norway has come to stay. No pasaran\u2014the line is drawn here.\n\nThose last words, of course, were a quote from Che Guevara\u2014which gave a helpful hint as to exactly where, ideologically, these nasty lucubrations had their origin. (Though it should have been No pasar\u00e1n, with an accent over the third a.)\n\nLate August saw the publication of more thorough, sustained attacks on the critics of Islam and of multiculturalism\u2014attacks that had obviously been in the works for some time. They reached new level of propagandistic poison. The malice and mendacity were palpable; it was now no longer disputable that the New Quislings were out to destroy\u2014nothing less. By now it was also clear that many of them considered the \"Eurabia\" line of attack a winner.\n\nOn August 19, the Norwegian weekly Morgenbladet ran a long, mischievous article by Maren N\u00e6ss Olsen and Anders B. Bisgaard titled \"The Eurabian Verses.\" It was yet another attempt to link critics of Islam with Breivik\u2014and yet another in a years-long list of attempts by left-wing journalists across the Western world to dismiss concerns about the Islamization of Europe as the product of misinformation by a few nutty extremists. Indeed, even given the ostrich-like attitude of the Western mass media generally toward the darker facts about Islam, Olsen and Bisgaard's article was well-nigh breathtaking in its utter refusal to acknowledge basic realities about the world we live in.\n\nAccording to the tale spun by Olsen and Bisgaard, pretty much all of Islam criticism, it seems, can be traced to the work of one whacked-out lady, and then, in turn, to the work of another whacked-out lady. \"The mass murderer Anders Behring Breivik, the blogger Fjordman, the Dutch politician Geert Wilders, the Oslo-based author Bruce Bawer, the Libyan dictator Muammar al-Gaddafi, and [Norwegian] Conservative Party veteran Hallgrim Berg,\" the Morgenbladet authors wrote, \"are among those who have embraced all or parts of Bat Ye'or's imaginative Eurabia universe, which in turn is built on the thoughts of the Italian journalist and author Oriana Fallaci. Ye'or's book, in time, has in time spawned an entire genre, with titles like Londonistan, The Last Days of Europe, Defeating Eurabia, and While Europe Slept.\"\n\nOlsen and Bisgaard called me, Wilders, Ye'or, Berg, Walter Laqueur, Melanie Phillips, and other critics of Islam \"conspiracy theorists.\" But it was Olsen and Bisgaard's article that was framing a conspiracy theory. For their whole agenda was to dismiss all concerns about the Islamization of Europe as the product of a cultish conspiracy by us, a group of loony right-wing bigots who are the disciples of a lone crackpot and whose views have gained no traction whatsoever among academic \"experts\" in Islam and immigration\u2014but who, for some mysterious reason, have managed to convince millions of readers that there is something to what we say.\n\nOlsen and Bisgaard spoke of the \"parallel universe\" of Islam critics and interviewed a professor at Uppsala University who dismissed our work as \"Islamophobia\" and \"pure conspiracy theories\" and compared Ye'or's views to \"the theory that flourished before the Second World War of a Jewish world conspiracy.\" (In a thoroughly redundant sidebar, Lena Lindgren helpfully described Eurabia as \"a fantasyland\" and reassured Morgenbladet readers that all is well.) Olsen and Bisgaard refused to acknowledge that the books of Islam criticism that they mentioned, far from being the work of a pack of anyone's disciples, are in fact the work of a very non-uniform group of writers who have a wide range of backgrounds and political convictions; they refused to recognize that these books, far from being faint echoes of Ye'or's works, approach the subject of Islam in Europe from diverse perspectives and with their own special emphases, all of them written not out of discipleship of anybody (or, for that matter, out of loyalty to some academic orthodoxy, such as the see-no-evil orthodoxy that has hobbled Middle Eastern studies) but, in very large part, out of the authors' own observations and experience. And they refused to acknowledge that if many readers are receptive to what these authors have to say, it is largely because those readers have had observations and experiences similar to those that the authors relate, and have come to similar conclusions.\n\nThis latter point is one that Olsen and Bisgaard do not wish to grant, for the entire premise of their article is that those of us who have written books critical of Islam have somehow convinced millions of people in the West to feel trepidation about something that they would otherwise not be worried about. On the contrary, our books have struck a chord precisely because they have addressed concerns that are already out there that are founded in people's very real worries about social changes that they have witnessed firsthand and that the political establishment and mass media have largely refused to address. (How far do you think you'd get if you tried to whip up anxiety in the West about, say, Hinduism or Buddhism?)\n\nOlsen and Bisgaard devoted a good deal of space to me. They described me as a \"self-appointed victim of the Islamic threat\" who \"never gives interviews in the Norwegian media\"\u2014implying, apparently, that I've been hiding from the press. This is a hilarious charge, given that, as Hans Rustad noted at document.no on August 24, I've been pretty much \"boycotted by the Norwegian media\" throughout my years in Norway. By contrast, during those same years I've done innumerable interviews with non-Norwegian journalists\u2014a long sit-down with Bill Moyers on his TV series, a couple of radio chats with Dennis Miller, several radio interviews in Canada, podcasts with Shire Network News in Australia and with John J. Miller of the National Review, as well as interviews with the Danish papers Berlingske Tidende and Jyllands-Posten (twice), the Dutch newsweekly Elsevier, L'Occidentale and Il Foglio in Italy, and the Jerusalem Post, plus many, many others. The fact that I've never been interviewed in the Norwegian media, in short, says nothing about me but a great deal about the Norwegian media, which can sometimes seem to think that the only people in Norway who know anything about anything are either members of Parliament or professors at the University of Oslo. (Or, of course, journalists.)\n\nDespite my putative refusal to be interviewed by the Norwegian media, Olsen and Bisgaard went on, \"Bawer does not hesitate . . . to use his experiences in Oslo as the basis for the Eurabia arguments he sets forth in right-wing American media . . . and in his book While Europe Slept.\" Huh? Was I now being attacked for basing my arguments about Europe on my experiences in Europe? Isn't this how these things are supposed to work? Clearly not in the New Quislings' world, where ideology trumps reality, and where the first rule of journalism is not to believe your lying eyes. This is how they think. Their need to deny reality in order to preserve the edifice of multiculturalism is that powerful.\n\nJust for the record, I didn't read a word by Bat Ye'or, and knew nothing of her work, until I'd already finished writing a near-final draft of While Europe Slept; after I read Eurabia I just barely had time to insert a short passage about it\u2014less than a page\u2014into my book. A search of the dozens of articles I've written about these issues since reveals exactly one fleeting mention of Ye'or. You'd never know this from reading Olsen and Bisgaard.\n\nUnsurprisingly, Olsen and Bisgaard turned to academic \"experts\" on immigration and Islam (the same kind of people who assured us before 9\/11 that there was no \"Islamic threat\") for reassurance that there is nothing of value in the work of any of us critics of Islam. The Dutch academic Cas Mudde, who teaches at DePauw University in Indiana and is identified as an expert on the European far right, told the Morgenbladet reporters that when he moved to the United States \"he was surprised by how deeply the Eurabia conspiracy and people like Bruce Bawer had penetrated.\"\n\n\"I met conservatives who obviously were not crazy who asked about Eurabia,\" said Mudde. \"What I hadn't grasped when I lived in Europe was how mainstream people like Bruce Bawer are in the U.S. Those who make the Eurabia arguments are influential people in the conservative movement. Bawer is considered an expert on European conditions because he lives there.\"\n\nIndeed, one of Olsen and Bisgaard's main contentions was that these books about the Islamization of Europe have only been popular in America and haven't gotten (as they put it) \"the same foothold in Europe,\" apparently because Europeans, being closer to the real situation, know better. (There was also an insinuation that we Islam critics are peddling nonsense that only stupid, bigoted Americans would buy, and that Europeans are too sophisticated and intelligent to fall for.) In fact, a host of European writers have also written important and widely read books in this genre\u2014among them Henryk Broder and Thilo Sarrazin in Germany (Sarrazin's book Deutschland schafft sich ab, or Germany Does Away with Itself, was the biggest-selling political book in Germany in a decade), Lars Hedegaard and Helle Merete Brix in Denmark, and Guy Milli\u00e8re, Robert Redeker, and Chahdortt Djavann in France. Olsen and Bisgaard did interview Hallgrim Berg, author of a Norwegian bestseller about the Islamization of Europe, but, curiously, when it came around to talking about the European versus American markets for these books, dropped him down the memory hole. They also mentioned Fallaci, of course, but neglected to mention that her first book on Islam, The Rage and the Pride, was the largest bestseller ever in her native Italy, and a big hit across Europe as well.\n\nThe title of Olsen and Bisgaard's piece was disconcerting. Plainly, it was meant to pun on Salman Rushdie's The Satanic Verses\u2014which, as the world knows, resulted in a fatwa that forced Rushdie to go into hiding for years. What were Olsen and Bisgaard trying to say by linking the \"Eurabia writers,\" as they called us, to Rushdie? That the fatwa against him was, like our work, nothing more than the product of a fevered imagination?\n\nOn August 22, Sindre Bangstad, who, as we have seen, had already savaged the critics of Islam and of multiculturalism in the Danish newspaper Politiken, published an even longer and even more vicious piece on the Open Democracy website. He began by referencing a \"peaceful Muslim\" demonstration that had taken place some months earlier at University Square in Oslo, then criticized Hege for writing a negative piece about that demonstration in which \"incitement to violence\u2014or 'fighting words'\u2014directed against Norwegian Muslims hover below the surface.\" What Bangstad neglected to say about these demonstrators is that they had cheered a call for a new 9\/11 in Norway, and that the whole point of Hege's piece had been to highlight, and to condemn, the explicit incitement to violence that had taken place at that event.\n\nAfter smearing Hege, Bangstad proceeded to call me a \"Eurabia author\" and to attack Aftenposted opinion editor Knut Olav \u00c5m\u00e5s, whom he described as an \"ardent fan of Ayaan Hirsi Ali and Alan Dershowitz, and a personal friend of the Danish editor Flemming Rose (who commissioned the cartoons which provoked the global cartoon crisis in 2005\u201306)\"\u2014all of which facts Bangstad presumably considers suspicious. This was classic McCarthyism\u2014attacking \u00c5m\u00e5s for his friendships and other associations. Also to his apparent discredit, \"\u00c5m\u00e5s has on no less than two occasions recommended Bruce Bawer's Eurabia-books to his readers in editorial columns.\" No less than two occasions? Does this mean \"two\"? What kind of a McCarthyite locution is this? Liberals are supposed to recoil at such rhetoric\u2014but Bangstad was no liberal, rejecting \u00c5m\u00e5s's enthusiasm for freedom of expression and his belief, paraphrased by Bangstad, \"that most\u2014if not all\u2014opinions should be aired, so that they may be 'debated.' \" Bangstad's response:\n\nThis is a mistaken view, inasmuch as it is based on the contention that most, if not all, opinions will be challenged and contested in the public square. Norwegians who have become used to more and more vile public expressions of Islamophobia and racism in recent years would recognise the futility of debating publicly with Ms Storhaug and others who have pushed the limits of acceptable speech to extremes.\n\nBangstad cast his net wide. He went after Walid al-Kubaisi, for his 2010 documentary about the Muslim Brotherhood. Bangstad claimed that \"echoes of Eurabia-literature were more than evident in the 'documentary' \" and found it deplorable that the film \"was co-financed by the prestigious Fritt Ord Foundation and TV2, and earned public plaudits and recommendations from several Norwegian professors, among them Prof. Terje Tvedt at the University of Bergen and Prof Unni Wikan at the University of Oslo.\" Bangstad was also appalled that major Oslo publishers issued Norwegian editions of books by Oriana Fallaci and Ayaan Hirsi Ali, both of whom, after all, were on Breivik's reading list. Breivik, it seemed\u2014this solitary madman\u2014was henceforth to be the touchstone of what could and couldn't be said and written in the Kingdom of Norway.\n\nOne sentence of Bangstad's stood out in particular:\n\nIn recent years, I have often been approached by young, well-educated and upwardly mobile Norwegian Muslims after public lectures, with the question as to why a society which from government level to that of the media and civil society opposes anti-Semitism in all its forms with all its might, can still deem Islamophobic speech and utterances quite acceptable. I have not been able to provide any plausible answer\u2014let alone comfort for them in their despair.\n\n\"Opposes anti-Semitism in all its forms with all its might\"? \"Deem[s] Islamophobic speech and utterances quite acceptable\"? This is Orwellian, period.\n\nHege Storhaug, Ayaan Hirsi Ali, Oriana Fallaci, Walid al-Kubaisi, me: Bangstad accused us and many others of having \"provided the echo chambers for Anders Behring Breivik's thoughts and ideas.\" And after serving up the rote acknowledgment that we don't \"share any direct responsibility for his deeds,\" he made it clear that he considers us indirectly responsible\u2014for \"mass murder . . . requires ideological preparation. And that ideological preparation involves de-humanizing the 'other'\u2014whether she be a social democrat, a Muslim or both.\" Of course the whole point of my writing about Islam and related issues, and of everything I have read by people like Hege Storhaug and Ayaan Hirsi Ali, is to attend to the dignity and rights of the human individual\u2014as opposed to the cultural or religious group. The fundamental problem with multiculturalism is its exaltation of the group over the individual; our purpose is to reverse that emphasis. Dehumanization is the very opposite of what we are about.\n\nFor all his concerns, Bangstad was positive about Norway's future. Henceforth, he trusted, the gatekeepers of the Norwegian media would be less inclined to give a platform to \"Eurabia writers\" and other \"Islamophobes.\" Bangstad set himself against what he calls \"the ultra-liberalist champions of free speech\": in his view, censoring certain opinions is vital to the creation of the kind of society he wants.\n\nThe \"Eurabia\" pieces were now coming fast and furious. On August 29, not one but at least two opinion pieces pushed the meme. In Aftenposten, Mohammed Usman Rana (who, as head of the Muslim Student Association at the University of Oslo, had refused in 2007 to say whether he supported the death penalty for homosexuality) argued that some of those who had \"helped shape Behring Breivik's thoughts\" had failed to publicly distance themselves from him. His prime example was me, whom he described as having lamented in the Wall Street Journal that Breivik's atrocities \"would be a shot across the bow for [my] Eurabia theories.\" I had not even mentioned Eurabia in my Journal piece, but this hardly mattered: Eurabia was now the weapon of choice for those out to silence critics of Islam.\n\nEurabia\u2014this was the new \"big lie.\" People like me and Hege and Ayaan Hirsi Ali were \"Eurabia writers\"\u2014disciples of Bat Ye'or, members of an intellectual conspiracy. On the contrary, what was striking about While Europe Slept and so many of the other books of Islam criticism that were published around the same time was that writers with such a range of backgrounds had independently and (roughly) simultaneously decided to write about the rise of Islam in the West, unaware that other writers were doing the same thing, and that all had come to pretty much the same conclusions. This was not a conspiracy\u2014it was a case of several people responding sincerely to things that had deeply troubled them.\n\nThese New Quislings did not even try to engage with our ideas, to defeat us by quoting our arguments fairly and challenging them honestly. No, they were simply smearing us as bigots\u2014a nefarious cabal of bigots who had inspired a murderer, and who were that murderer's moral and spiritual kin. We had voiced our views, and now these tools of the Islamists were out to punish us for it\u2014by seeking to bring about our utter personal and professional destruction.\n\nIt did not seem a coincidence that the woman who was deemed the leader of this conspiracy was Jewish. Do we need to point out the parallel between the New Quislings' \"germ theory\" of ideological transmission and the Nazi war against \"Jewish thinking\"?\n\nOn August 5, Peder Jensen, a thirty-six-year-old man from \u00c5lesund, living in Oslo, told VG that he was the anonymous blogger known as \"Fjordman,\" whom Breivik had identified as his favorite writer and thirty-nine of whose essays Breivik had reprinted in his manifesto.\n\nI knew Jensen. A few years earlier he had contacted me and we had met for drinks a couple of times. We also e-mailed frequently, and when I was attending the Pim Fortuyn Memorial Conference in The Hague in 2006, I phoned him and suggested he come down, which he did. (It was at that conference that he first met Islam critics like Robert Spencer and Bat Ye'or, with whom he would become friendly.)\n\nJensen had studied Arabic, worked in the Norwegian foreign service, and been stationed in Hebron. I was impressed. He was polite, friendly, smart, serious, obviously very widely read, and knew what he was talking about when he talked about Arabic culture and about Islam. I never knew him to say anything racist or otherwise offensive, except perhaps for a few comments about women: he thought feminism had been the ruin of Norway, destroying the once proud Viking nation's willingness to stand up for itself. As for Islam, he recognized it as a threat to Europe, but I don't remember him ever talking about Arabs or Muslims personally in an offensive way; on the contrary, he was steeped in Arabic culture and in many ways admired it.\n\nI liked him, in short, and was happy to have made a new acquaintance with whom I could talk intelligently about matters of common concern. I did think the nickname Fjordman was terribly silly and told him so, and encouraged him to write under his own name. But he was determined to stay anonymous, certain that he would otherwise be in terrible peril.\n\nIndeed he was certain, I soon learned, about almost everything. His self-assurance proved daunting. He was convinced, for example, that his magnum opus about Islam in Europe, when it came out, would save Europe.\n\nI tried to give him advice about publishing, but he seemed uninterested. Indeed he had a lack of social antennae that gave me pause: virtually every time we spoke, he disparaged my work, comparing it unfavorably with his own, and doing so in a matter-of-fact tone that made it clear he had no idea he was giving offense.\n\nIn time it became clear to me that Jensen was rather too comfortable with nationalist groups of the kind I didn't want to have anything to do with. In the end, he was one of those with whom I broke off contact in connection with the Vlaams Belang matter. Like many of the others with whom I broke off contact, he still had my respect; I just didn't respect some of the people he was willing to associate with, and I didn't think that those associations could lead to anything good\u2014though, I might add, I wasn't about to trumpet that concern to the world at every opportunity or make it the centerpiece of my worldview.\n\nHe seemed truly hurt when I cut him off, and while others with whom I broke off contact responded with hostility and vindictiveness, Jensen remained friendly and solicitous. He repeatedly tried to reestablish contact, and if I remember correctly I backslid once or twice, replying to messages from him and thanking him for forwarding items of interest to me, because I still felt kindly toward him: to judge by what I knew of him and what I had read by him, he did not seem to me in any way to be a bad person, just someone who was inclined to fall too precipitously into the ideological orbit of bad people to achieve what he saw as a good end. (Making an alliance with Stalin may be necessary, but don't do it until you're sure you have to.)\n\nIn any event, at the time of the atrocities I had not been in contact with him for a couple of years, had seen virtually none of his recent work, and had actually forgotten his real name. As soon as it emerged that he was Breivik's \"hero,\" I was overcome with sympathy for him. As far as I knew, he had never written anything that any sane person would read as encouraging violence. In my view, he was an earnest, intelligent young man for whom there had been no place in a foreign service that treats Hamas with more respect than it does Israel, and who therefore sought to serve his country's interests in the only way he could come up with\u2014by writing about the truth as he saw it.\n\nNow he was being tarred mercilessly by the Norwegian media because his writing had been admired by a mass murderer. And not just tarred. After he came forward voluntarily, the police treated him, he felt, like an accomplice to murder. A dozen cops spent hours ransacking his apartment, going through everything\u2014including photographs and kitchen supplies\u2014and confiscated books, clothing, and electronic equipment, including a laptop. According to Jensen, his lawyer said their conduct was, at best, just barely on the borderline of legality. Jensen concluded that the Norwegian authorities wanted to scour his laptop for information on critics of Islam.\n\nIt was not only Peder Jensen who was demonized. After Hege publicly acknowledged that she had met him once, at his request, several years earlier, the New Quislings began attacking her for that. In short, it was okay that leading Norwegian politicians had friendly ties with Hamas and Hezbollah terrorists\u2014but not okay for someone like Hege to have agreed, years ago, to meet a writer whose work would later turn out to have been read with enthusiasm by a terrorist.\n\nThere were, to be sure, sane voices amid the madness.\n\nA noted Norwegian critic of Islam wrote to me a few days after the murders that \"NRK and the Labor Party and the Socialist Left Party intend to use this event politically. . . . they are not in grief, they are going for our throats. . . . It started just hours after the carnage. Their dishonesty never stops amazing me. Civil debate is what they do not want. Silencing debate has been their objective since I was [a] student in the Sixties.\"\n\nOn August 13, in a long and searching article in Klassekampen, Walid al-Kubaisi, too, expressed alarm that leading figures in Norway were now discussing \"ways to limit free speech,\" with a special focus on speech about immigration and Islam. But he pointed out that Breivik had not attacked a mosque or other Islamic target\u2014he had gone after the Labor Party. Should we therefore, Kubaisi asked, \"forbid criticism of Labor Party policy?\"\n\nIn any event, he added, concern about the airing of right-wing extremist ideas was irrelevant to the case of Breivik, for the views expressed in his writings were not extremist but \"moderate.\" Kubaisi further noted that, despite all the post\u2013July 22 rhetoric to the contrary, nobody had ever bashed Muslims in Norway's mainstream media, for the media had never allowed it. The people now being accused of bashing Muslims had, in fact, presented facts and arguments\u2014and their opponents, instead of characterizing them as mudslinging bigots and trying to silence them, should answer their facts with facts and their arguments with arguments.\n\nWere the critics of Islam veritable accomplices of Breivik, as was now being argued? On the contrary, said Kubaisi: it was the opponents of open debate who were \"Breivik's indirect accomplices.\" For Breivik's goal, after all, had been to shut down democracy. And that was exactly what they were now doing. And the more successful they were at stifling free speech, the more right-wing extremism would grow.\n\nInterestingly, it was a week to the day after the murders that several of my Norwegian Facebook friends and friends-of-friends broke their silence and began to rebel against the exploitation of July 22 by the New Quislings. One of those Facebook friends posted a grim comment about \"NRK's Gestapo hunt for all 'right-wing extremists.' \" Here are some comments by others:\n\n[P]eople on the left are now doing exactly what they have accused others of, namely stigmatizing. Now everyone who is against immigration is more or less an accomplice. They are of course using this unique chance to gag immigration opponents as much as possible, especially those who point to the danger of a large-scale influx of Muslims. Now all opposition will be crushed, once and for all. May it not happen!\n\nIndoctrination will continue as before, if not even worse.\n\nThe press's aggression in this case is, in my view, already a warning. . . .\n\nThe forces that are using this tragedy to further prevent freedom of speech must be totally ignored.\n\nNow we can see what a mourning period means for the blood red [i.e., the socialist, or \"red,\" parties, as opposed to the nonsocialist, or \"blue,\" parties].\n\nThe Labor Party's new motto must be \"Strike while the corpses are hot!\"\n\nAt the end of August, one of my Norwegian Facebook friends wrote that he had spent almost the entire month in Italy, where as a Norwegian had been asked many questions about July 22. The Italians he met viewed Breivik not as a right-wing extremist but as a madman. They were astonished, moreover, by the idea of a political summer camp for teenagers, which reminded them of Nazi and Stalinist brainwashing. And they all had great sympathy for my Facebook friend for having to live in a country where the debate was now being controlled by what they saw as a \"red-brown Communist regime\"\u2014for the kind of harassment of the opposition that was under way in Norway, the Italians pointed out, only takes place in dictatorships. Were they wrong?\n\nIt was hard not to conclude that the full-court press by the New Quislings was working like a charm. Normally tough opposition figures were plainly shaken. Formerly unblinking critics of Islam and multiculturalism were now mewling out meek mea culpas. It was dispiriting to read, on August 2, that Progress Party leader Siv Jensen, a strong, articulate woman whom I had compared in the British magazine Standpoint to Margaret Thatcher, was now confessing to the media she regretted things she had said in the past about Islam and immigration. Although she did, to her great credit, acknowledge the \"witch hunt\" to which she and her party were being subjected, she promised to alter her tone in debates.\n\n\"I think we have all already changed our behavior, and we will not be the same again,\" she said. Asked whether there were specific words she regretted using, she said: \"Yes there definitely are. But I do not think I should subject myself to this witch hunt. I think I will focus on contributing to the dignity that the nation needs to get through this grief.\"\n\nThe same article reported that many local Progress Party leaders had now fallen into line, distancing themselves from their party's rhetoric on immigration and integration, such as the word snikislamisering, meaning stealth Islamization. The party leader for Oslo said that policy positions must be expressed in a way that does not \"offend anyone\"; the Progress Party mayor of Mandal called for a change in the party's rhetoric about immigration; the party leader for Ask\u00f8y looked forward to \"another kind of discussion\" about immigration and condemned an article written in 2010 by a Progress Party MP who had criticized multiculturalism as \"idiocy.\" Such rhetoric, he said, should now be abandoned.\n\nBut none of this kept the media from demonizing the Progress Party in a way that went far beyond the levels of pre\u2013July 22 stigmatizing. At document.no, Hans Rustad reported that Siv Jensen, asked by an NRK correspondent during a hospital visit about an op-ed she and her predecessor, Carl I. Hagen, had written in 2005 about \"the overrepresentation of Muslims among terrorists,\" said that serious discussion of such matters could not be terminated because of July 22. When NRK aired this exchange on August 15, it was followed by an interview with Hajo Funke, a German political scientist who writes about right-wing extremism in Europe. \"Politicians who bash Islam are taking on a great responsibility,\" pronounced Funke, who went on to compare Jensen's party to neo-Nazis; by way of illustration, NRK created a montage in which images of marching neo-Nazis were shown alongside images of Carl I. Hagen.\n\nWith such taxpayer-funded propaganda supporting the New Quisling agenda, who would dare to dissent? On August 15, an article by Eirik Bergesen was posted on the website of the intellectual journal Minerva. Bergesen, who at the time was on leave from the Norwegian foreign service, noted that since July 22, \"Some individuals on the left want to spread responsibility for the tragedy to those whose words helped shape the context within which the perpetrator acted.\" He reported that on August 1, during an appearance on Dagsnytt, Magnus Marsdal had said that while he was a \"free-speech fundamentalist,\" he wondered, apropos of Knut Olav \u00c5m\u00e5s's words of praise in Aftenposten for my book While Europe Slept, whether it should any longer be permitted to say that one feared or opposed the influence of Islam. Bergesen's point was not to defend my work (he appeared to accept the notion that I am a far-right extremist) but to defend free speech: \"Right-wing and Islamist extremists are evil stepsisters,\" he wrote, but the way to fight them both is with more speech, not less.\n\nYet few dared agree out loud. And that was the whole idea. The New Quislings wanted their opponents to feel imperiled. They wanted to tame us, and if possible silence us entirely. Siv Jensen was right: a full-scale witch hunt was indeed under way in Norway. I had read about such witch hunts in history books, but had never experienced one in person before. It was profoundly unsettling. Conservatives and liberals alike were being put on the defensive by radical leftists. And all too many of the targets of this witch hunt were indeed running scared\u2014confessing their past sins, regretting their use of language, changing their opinions. It was tragic to see this happening in a supposedly free country. And it all just proved that when I worried, in my pieces for Pajamas Media and the Wall Street Journal, that the atrocities of July 22 would make it impossible to have an honest debate about Islam in Norway, I was even more correct than I thought.\n\n(Perhaps a gentle reminder is in order that, when it comes to Islam and all of Norway's failed multicultural policies, everything is, in fact, just as it was before. The imams who were embraced by Norwegian politicians and by members of the Norwegian royal family after July 22 still have the same views they had before July 22.)\n\nOn August 21 a national memorial ceremony for the victims of July 22 was held at Oslo Spektrum, Norway's answer to Madison Square Garden. The king and prime minister spoke, the names of the dead were read aloud, the NRK orchestra played Mozart and Beethoven, the 1980s Norwegian boy band a-ha performed, and someone sang \"Bridge over Troubled Water.\" And in a taped segment, the current head of the Norwegian Humanist Society, \u00c5se Kleveland, joined a group of religious leaders in speaking words of healing and unity into the camera. The leaders included a Church of Norway pastor, a Hindu priest, a rabbi, a Buddhist monk\u2014and the head of the Islamic Council of Norway, an imam named Senaid Kobilica. The segment plainly sought to suggest that all of these religious and secular leaders stood for the same loving, humane values. The organizers had apparently chosen to overlook the fact that Kobilica, not very long ago, made headlines by refusing to condemn the death penalty for homosexuality. What was presented as a display of diversity and tolerance, then, was in fact a confirmation of the new official determination to sweep the disturbing reality of Islamic theology under the rug.\n\nWhat I viewed at the time as the New Quislings' ultimate Statement of Principles appeared on August 22. It came in the form of an Aftenposten op-ed coauthored by Bangstad, Hylland Eriksen, University of Oslo philosophy professor Arne Johan Vetlesen, and a young woman named Bushra Ishaq, who is a medical student, a board member of the Anti-Racist Center, a member of a Conservative Party committee on religious policy, a \"peace worker\" for something called the Youth Global Harmony Association, a member of the women's panel of the Ministry of Children, Equality, and Inclusion, a participant in ecumenical dialogue between the Islamic Council and the Norwegian Church Council, an official Norwegian participant (nominated by Crown Prince Haakon) in an international forum called One Young World, and a former head of the Muslim Student Association.\n\nThe op-ed, titled \"Hateful Utterances,\" was a strident call for tighter limits on free speech in the wake of July 22.\n\n\"Certain hateful utterances,\" the four coauthors insisted, \"are legally and morally unacceptable. . . . Neither freedom of speech or the right to express oneself are absolute in any existing human society. Nor does freedom of speech stand above other rights and compliance with key human rights declarations.\" Although \"freedom of speech is a key value in a free and democratic society,\" they wrote, it is not \"unlimited.\"\n\nDecrying \"free speech absolutism,\" and explicitly rejecting the United States (\"the country in the world that goes the furthest in protecting the right to expression\u2014including hateful expression\") as a \"role model,\" the authors noted that the European Human Rights Convention \"is clear that the exercise of freedom of speech imposes a responsibility upon the person expressing himself.\" Yet in the last decade, they complained, \"the limits to hateful speech . . . have been stretched very far\" in Norway. This, they insisted, needed to be reversed in the aftermath of July 22\u2014the implication being that Breivik's atrocities were the consequence of the exercise of free speech by certain individuals. In the coming years, the op-ed argued, \"Norwegian editors as well as politicians\" needed to make it clear that \"it is not a human right to express oneself in public; and that certain hateful utterances . . . are not acceptable.\"\n\nThe New Quislings' determination to use the events of July 22 to silence their political opponents had never been more blatant. Hateful utterances, indeed!\n\nAnthropologist Runar D\u00f8ving was quick to agree, declaring flatly, in a September 2 interview with Morgenbladet, that the \"conspiracy theories\" of people like Hege Storhaug should be censored. As an example of these \"conspiracy theories\" D\u00f8ving cited Hege's January 6 Aftenposten op-ed, \"A Growing Unease,\" in which she reflected soberly and sensibly on the call for a Norwegian 9\/11 at that Muslim demonstration in University Square, the planning of a new mosque in Troms\u00f8 led by a woman whose husband has trained as a terrorist, and Iran's dispatching of imams to Norway to carry out such training. In D\u00f8ving's twisted view, Hege was not reporting in this op-ed on hatred; no, she was expressing a hatred\u2014and paranoia\u2014that, D\u00f8ving argued, is now ubiquitous in Norway and, in the wake of July 22, needed to be quashed. D\u00f8ving admitted readily that his view of the public square was, in a sense, \"authoritarian\"\u2014it should simply not be allowed, he said, to express certain ideas\u2014and that he was \"entirely in favor of what many people are now describing as a witch hunt,\" for \"there needs to be an investigation of what was written before July 22 so that we can see the connection between words and actions. Those who have demanded all along that Islam should be held responsible for Islamism must take responsibility for Islamophobic Christian hate violence.\"\n\nOn September 4, the Norwegian journalist \u00c5sne Seierstad\u2014whom I had admired for her readiness, in her international bestseller The Bookseller of Kabul, to take on political correctness by exposing the harsh patriarchal mentality of even a highly cultured and supposedly Westernized Afghani bookstore owner\u2014published in Newsweek a piece of outright character assassination. After dismissing the Norwegian public's concern about immigration and Islam as \"xenophobia\" and saying that the cause of this concern \"is somewhat of a puzzle\" given that \"[t]here has been no Islamic terror in Norway\u2014a picture that also fits the rest of increasingly immigrant-skeptic Europe\" (here she seemed to drop the London and Madrid bombings, among other atrocities, down the memory hole), Seierstad portrayed Hans Rustad and Siv Jensen as hard-hearted right-wing extremists and Marte Michelet as a gentle, diversity-loving soul.\n\nAs one Norwegian wrote in an online reader comment on Seierstad's article: \"Dear Americans. Please be aware that there is an information war going on in Norway.\" The reader noted that while document.no publishes \"articles that would be considered moderate in the USA, the left[-wing] Norwegian press is constantly trying to convince [its] audience that the topic[s], facts and opinions expressed on sites like document.no are right[-]wing extremism.\" By attempting \"to link Hans Rustad with the hideous terrorist attack,\" the mainstream Norwegian media were out \"to demonize all politics that are not left[-]wing enough for [them].\" The reader called the situation \"shameful\": in place of journalism, there was now \"pure propaganda.\"\n\nIn Aftenposten on September 6, Per Fugelli, a professor of social medicine at the University of Oslo, served up more of what was now becoming a tiresomely familiar dish: \"If we want to answer Behring Breivik with the opposite of his goal, answer number one must be to make life for our fellow citizens of the Muslim faith safer, more dignified, freer. . . .\" We must ask ourselves \"how they are doing\u2014how this evil deed has affected their security, sense of belonging, and sense of peace about the future.\" And we must do more to make them feel welcome: \"Have we met Fatima and Ali with the openness and trust they deserve?\"\n\nFugelli made the now-standard claim that he did not mean to blame any political party or person for Breivik's actions\u2014then, in now-standard fashion, started blaming away. \"The need for self-criticism,\" he thundered, \"is especially great in the Progress Party,\" which he accused of having spread the raw materials of \"fear\" and \"hate.\" But he lamented that \"there's little hope\" that the party would change its spots.\n\n\"For me,\" wrote Fugelli, \"this is a danger warning. We must . . . go into ourselves and ask: Have we stood up strongly enough against the forces that create enemy images of 'the others'?\" After all, \"Behring Breivik killed 68 people at Ut\u00f8ya because Workers Youth League is multicultural Norway in a nutshell. Workers Youth League is anti-racism in its heart and in its actions. Workers Youth League believes, with Nordahl Grieg: If we create equality, we create peace.\" In sum: \"Now we must emerge from the sweet narcotic of the roses and fight for what the young people at Ut\u00f8ya lived and died for. . . .\"\n\nNowhere in Fugelli's piece was there any recognition that trying to create \"equality\" for women and girls in Muslim communities is one of the goals of the Progress Party, and that you can't have both equality and multiculturalism\u2014for the latter obliges you to put the group's welfare and the preservation of its culture and values above the rights of individuals within that group. Nor, of course, was Fugelli prepared to acknowledge that more than a few Norwegian Muslims have opinions and beliefs that they might do well to reexamine. No, for Fugelli, it seemed, the Muslims around him were one-dimensional figures\u2014pure, unsullied, harmless victims\u2014who might almost have been dropped down in Norway to serve as reflections of non-Muslim Norwegians' goodness or evil, love or hatred.\n\nLife went on. On August 26 it was reported that several residents of an asylum center in western Norway had beaten, tortured, and poured boiling water over a fellow resident because he had converted from Islam to Christianity (which is, of course, a capital offense under sharia) and was therefore not fasting during Ramadan. The story served as a timely reminder that there are, indeed, aspects of Islam that merit criticism\u2014and that those who would silence such criticism are not heroes of diversity but enemies of freedom and enablers of Islamist tyranny.\n\nOn August 27, blogger Brage Baklien reported an incident he had witnessed earlier that day in downtown Oslo. It was now campaign season, during which each of the political parties sets up a little covered stand along Oslo's main street, Karl Johans Gate, not far from the Parliament building, where they hand out literature and discuss issues with passersby. While Baklien was minding the Progress Party stand, a group of \"20 enraged demonstrators from SOS Racism\" approached the person who was monitoring the adjacent stand for Kristent Samlingsparti, a tiny party of \"Bible-believing Christians,\" and kicked and tried to punch him. (This report, according to Dagbladet, was confirmed by several witnesses.) Baklien phoned the police, but by the time they arrived most of the thugs had disappeared. SOS Racism later claimed that they had simply held a peaceful, nonviolent demonstration. \"The event,\" observed Baklien on his blog, \"is an important reminder that powerful forces in Norwegian society want to curtail freedom of speech and democracy.\"\n\nThis was hardly the first time that members of SOS Racism had behaved like fascist gangsters. Still, it seemed more than likely that these \"demonstrators,\" in carrying out this particularly audacious assault (in the shadow of the Norwegian Parliament, no less) on freedom of expression and of assembly, had been inspired by the post\u2013July 22 atmosphere\u2014by, specifically, the New Quislings' message that it was high time to still Norway's non-PC voices.\n\nWhile the New Quislings, then, were claiming, against all reason, that the violent actions of a lone, insane terrorist had been influenced by scores of passionate, freedom-loving opponents of violence and terrorism, the New Quislings themselves, with their overheated rhetoric, were now successfully instigating precisely the kind of actions they wanted. Multicultural hooligans had begun to take action to cow, and to silence, the critics of multiculturalism\u2014just as Hylland Eriksen, Bangstad, and others so devoutly desired.\n\nAnd speaking of inspiration: in September 3, after weeks and weeks of shrill assertions throughout the Norwegian media that Breivik's atrocities had been inspired by a range of anti-jihadist writers, it was announced that the murderer, under interrogation by police, had said that his actions had in fact been inspired by the Red Army Faction, the far-left German terrorist group of the 1970s and '80s that was also known as the Baader-Meinhof Group. As Hans Rustad noted at document.no, Breivik shared the RAF's \"total ruthlessness in making war against society\"\u2014a modus operandi also evinced, he noted, by al-Qaeda.\n\nThis news might have silenced warriors with less determination\u2014or a greater capacity for shame\u2014than the New Quislings. But Bangstad, Hylland Eriksen, and company were unwavering. They knew what they wanted\u2014and, to a remarkable extent, they were getting it. Many Norwegians did indeed seem to be intimidated. They were doing penance for having thought for a couple of hours on July 22 that the bombings in Oslo were the work of Islamists. They were doing penance for having shared with this insane murderer\u2014and with Angela Merkel, David Cameron, and Nicolas Sarkozy\u2014the awareness that multiculturalism in Europe has been a failure. They were doing penance for having recognized that their country has critical problems with Islam, immigration, and integration that need to be addressed before it is too late.\n\nThey could not, one hoped, remain cowed forever. But it was unclear how long this state of affairs would continue. It was frightening to think that as a result of these atrocities, real discussion of multiculturalism, immigration, and Islam might remain in limbo for so long that Norway would miss its chance to save itself.\n\nI had hoped that in the September 12 local elections, Norwegian voters would prove their mettle and react strongly against the left's poisonous post\u2013July 22 rhetoric by voting in large numbers for the unfairly smeared Progress Party. But no. The election results showed that the poisonous rhetoric had, in fact, done its work. The Progress Party suffered its greatest losses ever, dropping from 17.5 percent of the vote in 2007 to 11.4 percent. Siv Jensen acknowledged what everyone knew\u2014that the fanatical effort by the party's opponents to link it to Breivik had driven supporters away in droves. It was depressing to discover that so many Norwegian voters could, indeed, be so easily swayed by what they well knew was a mendacious campaign of personal destruction.\n\nThe months went by. And the Norwegian media kept up their assault on the critics of Islam and multiculturalism. Nearly every day, one or another of the major newspapers ran an opinion piece making exactly the same charges that had already been made by Ekern, Nome, Bangstad, and company. My name came up constantly, but nobody, as far as I noticed, ever fairly represented my views or made a serious attempt to challenge any argument I had ever made; instead they tirelessly demonized me. It was pure name-calling: I grew used to seeing myself labeled a \"right-wing extremist,\" \"conspiracy theorist,\" and \"Eurabia writer.\" Nor was I alone in being targeted in this way.\n\nEvery now and then there was a brief flare-up of resistance. In November, for instance, in an intense exchange with Prime Minister Stoltenberg in front of the Norwegian Parliament, Per Sandberg, deputy chairman of the Progress Party, complained that the Labor Party had been playing the victim card ever since July 22. Stoltenberg replied heatedly that the Labor Party had, in fact, been the victim on July 22. Sandberg might have responded: \"I am not talking about those young people who were senselessly killed at Ut\u00f8ya. I am talking about the way in which the Labor Party and its supporters have exploited their deaths in the month since.\" Instead, Sandberg hastily withdrew his remarks and issued an abject apology.\n\nNovember also saw the publication of the first book about July 22.\n\nBefore Anders Behring Breivik came along, \u00d8yvind Str\u00f8mmen, born in 1980, had been a left-wing Norwegian blogger known mainly to a small coterie of like-minded readers. In the weeks after Breivik's atrocities, however, he won a degree of national attention as one of the leaders of the charge in the mainstream press against the critics of Islam. In the autumn of 2011, he was named \"freelancer of the year\" for \"his work monitoring Islam-hating environments on the net.\" When his book, The Dark Net: On Right-Wing Extremism, Contra-Jihadism and Terror in Europe, came out, it proved to be exactly what one expected.\n\nPublished by Cappelen, Str\u00f8mmen's book did not deviate in the slightest from the new party line. Str\u00f8mmen equated \"Fjordman\" with al-Qaeda's intellectual hero Sayyid Qutb. He described Serge Trifkovic, a serious critic of Islam, as \"one of the ideologues behind the modern Islam-hate.\" He lumped me and several other authors together as disciples of Bat Ye'or, writers of \"Eurabia literature\" and purveyors of conspiracy theories. He called Bat Ye'or \"a central source\" of my book While Europe Slept, and claimed that I treated her in that book \"as a guru.\" While admitting that \"there are immigrant-heavy areas in [Sweden] that have obvious social problems,\" Str\u00f8mmen insisted that my accounts of such problems \"are blown out of all proportion.\"\n\nBut what did he himself have to say about Islam in Europe? Virtually nothing. It was a subject on which he plainly did not wish to dwell. He had written an entire book about what he manifestly considered a dangerous epidemic of Islam-hatred in Europe\u2014but he was not interested in exploring the question of why, exactly, so many writers from so many different backgrounds had chosen to become, in his eyes, haters of Islam. To ask such a question would be to look into a reality Str\u00f8mmen was plainly out to avoid.\n\nHence he repeatedly quoted factual statements about Islam in a dismissive manner, as if they were so obviously untrue and rooted in bigotry as not to require refutation. For example, he scorned the notion of \"stealth Islamization\" without deigning to examine the evidence. He mockingly rejected the idea that Osama bin Laden, far from perverting his religion, had in fact been acting according to its dictates\u2014but did not dare to look at the relevant Koranic texts. And he described taqiyya as \"the Muslim-haters' answer to The Protocols of the Elders of Zion\"\u2014as if this Muslim doctrine, which permits believers to lie to infidels, were an invention of Islam's critics rather than an integral part of Islam itself. I may have missed it, but I don't remember seeing the word sharia once in St\u00f8mmen's entire book.\n\nThe first sentences of The Dark Net prefigured the way in which Str\u00f8mmen treated Islam throughout. He used to live, he told us, in a Muslim neighborhood in a Belgian town, where he had a perfectly nice relationship with the local merchants, who sold him \"Moroccan cakes . . . dripping with honey.\" This opening flourish was right out of the European cultural elite's ragged old playbook: Muslims are an exotic, enriching addition to European culture and cuisine\u2014period.\n\nNaturally, Str\u00f8mmen called for censorship\u2014while insisting that he was doing nothing of the kind. \"Freedom of expression and of the press,\" he wrote in his concluding pages, \"should be key elements of every democratic society. But they place us under an obligation, too. Good democratic debates required good soil and fresh water. If they lack this, seething pools of hate will develop. As citizens, we have a responsibility.\" It wasn't exactly clear what he was calling for here, but it certainly didn't sound good. In fact, it sounded downright totalitarian.\n\nHow did the Norwegian media receive The Dark Net? Guess. \"A strong contribution to the soul-searching the Norwegian community must go through after July 22,\" wrote NRK's reviewer. \"The year's most important book,\" pronounced Dagsavisen.\n\nBack in 1998, when I moved from America to Europe, I was on a personal, moral, and spiritual journey. I was in search of a home that was both liberal and willing to defend its liberal values. In Norway, alas, the defenders of liberal values now seemed to be in full retreat. In the weeks after July 22, for the first time in my life, I found myself breathing a sigh of relief that I was not in Norway\u2014and feeling a deep concern for all of the people I love and respect who were there, many of whom had now been placed in the position of having to defend liberalism from savage attacks by the New Quislings of the Norwegian left.\n\nThose New Quislings had been waiting for years for an opportunity to destroy their enemies utterly\u2014and they had now found it. They have been brutal in their attempt to stamp out the truth and to silence the truth-tellers, and so I will be brutal in my bluntness: speaking practically, Breivik is the best thing that has ever happened to them. As Walid al-Kubaisi has so cogently argued, if Breivik had \"indirect accomplices,\" they were not the critics of Islam and defenders of freedom, but the multiculturalist opponents of open democratic debate about Islam. Or as another wise observer of the situation put it to me recently: \"If you want to know who is responsible for Breivik, it's not the people whose books he read. It's the people who refused to debate and discuss the contents of those books and instead chose to stigmatize their authors\u2014and who in the aftermath of the Oslo massacre decided that this was an opportunity to win the argument without having to address the evidence. They're exploiting this episode as viciously as they can to try to restore their control over the parameters of public debate\u2014not understanding that that is precisely what caused the problem in the first place. And not understanding, either, that their 'solution' will only make things worse.\"\nAbout the Author\n\nA native New Yorker who has lived in Norway since 1999, Bruce Bawer has written several influential books on a range of issues. A Place at the Table: The Gay Individual in American Society (1993) was named by columnist Dale Carpenter as the most important nonfiction book about homosexuality published in the 1990s; Publishers Weekly called Stealing Jesus: How Fundamentalism Betrays Christianity (1997) \"a must-read book for anyone concerned with the relationship of Christianity to contemporary American culture\"; While Europe Slept: How Radical Islam Is Destroying the West from Within (2006) was a New York Times bestseller and a National Book Critics Circle Award finalist; and Surrender: Appeasing Islam, Sacrificing Freedom (2009) was hailed by Booklist as \"immensely important and urgent.\" He has also published several collections of literary and film criticism, including Diminishing Fictions and The Aspect of Eternity; and a collection of poetry, Coast to Coast, which was selected by the Dictionary of Literary Biography Yearbook as the best first book of poems published in 1993. He is a frequent contributor to such publications as The Hudson Review, City Journal, The American Scholar, Wilson Quarterly, and The Chronicle of Higher Education, and has reviewed books regularly for the New York Times Book Review, the Washington Post Book World, and the Wall Street Journal. His website is www.brucebawer.com.\n\nVisit www.AuthorTracker.com for exclusive information on your favorite HarperCollins authors.\nCopyright\n\nBroadside Books\u2122 and the Broadside logo are trademarks of HarperCollins Publishers.\n\nTHE NEW QUISLINGS. Copyright \u00a9 2012 by Bruce Bawer. All rights reserved under International and Pan-American Copyright Conventions. By payment of the required fees, you have been granted the non-exclusive, non-transferable right to access and read the text of this e-book on-screen. No part of this text may be reproduced, transmitted, down-loaded, decompiled, reverse engineered, or stored in or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical, now known or hereinafter invented, without the express written permission of HarperCollins e-books.\n\nEPUB PUBLISHED FEBRUARY 2012\n\nISBN: 9780062188694\n\n12 13 14 15 16 EPUB 10 9 8 7 6 5 4 3 2 1\nAbout the Publisher\n\nAustralia\n\nHarperCollins Publishers (Australia) Pty. Ltd.\n\nLevel 13, 201 Elizabeth Street\n\nSydney, NSW 2000, Australia\n\n<http:\/\/www.harpercollins.com.au>\n\nCanada\n\nHarperCollins Canada\n\n2 Bloor Street East - 20th Floor\n\nToronto, ON, M4W, 1A8, Canada\n\n<http:\/\/www.harpercollins.ca>\n\nNew Zealand\n\nHarperCollins Publishers (New Zealand) Limited\n\nP.O. 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+{"text":"\n\nThe   \nMEDICINAL  \nCHEF\n\n# Heart disease\n\nEat your way to better health\n\nDALE PINNOCK\n\n# CONTENTS\n\n  1. Title Page\n  2.   3. An introduction to cardiovascular disease \n  4. Stress and diet \n  5. The cardiovascular system: what it is and how it works \n  6. Key physiology \n  7. The cholesterol conundrum \n  8. Cardiovascular disease processes \n  9. The role of nutrition in heart health \n  10. Key heart-healthy ingredients \n  11. References, contacts and resources \n  12.   13. RECIPES \n  14. Breakfast \n  15. Weekday lunches \n  16. Weekend lunches \n  17. Quick dinners \n  18. Fancy dinners \n  19. Drinks, desserts and snacks \n  20.   21. Index \n  22. Copyright\n\n# An introduction to cardiovascular disease\n\n## CARDIOVASCULAR DISEASE IS NOW THE BIGGEST KILLER IN THE DEVELOPED WORLD. FACT!\n\nIn this day and age you would think that it would be something apocalyptic, such as famine or war, that would be humanity's downfall. But, alas, it seems that in terms of our health, we are the victims of our own 'progress'.\n\nWhen you look at the numbers in the UK alone, you start to see a very scary picture forming. According to The British Heart Foundation's latest set of released figures, this is the scale of the problem: coronary artery disease will kill one in six men and one in 10 women... and there are more than 2.3 million people living with the condition in the UK. There are 103,000 heart attacks and 152,000 strokes in the UK each year, while 750,000 people are living with heart failure.\n\nAs we look across to the United States, an even more grim tale unfolds. In the US someone dies from a heart attack every 33 seconds! More than 920,000 heart attacks are recorded annually and more than 80 million people have cardiovascular disease. This is a staggering picture. This is epidemic proportions.\n\nThe sad thing is, in these modern times, we are not seeing a decline. In fact, quite the opposite. Heart disease, its deaths and complications are on a rapid rise and are set to become the leading cause of death on the planet.\n\nPerhaps what is most alarming of all, though, is the fact that the highest proportion of these numbers come from avoidable circumstances. Granted, there are hereditary factors that can increase our risk of cardiovascular disease but, in the main, we are looking at a lifestyle condition. This means that we really can be in the driving seat here. Of course there are no guarantees in life, but if you don't want to get run over, then jogging blindfolded round the M25 is possibly not the best of ideas. Right? Making a few small changes to your lifestyle will be like whipping that blindfold off and getting on the footpath. Something may swerve off the road, but it's fair to say you are doing all you can to stay in the clear.\n\nOur lives today, with their stresses and strains and weird and wonderful habits, are driving the rapid movement towards a cardiovascular epidemic. There are some factors that are really fanning the flames, so let's examine them and see what we can do to help ourselves.\n\n# Stress and diet\n\n##   STRESS\n\nModern life is pretty insane. I think that's a reasonably fair assessment of things. The pressures imposed upon us by this life we have created for ourselves here on 21st century planet Earth are overwhelming. The worries that accompany our financial ebbs and flows are ever growing and, let's face it, listening to the news doesn't help. Juggling home and career is like an insane science. Raising a family. Moving home. Modern life is filled with things that can take their toll on us and cause us to become so far detached from how we are supposed to live.\n\nNow, I'm a realist and I happen to enjoy modern life, so I'm not suggesting you should sell your house, buy a yurt and set up a commune in Glastonbury. But learning to manage stress can have a huge impact on many aspects of our health, especially the health of the circulatory system.\n\nStress can seriously send up our blood pressure, increase inflammation and play havoc with blood sugar balance. As you will see later in the book, these are important factors in heart health and disease.\n\n##   DIET\n\nThis is where things have taken a massive nose dive. The modern diet in the West doesn't remotely resemble what we are meant to eat. The utter rubbish that has somehow become staple food makes the mind boggle. The consumption of processed food, refined food, fast food and \u2013 frankly \u2013 non-food is off the scale. There are people out there \u2013 I speak to a lot of them \u2013 who don't eat _any_ fruit and veg, unless you count cider and chips. This is a serious issue and it affects a big proportion of the population.\n\nThere are a lot of others who are trying to be health-conscious and make changes based on outdated and falsified information and guidelines (see page ). Their good intentions are actually putting them at greater risk of disease.\n\nThese factors can be addressed. With a little clarity, focus and effort, you don't have to become another statistic. We can all move away from this epidemic... it is not an inevitability.\n\nI will keep the information you need clear and to the point, but I won't skimp on detail. I want you to read this book without getting bored senseless, but also to learn enough from it to understand what is happening in your body, and how the food you eat can directly impact that for good and for bad. Then, best of all, I'll give you inspiration and ideas about how to put this picture all together rather deliciously.\n\n\"If you eat the standard Western diet that most people eat in the modern world, it is likely you will develop heart disease.\"\n\nDR JOEL FUHRMAN\n\n# THE CARDIOVASCULAR SYSTEM: WHAT IT IS AND HOW IT WORKS\n\nHaving a basic understanding of the cardiovascular system will enable you to start to build a clear picture of what is going on in your body, how small changes in your diet and lifestyle will have a great impact upon it, and especially how your current diet and changes you make to it may affect your specific issues. 'The cardiovascular system' refers to the heart, the blood vessels and their contents.\n\n### THE BLOOD\n\nThe most obvious place to start. This tissue is the whole reason the circulatory system exists and finding out what it is, the components in there and which plays what roles will be useful later.\n\nOne of the primary functions of the blood is as a transport system. It brings oxygen and nutrients to the cells and tissues of the body. The nutrients we take in \u2013 vitamins, minerals, amino acids, fats, glucose, or their by-products \u2013 play vital roles in the daily operations of every cell in every tissue in every system. These nutrients and their by-products get where they need to go via the blood. The blood also carries away waste. Our cells are very good at housekeeping; they process waste and throw it out as rubbish to be carried away in the circulatory system.\n\nThe blood is made up of several components:\n\n### PLASMA\n\nThis is the liquid portion of the blood, and makes up around 55 per cent of blood volume. It has very little colour \u2013 just a subtle pale yellow tinge \u2013 and is mostly water with a bundle of proteins, clotting factors and nutrients suspended in it. It also carries antibodies and other important elements for our immune function.\n\n### ERYTHROCYTES\n\nOtherwise known as red blood cells. These are the familiar disc-like cells that we often see in images and animations of the blood. Their main job is to transport oxygen to our tissues. Red blood cells contain a protein-based structure called haemoglobin. This is known as a metalloprotein (a protein that binds to metal), as iron makes up an important part of its structure. The iron in haemoglobin actually binds to oxygen to carry it around the bloodstream, where it can be deposited to cells and tissues. This is why people who have serious anaemia or iron deficiency become very tired and fatigued, as their capacity to deliver vital life-giving oxygen to cells is diminished. If cells don't get enough oxygen, their ability to create energy and perform many important functions is greatly impaired and severe fatigue and malaise soon set in.\n\n### LEUKOCYTES\n\nOtherwise known as white blood cells, these are the second most prominent type of cell in our blood. They are essentially the army of our immune systems, patrolling the body on the look out for anything that is upsetting the peace.\n\nThey can rapidly identify invaders that are trying to cause infection or damage. They can also identify our own cells that are suffering for whatever reason. They can tell if one of our cells has become infected and is in trouble. Or they can identify cells that are going through pathological changes, such as the changes that occur during the initiation of cancer. When they make this identification, they can set about a series of events that can deal with it. Some incidents can be dealt with by leukocytes there and then; others may require the leukocytes to recruit help and back-up.\n\nThere are several different types of white blood cells that do slightly different jobs. I won't go into all the details now but, as we go on, I will touch on the subtle differences as they become relevant to the whole picture of cardiovascular health.\n\n### THROMBOCYTES\n\nAlso called platelets, these are the third cell type that make up the non-liquid portion of our blood. Their role is to carry out what is called haemostasis. This is basically stopping bleeding at sites of injury. When you cut yourself, the blood doesn't keep oozing out of your body without stopping; we'd soon be in trouble at a very young age if that were the case. This is all thanks to our thrombocytes.\n\nThey stop the bleeding by rushing to the area of damage and forming a platelet plug. This is as it sounds, a clumping together of these cells to plug the wound. When this occurs, platelets send out a series of chemical messengers. Clotting factors (substances that assist with the clotting process) that are circulating in the plasma are sensitive to these signals and, when they get to the area of the platelet plug, they begin to lay down a fibrous structure called fibrin, which forms a mesh around the plug and strengthens it.\n\nThis series of events is an important thing to remember, as it is a vital part of understanding some of the things that take place in the body in cardiovascular disease.\n\n### THE HEART\n\nThis astounding pump system is so complex that it is beyond even the best human engineers. There have been numerous attempts to replicate it, all of which have failed miserably. There are artificial systems that can do its job during surgical procedures, but nothing that comes close to mirroring its functionality. About the size of a closed fist, the heart takes the deoxygenated blood (blood that has delivered all of its vital oxygen to the tissues) that is in your veins to the lungs to become oxygenated, before it is taken back off to the tissues of our body once again. It is divided into four chambers: two atria and two ventricles. Between each atrium and ventricle there is a one-way valve that prevents the backward flow of blood, ensuring the pump works as an effective continuous one-way system, with blood flowing in, then out in a perfectly orchestrated fashion.\n\nThe heart is divided in half, with two chambers per half. The right and left sides of the heart have two distinct jobs to do. The right side brings in blood that has low levels of oxygen and sends it to the lungs to get its oxygen levels topped up and also to remove its carbon dioxide. The left side of the heart takes the blood that has been freshly oxygenated and pumps it back out to the rest of the body, sending vital oxygen to our cells.\n\n### THE BLOOD VESSELS\n\nOur blood vessels (arteries and so on) resemble a network of incredibly complex plumbing. Thousands of vessels run through our body, some as thick as a hose pipe, others thinner than a single hair, delivering blood, oxygen and nutrients to our tissues. The thicker ones are called arteries, the next size down are arterioles, with the smallest and finest being capillaries.\n\nUnderstanding the structure of the blood vessels and how they work is a vital part of understanding the events that take place in cardiovascular disease, and to start seeing how diet and lifestyle may offer both prevention and intervention.\n\nBlood vessels are made up of several layers that all have different functions to carry out. Of these layers, the two I want you to become most familiar with \u2013 and those that I am going to discuss most frequently \u2013 are the endothelium and the smooth muscle layer.\n\n### SMOOTH MUSCLE\n\nThe bulk of our blood vessel walls is formed from smooth muscle. Smooth muscle is a type of involuntarily muscle (that means it reacts to environmental and chemical changes, rather than our conscious choice to move it, as we would a muscle in our legs).\n\nBlood vessels need to be incredibly responsive to the constantly changing environment of our bodies and the continual fluctuation in our tissues' needs for oxygen and nutrients. To be this responsive they must change size and shape very quickly.\n\nThe smooth muscle in the blood vessel walls can rapidly contract and relax to allow this change to occur. This has great relevance to heart disease as will be described in the next section (see page ).\n\n### ENDOTHELIUM\n\nThe endothelium is an incredibly thin yet unbelievably supple and complex inner skin that lines our blood vessels.\n\nAt face value level, the endothelium acts as a physical barrier between the blood vessel's contents and the rest of the vessel structure. This in itself is vitally important, as there are many potentially damaging components that can be in our circulation that could affect the health of the vessel.\n\nThe endothelium also regulates many aspects of blood vessel function, anything from responding to hormonal signalling to even controlling the activity of the smooth muscle described above. The health of the endothelium is of vast importance to cardiovascular health in general, and will be a recurrent theme in this book.\n\n# KEY PHYSIOLOGY\n\nOK, so I'm not going to expect you to suddenly become a heart surgeon or anything, but I do firmly believe that you should be as informed as possible about the inner workings of your body. There are a few aspects of how the cardiovascular system works that will really help you both to start to put the information in this book into some kind of context and to bring the bigger picture together. The more you can grasp what is going on, the better you can understand how nutrition is a key part of the solution. There are a few main areas, things that you would have heard about over and over \u2013 either from your doctor or in the news \u2013 that are vital to understand. The first of these is:\n\n### BLOOD PRESSURE\n\nWe all know by now that, if blood pressure is too high, we have a problem. The British Heart Foundation estimates that there could be in excess of five million people in the UK with undiagnosed high blood pressure. That is a serious number. But what is blood pressure? What does the term mean and why is it such a big deal?\n\nBlood pressure is basically the pressure that circulating blood places on the blood vessel walls. There has to be a certain amount of pressure in our vessels so that each contraction of the heart can push the blood to where it needs to go. As the blood is moved along, it exerts pressure against the vessel wall. That's it. So, why does it matter how high it is?\n\nThe higher your blood pressure is, the more force is placed upon the blood vessel walls, which figures. The vessel walls are designed to withstand a vast amount of force, but not a limitless amount. We get to a point where too much pressure is a problem. If your blood pressure is high enough for long enough, then the vessel becomes more susceptible to damage and any areas that have already been damaged from previous events run the risk of getting worse.\n\n### WHAT THE NUMBERS MEAN\n\nWhen we have our blood pressure checked, we are told (sometimes) a couple of numbers, then there is usually a suggestion as to whether they are good or bad. But what do the numbers mean? Following a blood pressure measurement, you will be told that your blood pressure is 'something over something'; 120 over 80 for example. The first number (systolic), represents the pressure exerted on the vessel wall when the heart squeezes and a large volume of blood is forced through the blood vessel. The second (diastolic) number points to the pressure put upon the vessel wall when the heart is at rest, or between beats. So which number is the most important? Well, in most cases it is the first one, the number that shows how much of a beating the vessel wall is taking under the most amount of force. The higher this is, the more risk there is of vascular injury, heart attack or stroke. More pressure = more chance of damage. (However, according to Blood Pressure UK, recently it has been thought that in those less than 40 years old, diastolic pressure is a greater predictor of risk. This may be because it can show that there is less flexibility in the vessel wall than expected, or that a kind of hardening has started to take place.)\n\n### WHAT IS NORMAL AND WHAT ISN'T?\n\nThere isn't really a gold standard perfect reading as such, and the old saying that your blood pressure should be 100 plus your age doesn't actually stand up to a lot, but these ranges (see right) should give you a rough idea.\n\n### WHAT CONTROLS BLOOD PRESSURE\n\nThe main driver of blood pressure is a pair of responses called vasoconstriction and vasodilation. Vasoconstriction makes the vessel get smaller and narrower. Vasodilation makes it get larger and wider. As a vessel constricts and gets narrower, the pressure within it gets much higher, as a specific volume of blood is having to be forced through a smaller space. When a vessel dilates and gets wider on the other hand, the pressure within it drops as there is more space for the blood to fill, hence less force exerted on the blood vessel wall. A healthy vessel is moving between these two states constantly to keep our blood flowing along nicely.\n\n\"Think about it. Heart disease and diabetes, which account for more deaths globally than anything else combined, are completely preventable by making comprehensive lifestyle changes. Without drugs or surgery.\"\n\nDR DEAN ORNISH\n\nEverything from physical activity to the health of our blood vessels will determine the rate and extent to which these changes occur. In a healthy individual, the move between vasodilation and vasoconstriction should be smooth and highly responsive. If you recall from the previous section (see page ), the bulk of our blood vessel walls are made up of layers of smooth muscle. This smooth muscle is the key component of the blood vessels that allows them to widen and constrict so readily. The muscle contracts; the vessel gets narrower. The muscle relaxes; the vessel gets wider.\n\nThink back to the previous section and you will recall that I placed great importance on the endothelium, that thin but vitally important inner skin that lines our blood vessels. Well, this seemingly simple structure is one of the major controllers of vasodilation. This is due to a highly active chemical that the endothelial cells produce, called nitric oxide. When the endothelial cells produce nitric oxide, it leaves the endothelial cells and then migrates out deep into the vessel walls, where it encourages the smooth muscle of the blood vessel to relax, which then allows the vessel to widen. Vasoconstriction is caused by a number of chemical factors, from calcium flowing into the muscle, through to neurotransmitters. Calcium, for example, causes muscle fibres to move together and muscles to contract, which in turn will narrow the blood vessel wall.\n\nIn terms of how nutrition can influence this whole picture, nitric oxide production and vasodilation is the most relevant part. The section of this book that describes cardiovascular disease processes will give you a good idea of how things can start to go wrong with the endothelium and the knock-on effects of that through the system as a whole, then when we get to explore the role of nutrition in cardiovascular health, we will begin to see how certain nutrients and dietary patterns can influence this. Hopefully, by building the picture piece by piece, you will finish reading the book with a better understanding of what's going on and what you can do about it.\n\n### BLOOD CLOTTING\n\nThis is a normal and absolutely vital response to injury and, without it, we would be in big trouble. It basically describes a series of events that stem bleeding when a vessel is injured. This can be the obvious type of injury, such as when you cut yourself, or silent internal injuries, such as damage to a blood vessel wall or a ruptured plaque (more on that later).\n\nSticking with the cut finger, you will realise that, when you cut yourself, you don't carry on bleeding to the point that you turn white and keel over. After a minute or so, the bleeding stops; give it a good few hours and a scab will start to form. This is the whole process of coagulation in action.\n\nWhen an area of a blood vessel becomes damaged, whether a kitchen knife ploughs through it or an atherosclerotic plaque ruptures (again, more on that later), a response is set in motion. Thrombocytes (platelets) begin to clump together around the site of injury to form a platelet plug. When this occurs, platelets send out a series of chemical messengers. Clotting factors that are circulating in the plasma are sensitive to these signals and, when they get to the area of the plug, they begin to lay down a fibrous structure called fibrin, which forms a mesh around the plug and strengthens it. This is essentially like a scab; the masking tape over the leak in the hose pipe. A makeshift repair job that stems the bleeding, while your body begins to repair damaged tissues. While this sequence of events is designed to save your life, as we'll see, when the process happens within a blood vessel, there is the potential for it to be life threatening.\n\n# THE CHOLESTEROL CONUNDRUM\n\nI don't think there is any greater area of misunderstanding, confusion, contradiction and outright panic than the area of cholesterol and heart health. So many clients that I have worked with over the years have been almost fixated on their cholesterol levels... and terrified by the numbers.\n\nMassive health campaigns that cross continents and span generations have been among the public health front runners. There have been TV campaigns, funny little drinks, you name it. And there have been many efforts to get us all to reduce our cholesterol and, of course, many a commercial opportunity, too. But how many of us actually understand our cholesterol, know what it is, or even know what half the terminology means?\n\nLet's get one thing perfectly clear from the off: cholesterol is a vital substance. The fact that our body produces up to one gram of it per day, regardless of what our diet looks like, is a pretty good indicator that it may actually need to be there and may not be the murderous villain that we are led to believe it is. Mechanisms that lead to that scale of production inside all our bodies cannot be some unfortunate physical flaw; they exist because the substance is vital to our health. Cholesterol is needed for the manufacture and maintenance of cell membranes.\n\nEach cell in our body consists of hundreds of different pieces of machinery and a host of biochemical signalling and relaying systems. These substances are held in place by a double-layered fatty bubble called the membrane. The membrane also helps our cells to function, as it actively gets involved in carrying messages from outside the cell to the inside, and moving things in and out. So, all in all, pretty important! Cholesterol helps strengthen the bonds within this structure, so it is more resilient. It also helps to secure specific proteins found within cell membrane walls that are involved in relaying signals between the inside and outside of cells.\n\nCholesterol plays an incredibly important role in digestion, too, as it is also used to create the bile acids that are released from the liver during digestion. Specifically they are involved in the breakdown of fats into smaller, more manageable particles, ready for absorption. Cholesterol has another vital role to play. It is the metabolic precursor (the chemical building block) for some vital substances in the body. One of the most important is vitamin D.\n\nAs you may be aware, vitamin D is the latest nutritional darling and the centre of a huge amount of research. What we are discovering about it is truly remarkable. We all know that it is important for maintaining healthy bones, because it helps the body to use calcium properly. But its benefits don't stop there. It has been shown to affect both mind and mood and it also regulates immunological responses.\n\nWhere does it come from? Well, a certain amount can come from our diet, from foods such as oily fish and offal. But the primary source of vitamin D for humans is the conversion of cholesterol into vitamin D when our skin is exposed to ultraviolet radiation (the sun)! Here in good old England, the sun is little more than a rumour for most of the year, so if the benefits of what little we do get are stifled by having very low levels of vitamin D precursors, we are in a bit of trouble.\n\nCholesterol is also the precursor for our main sex hormones: oestrogen and testosterone. The body needs cholesterol to make these. I don't know about you, but I for one don't want to see my levels of testosterone plummet any time soon! So, with all this in mind, I think it is clear that cholesterol isn't the demonic destroyer of health that we automatically suppose.\n\n### LDL AND HDL\n\nI guess you might have heard the terms LDL cholesterol and HDL cholesterol. These are sometimes also called 'bad' and 'good' cholesterol. What do they mean? Well, to start with, there is only one type of cholesterol. Cholesterol = cholesterol. It is a thick waxy substance. As such, it doesn't mix well with our blood (oil and water just won't mix) so, left to its own devices, it wouldn't get very far or fare very well just bobbing around fattily in our bloodstreams.\n\nTo this end, the body has its own transport system to shuttle cholesterol around the body. These are like two different bus routes and the bus is called a lipoprotein, a protein that can give fatty substances a piggy back. LDL = Low Density Lipoprotein, HDL = High Density Lipoprotein. LDL carries cholesterol out into our bodies' tissues via the bloodstream. HDL returns cholesterol from the blood to the liver for recycling and breakdown.\n\nSo, the theory goes that if your LDL (bad) cholesterol is high, then you are at greater risk of heart disease, but if your HDL is high, then it's good news. The basic proposition was \u2013 for a very long time \u2013 that an excess of cholesterol in the blood would begin to deposit itself in the walls of the blood vessels and cause a plaque. It was as simple as that. The more there was, it was thought, the greater your risk of developing heart disease, as more cholesterol would be getting deposited out into your tissues. The resulting medical treatment protocol for the prevention of cardiovascular disease focused upon getting levels of cholesterol down.\n\nFor a couple of decades, the medical profession were happily able to target a specific biochemical marker (cholesterol) in an attempt to decrease cardiovascular disease. Very soon there was a multi-billion dollar market in pharmaceuticals such as statins, while the functional foods market (those funky little cholesterol-lowering drinks) was also beginning to boom.\n\nBut, as the years went by and research moved forward, this clear picture and perfect theory began to fall apart. Did you know that almost 75 per cent of people who have a heart attack have clinically 'normal' cholesterol levels? Normal, as in at healthy levels... now there's a conundrum! Recent studies have even shown that a large proportion of patients with heart disease have a lower-than-average level of cholesterol. If it were purely a numbers game, then this simply would not be the case. Something else must be going on.\n\nPerhaps we have missed the trick! There are populations on the Earth, such as the Inuit people, that have been shown to have staggeringly high cholesterol levels, yet heart disease in their communities is as good as non-existent. Is there something else in their environment, diet or even their genes that offers them protection? If cholesterol were the single pathogenic factor that we have been looking for, then this lack of clarity as well as the seemingly outright contradiction would simply not exist.\n\n# CARDIOVASCULAR DISEASE PROCESSES\n\nHeart disease isn't something you just get struck down with. It is the result of a lot of small changes coming together over time. Many of the things that you have heard of as being risk factors for heart disease \u2013 such as high blood pressure, or smoking \u2013 essentially set the stage for a series of events to occur which can lead to the condition ultimately known as heart disease.\n\nThere are several pathological (disease causing) events that take place. There isn't always a specific order for these occurring and, very often, one gives rise to another in a vicious cycle. Here are the main events, the key pathological processes and certainly the ones that have been at the centre of most studies. Understanding them properly will help you get a better grasp on how nutrition and lifestyle can be one of the most powerful parts of your armoury against cardiovascular disease.\n\n### ENDOTHELIAL DYSFUNCTION\n\nThe endothelium, as we have seen earlier in this book, is the skin that lines the inside of our blood vessels. This thin skin is absolutely vital in maintaining the function of the rest of the blood vessel and, when it goes wrong in some way, the consequences can be devastating to cardiovascular health.\n\nAnd one of the fundamental areas where the endothelium can start to malfunction is when it has a reduced production or utilisation or release of nitric oxide. This is a chemical that is naturally made by \u2013 and released by \u2013 the endothelial cells, and which controls several aspects of vascular biology. It reduces blood clotting, reduces the movement of white blood cells into the vessel walls (see plaque formation, page 30), and also reduces the oxidation of LDL cholesterol. The major and most widely understood role for nitric oxide, however, is vasodilation, which means the widening of blood vessels (remember from when we explored blood pressure, see page ). This is the relaxation of the muscular walls of the blood vessels. It is normally stimulated mostly by sheer stress placed on the vessel walls by blood flowing through. Nitric oxide is produced and released by endothelial cells in response to immediate localised changes that signal a need for a change in blood pressure or vessel function.\n\nProblems arise when nitric oxide release or utilisation is impaired. The first and most obvious consequence is the reduced capacity for the vessels to widen under stress. Lets use the analogy of a hose pipe to give some clarity to this. Imagine you have two hose pipes. One is made of flexible, responsive rubber, the other of stiff, inflexible plastic. When water runs through them at a normal and steady pace, they both perform perfectly well. But, what happens if you should turn on the taps at full pelt? The rubber hose, when faced with the sudden rise in pressure, will simply stretch and expand and 'go with the flow'. The plastic one has no give, so begins to crack and split under the pressure.\n\nWell, this gives you an idea of how things go awry when our blood vessels are less responsive to changes in pressure. Suddenly we are at more risk of damage to the endothelium from the increased pressure against the vessel walls, and any areas of repaired damage and plaques (see page 30) are more susceptible to further damage and rupture. The initial stages of endothelial damage, whether induced by physical stress or other events, involve and lead to...\n\n### INFLAMMATION\n\nWe are now at the point, with research going in the direction that it is, where we can say with certainty that, despite whatever else is going on in the body, cardiovascular disease is essentially an inflammatory condition. Inflammation that causes damage to the vital endothelium and then fuels further pathophysiological changes in the body.\n\nInflammation is a normal, natural and vital thing. It aids our immune system in dealing with pathogens, infection or damaged tissue. In cardiovascular disease, it seems there is a two-way street, or a vicious cycle. Inflammation can cause endothelial dysfunction; endothelial dysfunction can cause inflammation.\n\nOne of the main and most widely established causes of inflammation within the endothelium is the oxidation of LDL cholesterol. LDL cholesterol can become damaged by circulating free radicals (reactive oxygen molecules that cause damage) and be readily oxidised (damaged and chemically altered). When this happens, the oxidised cholesterol can cause damage to the endothelium. Oxidation makes LDL far more able to penetrate the endothelium and cause some of the damage outlined over the page (plaque formation). Other factors that can trigger inflammation are smoking, high insulin levels \u2013 caused by eating too many fast-release carbohydrates for too long \u2013 and stress.\n\nBut, probably, the biggest factor of all for most of us in the Western world is the wrong types of fats in our diet. I am going to go into much more detail in the next chapter on nutrition and heart disease and heart health, but in the Western world we are eating too much of a type of fat that may be killing us slowly. Now, before you think this may be that old-school message about saturated fat that you have heard a million times for decades and that has now been proven to be wrong, think again. Listen up: saturated fat is not the villain that you might have thought.\n\nIn fact, the wrongdoer was the thing we moved over to when we all began abandoning butter for 'heart-healthy' margarines! We are consuming too much of something called omega 6 (see page  for more on this). Omega 6 is a polyunsaturated fatty acid that, when metabolised by the body in more than minuscule amounts, actually exacerbates inflammation.\n\nWhen inflammation arises within the endothelium, the next series of events that can occur are...\n\n### PLAQUE FORMATION\n\nPlaques are the things that form in the blood vessels walls during what is called atherosclerosis. This is what people are referring to when they use the rather crude terminology of 'furring up', or 'clogging', of the arteries. They are the result of a series of events and knowing some of the stages will allow you to understand those elements of diet and lifestyle that may offer help in the prevention and management of the condition.\n\nThe first stage of this process stems from damage to the endothelium, that thin inner skin that lines the blood vessel. This can be susceptible to damage, given the right circumstances (such as those that stem from endothelial dysfunction described on page 27). When this damage occurs, circulating materials in the bloodstream \u2013 such as cholesterol and fats \u2013 can get trapped in the area of damage. Cholesterol that has become trapped in this area suddenly becomes more susceptible to oxidation and damage, due to the array of chemical responses taking place as all this circulatory junk accumulates. When the cholesterol oxidises, it triggers an inflammatory response. This then alerts circulating white blood cells, which move to the site of vascular injury. White blood cells, being what they are, wade in and try to help clean up the mess because, after all, this consistent oxidation of cholesterol can cause untold damage if not managed. So, in order to contain this, the white blood cells begin to swallow up oxidised cholesterol.\n\nWhen white blood cells do this, they begin to change and transform and become what is known as foam cells. When they have changed in this way, their normal ability to move and circulate disappears and they stay put at the site of injury. This is the first stage of what is termed a fatty streak, or fatty build-up within the blood vessel wall.\n\nAs this matures, smooth muscle cells from the muscular walls of the vessel also begin to move into the mass of foam cells and aid in supplying a matrix of fibres that can make this fatty streak more stable. It becomes a collection of fatty material, topped with a fibrous cap that is essentially holding everything in place.\n\nThis plaque can sometimes be very stable and lay unaffected in the blood vessel for a whole lifetime. At other times, plaques can be very unstable, meaning that the slightest increase in blood pressure, or increased force on the vessel wall from blood flow, can cause the plaque to rupture, which gives rise to a thrombus (see below). Also, chronic inflammation that has built up over a long time can give rise to the release of enzymes that can break down the fibrous cap, again leading to rupture. When this happens, the next stage is...\n\n### THROMBUS FORMATION\n\nWhen atherosclerotic plaques rupture, a blood clot quickly forms around the site of rupture. This can be likened to the formation of a scab when you cut your finger. When damage occurs, the affected area sends out chemicals that activate platelets in the blood. Platelets are known as cell fragments. They are cells without a nucleus and contain much less complicated machinery than most cells in our bodies.\n\nWhen the platelets are activated, they become sensitive to the effects of different clotting factors. These varying clotting factors come into play, binding platelets together using a fibrous mesh called fibrin. This ends up almost like a layer of netting that holds everything in place.\n\nThis clot can grow quite large, sometimes large enough to completely block the blood vessel it is inside. When this happens, the tissue it supplies becomes oxygen starved. Depending on how long this state lasts, the tissue may lose some of its function, or die completely. This is what is known as infarction.\n\nIn a heart attack, this occurs in a vessel that supplies blood to the heart muscle. In a stroke, this happens in a vessel that supplies blood to the brain.\n\nSometimes, the clot forms in a relatively wide blood vessel and is in no way big enough to cause occlusion (blockage) of the vessel. But, with changes in blood pressure and the force exerted on to the blood vessel wall from blood flow, clots (thrombus) can be dislodged. They can then move through the circulatory system.\n\nAs the blood vessels get closer to key tissues, they get smaller and smaller and their networks more intricate. As a thrombus moves through this seemingly endless network, sooner or later it will end up reaching a vessel that is just too small to accommodate it, where it will then cause a blockage.\n\n# The role of nutrition in heart health\n\n## THE ROLE OF NUTRITION IN HEART HEALTH, DISEASE PREVENTION AND DISEASE MANAGEMENT\n\nIt is a certainty that 90 per cent of cases of cardiovascular disease are ultimately preventable. That sounds like a bold statement, I know, but one I stand by. They are a result of our environment. This is of course partly the external environment we live in, such as stress, pollution and so on. But, when we talk of environment, we are referring to the internal biochemical terrain of the body. There is nothing that can influence this biochemical terrain more than our diet. With a few simple changes, we can guide our diet towards being cardioprotective. This means it can support cardiovascular health, potentially prevent the damaging issues and play a role in the management of any existing cardiovascular issues.\n\n### OMEGA 3, OMEGA 6 AND A QUESTION OF BALANCE\n\nMany of you that are familiar with my work will have probably twigged by now that I am a little obsessed with dietary fats. It is my belief that the fat composition of our diet is one of the key factors in cardiovascular health and disease. The fixation with dietary fats and cardiovascular health is, however, the reason we have got into such a mess in the first place, with the huge prevalence of this disease globally. In the last four or five decades, the patterns of fat intake in our diet has changed drastically. This is mostly thanks to the work of a man by the name of Ancel Keys.\n\nKeys was an American physiologist who came up with a hypothesis that the cause of cardiovascular disease was saturated fat intake. He was a very ambitious chap and set out to prove this hypothesis with vigour. He designed a 22-country study. It literally was as the name suggests, a study of 22 countries, searching for a correlation between saturated fat intake and cardiovascular disease. Now, the odd thing was, when this study was published, it was as 'The Seven Countries Study'; only seven of the 22 countries' results were used and the results looked very impressive indeed. The data produced a beautiful positive curve and essentially proved Keys's hypothesis that saturated fat intake was indeed associated with cardiovascular disease. But hang on a minute. What about the other 15 countries? What's going on here?\n\nAs it turns out, the seven countries selected were those that actually supported his theory. Had Keys used all 22 countries, the data would have shown absolutely no correlation whatsoever between saturated fat intake and cardiovascular disease. What was published was basically a fraudulent and engineered piece of reporting. Selective inclusion and exclusion of data that 'proved' something that didn't exist. But, alas, this study was taken on board around the world and Keys became a hero.\n\nBefore long he appeared on the cover of _Time_ magazine and his misleading study became the inspiration for the biggest public health cock-up known to man. In no time at all, the American government were developing a public health campaign that encouraged the population to ditch saturated fat and move towards a diet that was high in starchy foods and the supposed 'heart-healthy' oils such as sunflower oil and margarine. The same public health message made it to the UK soon after and then began to dominate the Western world. We took it on board. Didn't we just! This is where the problem began.\n\nYou can actually see, by looking at data from institutions such as the World Health Organisation, that as these changes in our diets occurred and we moved towards more starchy foods and more polyunsaturated oils, the incidence of cardiovascular disease, type-2 diabetes and cancer began to soar and, all of a sudden, we saw an obesity epidemic.\n\nSo, why are these dietary changes an issue? Well, I will talk about the starchy foods in greater detail when I discuss the glycaemic effects of foods and their relevance to heart health. But, for now, let's look at the oils that we started to consume in place of saturated fats. The message was that we needed to move towards a higher intake of vegetable oils, so sunflower, corn and soy oils and spreads became super-popular. Sickeningly they began (and still do) adding the 'heart-healthy' label to their products and advertising.\n\n### OMEGA 6\n\nThe problem that was completely overlooked in those early days was that most vegetable oils are incredibly high in things called omega 6 fatty acids. These are essential fatty acids that are vital to the body and must come from the diet as our body can't make them itself. All good so far. The snag is, however, that we only need a very small and finite amount of omega 6. Once we go over this level, the body metabolises it in a slightly different way than it would when we are at safe levels and changes it for the worse. Fatty acids in the diet are the metabolic building blocks for several important structures and compounds in the body. One of the big and vital groups that they give rise to are a group of communication compounds called prostaglandins. One of the main roles that prostaglandins carry out in the body \u2013 and this is important \u2013 is in the management of inflammation.\n\nThere are three different types of prostaglandins: Series 1, Series 2 and Series 3. Series 1 are mildly anti-inflammatory. Series 3 are strongly anti-inflammatory, switching off or down and regulating inflammation, and regulating pain signalling. Series 2 prostaglandins, on the other hand, actually switch on and exacerbate inflammation. This isn't a bad thing per se, providing that the body can be in a state of flux and produce sufficient amounts of these compounds to manage inflammation adequately.\n\nBut the balance of dietary fats in our bodies can disrupt this process. Different dietary fats are metabolised to form different series of prostaglandins. Omega 6 fatty acids are the metabolic precursors to \u2013 you guessed it \u2013 the Series 2 prostaglandins that switch inflammation on. The drastic shift in dietary fat intake in the last decades has meant that in the UK we take in almost 23 times more omega 6 fatty acids than we need _per day_!\n\nWe are essentially force-feeding metabolic pathways that manufacture prostaglandins, and our body's expression of the pro-inflammatory Series 2 goes into overdrive. The end result is a state of subclinical (your foot doesn't suddenly swell up, this is happening on a microscopic level within tissues), chronic (consistent and long-term) inflammation in the body. These compounds travel around the body in our circulation, so one of the first tissues to take a battering is, of course, the endothelium, as it is the tissue that is immediately exposed to their changing levels.\n\nIf you recall from the previous chapter, inflammatory damage within the endothelium sets the stage for plaque formation and, in essence, cardiovascular disease. The dietary change that was supposed to bring down cardiovascular disease ended up killing us faster. It was akin to trying to put out a bonfire with petrol.\n\n### OMEGA 3\n\nThis is the perfect time to bring in the other big dietary fatty acid, one you have probably heard a great deal about: omega 3 fatty acids. The benefits of omega 3 on heart health are well documented and have been studied widely for at least 20 years. These amazing fatty acids are the antidote to what we have just learned. There are three main types of omega 3: ALA, EPA and DHA. EPA and DHA are metabolised to form Series 3 prostaglandins (EPA more so). These are the most potently anti-inflammatory. So, eating good amounts of omega 3 fatty acids encourages our body to produce more anti-inflammatory prostaglandins.\n\nA growing body of evidence is showing that fish and fish oil consumption appears to offer significant protective benefit against heart disease; indeed, several studies have shown that fish consumption is directly related to a reduced risk of heart disease. A review of three large-scale epidemiological studies found that men who ate at least some fish per week had lower incidence of heart disease than those who ate none  . Similar patterns were also found in women. A 2002 report from The Nurses' Health Study showed that, compared to women who ate no fish, risk of cardiovascular disease deaths were 21 per cent, 29 per cent, 31 per cent and 34 per cent lower for a fish consumption of respectively one to three times per month, once per week, two to four times per week, and more than five times per week  .\n\n\"I'm not comfortable recommending people eat saturated fat with abandon, but it is clear to me that sugar, flour and oxidised seed oils create inflammatory effects in the body that almost certainly bear most of the responsibility for elevating heart disease risk.\"\n\nDR ANDREW WEIL\n\nOmega 3 fatty acids have also been shown to reduce levels of triglycerides. These are fats in the blood that can arise from dietary fat intake and from eating very high-GI foods (see page 41). These fats are believed to be very susceptible to oxidative damage, which could cause or aggravate endothelial inflammation and oxidise LDL cholesterol. A 1997 review of human studies found that around 4g per day of marine-derived omega 3 fatty acids reduced triglycerides in the blood by 25\u201330 per cent  .\n\nPost-prandial triglyceridemia is the elevation of fats in the blood following a meal. This elevation in triglycerides appears to be very sensitive to omega 3 fatty acids, with a dose of around 2g per day reducing it significantly  . These kinds of doses would come from supplementation. (See page  for recommendations.) My approach \u2013 and my advice to you \u2013 is to eat fish and plenty of it and take supplements, too. Omega 3 fatty acids have also been shown both to deliver a dose dependent (that is, greater intake = greater result) reduction in blood pressure  , and to reduce clotting factors that may offer some protection against thrombus formation  .\n\n### THE BALANCING ACT\n\nSo, as you can see, omega 3 fatty acids are a pretty important part of the picture, while too much omega 6 can cause a problem. So it is therefore vital that we get the balance right. With the current trends arising from research, the recommendation now is to aim for a 2:1 ratio in favour of omega 3. That basically means that you need to be eating twice as much omega 3 as omega 6 in order to maximise the potential benefits, and counteract any negative effects of omega 6 in the body. Thankfully, this is pretty easy to manage in practice.\n\nThe first step is to avoid most vegetable oils like the plague. These are the so-called 'heart-healthy' oils such as sunflower oil, corn oil or the generic vegetable oil. These are basically pure omega 6 and will send your levels rocketing up very fast.\n\nIn place of these oils there are two cooking oils to choose from. In most of my cooking I use olive oil. The dominant fatty acid in olive oil is something called oleic acid which comes into a third category: omega 9. Omega 9 fatty acids have zero influence on omega balance, so don't particularly present a problem at all.\n\nThe other oil I use is coconut oil. This is best for high temperature cooking as it is completely heat stable. Also the fatty acids found in there, medium chain triglycerides, are rapidly broken down and used as an energy source, so their impact on postprandial lipaemia (elevation of blood fats after a meal) is minimal.\n\nThe next step in aiming for omega balance is to drastically cut back on processed foods. This is good advice for a million and one reasons but, in terms of omega balance, many processed foods use untold amounts of vegetable oils. They are cheap as chips and, for decades, food manufacturers have been under pressure to reduce saturated fat in foods, so have moved over to cheap vegetable oils as an alternative. Most ready meals, pre-made sauces, biscuits, cakes and so on will have a lot of omega 6 in them. Get back to basics, as we do in the recipes in this book, and get cooking from scratch as much as you can.\n\nThe second part of the solution is to up the levels of omega 3 in your diet. The first and most obvious place to start is by making sure you eat oily fish around three times every week. Then you could also consider taking supplements. I personally take an omega 3 supplement that contains 750mg of EPA and 250mg of DHA twice daily. (But if you are taking medication such as warfarin, or if you have recently had a heparin injection, please check with your doctor before using high-dose fish oil supplements as there is potential for interaction here.)\n\n### KNOW YOUR NUMBERS\n\nFor those of you that really want to be serious about getting your omega balance in check, there is now a home test available online that you can carry out which essentially tells you the ratio between omega 3 and omega 6 in your tissues.\n\n### THE GLYCAEMIC RESPONSE OF FOODS\n\nOne area that is very often overlooked in cardiovascular health is the glycaemic response of foods. This basically describes the rate and extent to which a food raises our blood sugar. Different foods, because of their composition, will release their energy at different rates. Pure glucose, for example, will send blood sugar up very rapidly and vigorously. Glucose is actually the benchmark against which all other foods are measured. It is the simplest form of sugar, so requires no digestive effort. It is consumed, then goes straight into circulation.\n\nFoods vary in their make up and complexity and certain factors will influence how rapidly foods release their energy. Fibre is one of the biggest factors. Let's compare white and brown bread, for example. Brown bread has all the fibre from the wheat husk and many brown breads have additional seeds and fibres added to them. White bread, on the other hand, has had all of the wheat husks removed and so the fibre content is drastically lower. The fibre in the brown bread will simply make the sugars in the bread harder to get to and will require more digestive effort to release. With the refined white bread, on the other hand, the lack of fibre makes the sugar much easier to get at. In the higher fibre food, the sugar is released at a more slow and steady pace, whereas with refined foods (anything white is usually a culprit) it is released at a very rapid pace as it takes far less digestive effort in the gut to liberate the easy-to-get-at glucose.\n\nAnother influence on glycaemic response is the combinations in which you eat certain foods. Adding protein to your carbohydrates, for example, will require a great deal more digestive effort to liberate the glucose. This is because proteins are digested more slowly, so there is a lot more work for the digestive system to do when you eat a combination of protein and carbohydrate. The end result is that you will get a slow, even drip-feeding of glucose into the bloodstream, rather than the giant surge you get when eating refined carbohydrates.\n\nBut why does any of this matter? Well, an obvious reason is that it will greatly influence your energy levels and mood stability, but that is by the by for your heart, which is what we are concerned with in this book. The glycaemic response of your diet over the long term is of great importance to cardiovascular health.\n\nWhen our blood sugar rises, our bodies secrete a hormone called insulin. This hormone basically tells our cells to take in glucose for converting into a substance called ATP, the energy unit that cells run off. So, the first reason insulin is secreted is so that the cells know there is glucose available for use. But the other factor to consider is that our blood sugar must stay at a very precise level. If it gets too high or too low, both states are potentially life threatening. In light of this, there are very precise balance homeostatic (homeostasis = the physiological control of balance in the body) mechanisms in place that control blood sugar. If it drops too low, the secretion of hormones that stimulate appetite is upregulated. Another hormone called glucagon is secreted from the pancreas which encourages the body to release glycogen, the storage form of glucose, for immediate use. If blood sugar gets too high, insulin production goes up, so at the same time our cells' uptake of sugar increases.\n\nHowever, this is where things can begin to go awry. Our cells only have a certain capacity for how much glucose they can take up at any given time, because if they take in more than they can readily metabolise and change into ATP, what is left over can oxidise and cause damage inside the cell. They can get full. If our cells are full to capacity and our blood sugar remains high, the excess sugar must be dealt with somehow and got out of the system as painlessly and effectively as possible before it does damage.\n\nAfter filling cells up to their maximum with glucose, the next most satisfactory way of dealing with it is via a reaction called de novo lipogenesis. This is where the glucose gets converted into a fatty substance called triacylglycerol, a fat that can be taken to the adipose tissue (our bodies' fat cells) for storage and taken away as rapidly as possible.\n\nAnother word for triacylglycerol is triglycerides... Sound familiar? They are often measured during routine blood tests that monitor cholesterol and other cardiovascular disease markers. These are the fats that, when in circulation, are susceptible to oxidative damage which can then cause damage to the endothelium. They also encourage oxidation of LDL, which can further damage the endothelium. Further, they make the LDL particles more susceptible to penetrating the endothelium as in the description of plaque formation (see page ). The clincher is that insulin also increases the likelihood of LDL oxidation, so you get a double whammy blow here. Higher blood sugar on a consistent basis means more triglycerides plus higher levels of insulin. None of this is good news!\n\nNow if you recall from my discussion of fatty acids above, following the 'healthy heart' public health campaigns that arose from Ancel Keys's work, we were all encouraged to fill up on more fruit and veg (that's a good thing) and more starchy foods (that's not a good thing). We started eating more and more bread, potatoes, pasta, grains and so on, every day and at every meal.\n\nNow, before anyone thinks I'm trying to get everyone on the Atkins diet, there is nothing wrong with these foods, but in general in the Western world we are eating way more than we should and, in essence, the balance on our plates is all wrong.\n\nOur preoccupation with fat and the advice to veer away from it and eat more starchy foods mean that we are eating a level that is harmful. These foods can raise our blood sugar notably. Now, once in a while that is no big deal. You will simply send out a bit more insulin, your cells will take in more glucose, problem solved. But, our intake isn't just every now and again.\n\nLet's see if this sounds like an inaccurate or extreme picture: how many people would have cereal and a slice of toast for breakfast? A sandwich for lunch? Then perhaps meat, vegetables and potatoes \u2013 or maybe pasta \u2013 for dinner? That sounds pretty common, right? Well, do that every day for a week, a month, a year and you will soon find your body's blood sugar staying consistently high and more insulin being produced, meaning more lipogenesis, more LDL oxidation, more endothelial damage. Nasty!\n\nThis situation is such an easy thing to remedy though, using a few simple steps:\n\n### REDUCE YOUR INTAKE OF STARCHY FOODS\n\nOK, so this may sound a bit obvious, but this is the place to start. For breakfast, go for a good source of protein such as eggs, smoked salmon or kippers. Ditch the cereal most days and, when you are craving cereal, opt for porridge, as oats have a low glycaemic response (see page ).\n\nLunches should be built around a good protein source, vegetables and salads. One of my lunch staples is salmon salad with a bit of feta and an olive oil-based dressing.\n\nThe evening meal is one where you can afford to have a bit of carbohydrate, as the carbs help the brain to take up the amino acid tryptophan, which helps us sleep. But this doesn't mean scoffing a bowl of pasta or a big jacket spud. Instead, go for choices such as roasted squash or sweet potato. Maybe add some high-protein quinoa or fibre-filled bulgar wheat, or brown rice. These are all very low-GI options and will fill you up and satisfy your appetite. Still, I would advise you only have a very small portion.\n\n### WHEN YOU HAVE CARBS, ALSO HAVE PROTEIN AND FAT\n\nThis is one of the real keys to buffering the effects of the carbohydrates on blood sugar as much as possible. Both protein and fat really slow down the digestion of a meal, meaning that available sugar will be freed slowly and blood sugar will be drip-fed. This is really easy in practice. You could have poached egg and avocado on toast (delicious, trust me). Maybe a piece of grilled fish with roasted sweet potato and some buttered greens. It truly is pretty straightforward.\n\nBy making these simple changes, you prevent the blood sugar roller coaster that, aside from making you feel rubbish, can completely destroy your long-term health. From damaging your cardiovascular system, to causing long-term insulin resistance. See my book _Diabetes: Eat Your Way to Better Health_ to see how this starch-laden diet that dominates the West is causing an epidemic of type-2 diabetes.\n\n### DIETARY FIBRE\n\nWhile we are on the subject of such foods, I wanted to add a little note on dietary fibre. We have all heard of the importance of dietary fibre. It is obviously beneficial for digestive health, but we won't go into that now, because there are also many benefits for what we are concerned with here: the cardiovascular system.\n\nNow, due to the conundrums surrounding cholesterol, I am sitting on the fence and watching what happens with the evidence as it unfolds. But, for many, lowering cholesterol is an important goal and until I can be more certain about what the evidence is really telling us, I won't argue against that, despite what my own personal convictions may be. Well, dietary fibre is a useful tool here. As we have already discussed, cholesterol is made in the body naturally. A small amount of this cholesterol leaves the liver and goes straight into circulation. Most of it, however, takes a bit of a scenic route. It is released from the liver with bile, where it enters the digestive tract. Once it gets in there, it is then re-absorbed back into the circulation.\n\nCertain types of fibre, known as soluble fibre, actually form a gel-like substance in the digestive tract which binds to this cholesterol and carries it away via the bowel before it gets the chance to be absorbed. As there is less cholesterol being absorbed, the liver takes more from the blood to make bile acids and for metabolic usage. This takes blood cholesterol levels down. This has been clinically proven with the fibre from oats, a particularly effective soluble fibre called beta glucan. The recipes in this book have a good fibre content and ingredients such as oats are well represented.\n\n### THE MAGIC OF MINERALS\n\nWe always hear so much about the array of vitamins in our foods. Weird and wonderful fats and fatty acids (guilty) and more antioxidant compounds than you can shake a stick at. However, a group of nutrients that are often overlooked are minerals, some of the substances so vital for human health that even the most tiny microgram difference in intake can be detrimental to our health. In terms of heart health, there are four minerals that are relevant and three of which, if you increase your intake, can have a positive impact on the health of your heart and blood vessels.\n\n### SODIUM\/POTASSIUM\n\nSodium and potassium are two of the most important minerals to be aware of in your daily diet, especially when it comes to managing blood pressure. Sodium has been at the forefront of heart health campaigns for many years and rightfully so. We have for a long time been encouraged to reduce our intake of salt. Why? Well, cheap table salts and most refined sea salts are predominantly composed of sodium chloride. Sodium is an important mineral in the body and we cannot be without it. An excess, however, can create real problems in the body.\n\nSodium has an important role to play in kidney function. Different minerals in different concentrations affect the rate at which fluids move through our kidneys. Sodium basically slows the movement down. When there are high concentrations of sodium in the body, the movement of fluid through the kidneys slows down sufficiently to cause the body to start retaining water. When this happens, the watery portion of our blood, the plasma, begins to increase in volume. This of course increases the volume of blood within the vessel. Which then increases the pressure against the vessel walls, simply because there is more blood in that tight space pushing against it.\n\nAdd to this picture the fact that the substance sodium can in itself be vasoconstrictive (cause contraction of the blood vessels, that makes them narrower) and it soon becomes a serious situation, where the risk of endothelial damage or the rupture of a plaque becomes very real.\n\nPotassium, on the other hand, is like the mirror to this. It is a mineral that we certainly don't get enough of, because its common sources are dark green leafy vegetables, and \u2013 admit it \u2013 these are definitely not top of the list of British favourites. Potassium can speed up the movement of fluid through the filtration mechanism of the kidneys (called the nephron). This can give a diuretic effect and soon begin to reduce plasma volume. In turn, this can take some burden off the vessel walls. The less volume within the vessels, the lower the pressure will be in them, as there is physically less pressing against the vessel wall. Potassium can also help to relax the blood vessel walls, giving a vasodilatory effect.\n\nTo reduce sodium intake, do not use table salt and also avoid refined sea salts. A natural sea salt should have a dull, dirty grey colour. Refined white sea salts have all the other vital minerals removed and are no better than table salt. One option is to go for a low-sodium\/high-potassium salt. There is a subtle taste difference, but when you are using so many fantastic flavoursome ingredients \u2013 such as those in this book \u2013 you will never know about it and you will benefit your health in a big way. Also, again, avoid processed foods such as ready meals and shop-bought sauces. These contain untold amounts of hidden sodium. Get back to cooking from scratch as much as possible.\n\nAt the same time, increase your intake of potassium-rich foods. The best sources are bananas, sweet potatoes, greens, mushrooms, dairy produce, tomatoes and some fish, such as tuna and halibut.\n\n### MAGNESIUM\/CALCIUM\n\nMagnesium and calcium are joined at the hip! Well, not quite, but they do work in tandem with each other all day and all night. This partnership is particularly important in muscle, where they are potent partners in crime. Calcium stimulates muscle fibres to contract, whereas magnesium causes muscle fibres to relax. The two move back and forth, allowing muscles to contract and relax all day. So notable is the effect of these two minerals that they are often used therapeutically. For example, a popular drug for stubborn hypertension is a class of drug called a calcium channel blocker. This reduces the amount of calcium that can get into muscle cells and reduces contraction, in short encouraging muscles to relax.\n\nMagnesium has also been studied as a potential hypotensive agent (something that lowers blood pressure). A 2012 meta-analysis (study of many other studies to determine the significance of results) of 1,173 people found that magnesium supplementation gave a reduction of both diastolic and systolic blood pressure, with the greatest reduction in intakes of over 370mg\/day  .\n\nI feel that supplements are worth considering here. As always, it's all about the food and your emphasis should be on that, but a little extra magnesium in supplement form really wouldn't hurt. (See page , for more information.)\n\nIn terms of foods, greens are definitely at the top of the list. Green vegetables are rich in something called chlorophyll. This is what makes them green. Chlorophyll has a significant amount of magnesium bound to it by its very nature. So, if it's green, it has got decent levels of magnesium in it. Nuts and seeds, oily fish and pulses are other rich sources, but greens definitely rule the roost!\n\n### FLAVONOIDS\n\nThere are a very exciting group of compounds that are rapidly becoming the new superstars of nutritional research in the field of heart health. These are the flavonoids. They are phytochemicals, biologically active, non-nutrient compounds derived from plants. (When I say non-nutrients, I mean that there is no recognised deficiency disease attached to them. Things such as vitamin C, for example, you can be deficient in. Its intake is absolutely essential for our body to function.)\n\nPhytochemicals, on the other hand, are non-essential. You won't die if you don't consume them. But please don't for a moment think that they are not useful! In fact, when it comes to heart health, I would go as far to say that they are essential. I think they have a vital role to play in a healthy diet.\n\nThe richness of phytochemicals in fruit and veg and the power of their activity is part of the motivation behind the five-a-day campaign and a big contributor to the disease protection that is observed in high fruit and veg consumers. Phytochemicals are biologically active, which means that they can directly affect cells, tissues, genes, hormones, enzymes, reactions... you name it! These compounds literally are like nature's medicine cabinet. There are thousands of phytochemicals in plant foods and many that are being researched for every imaginable aspect of health. But, in terms of cardiovascular health, it seems to be the flavonoids that have come up trumps!\n\nFlavonoids are very broadly distributed phytochemicals, found in almost all plants. In short, they are colour pigments and are responsible for colours in plants from yellow and orange, through to deep red and purple. For the most part, flavonoids are known to be powerful antioxidants, helping to protect cells and tissues from free radical damage. However, in recent years, research has uncovered that they may prove to be superheroes in the fight against heart disease. The initial observations here come from meta-analyses of epidemiological data that has, for example, found a correlation between tea drinking and reduced incidence of cardiovascular disease  . It has been found that there is an average 11 per cent reduction in risk for every three cup increase of tea each day  .\n\nProbably the most well known of epidemiological observations is the curious relationship between wine consumption and heart disease. Many studies have shown that there is an observable dose-related (more intake = greater response, although with wine there is a fine line between benefit and risk) benefit to heart health from the regular consumption of wine  . This is where the model of the French Paradox came from, the observation that the French, despite a diet high in dairy, meat and foods high in the saturated fats that were dietary heresy in terms of heart health, had a notably lower risk of cardiovascular disease than did the English, for example  .\n\nWhile these observations of association were being made decades ago, it is only in recent years that we have started to figure out how flavonoid-rich foods may actually be delivering their benefits to our hearts and protecting them from disease.\n\nThink back to earlier in this book, when I described the structure of our blood vessels and the role that these structures played. We now understand that flavonoids interact with the endothelium and that is how the above results are most likely achieved.\n\nWe know that flavonoids actually get taken up by the endothelial cells. Once inside, they cause a little bit of chaos and act almost like an irritant. When this happens, the endothelial cells begin to secrete higher levels of nitric oxide  .\n\nIf you recall (see page ), nitric oxide is a powerful vasodilator. The nitric oxide moves from the endothelial cells into the muscular walls of the blood vessel and causes the smooth muscle to relax.\n\nAs the muscle relaxes, the vessel dilates and gets bigger. As it gets bigger, the pressure within it drops. Evidence now tells us that consistent, regular consumption of flavonoids can have a notable lowering effect upon blood pressure.\n\n# KEY HEART-HEALTHY INGREDIENTS\n\nThis is by no means an exhaustive list, but below are some of the everyday ingredients that I think are the real heroes when it comes to keeping our hearts healthy. The good news, too, is that there's nothing obscure here: they are all regular and familiar ingredients that you can find at your local grocery shop.\n\n##### APPLES\n\nThis fruit is a very simple, easily accessible and versatile heart-healthy food. Why are they so good? Apples are very rich in a soluble fibre called pectin. Any of you that make jam will know that pectin is an effective gelling agent. This gel-like soluble fibre will bind to cholesterol in the digestive tract and carry it off before it gets the chance to be absorbed.\n\n##### AVOCADOS\n\nFor years, people thought of avocado as a fattening food. This was back in the days when we were completely obsessed with fat and the merest mention of it would strike fear into the hearts of many. This is, of course, ridiculous. The fats in avocado are unique, amazing for our health and they should be seen as nothing other than a health food. The fruit is very high in a group of compounds called phytosterols. These are the same compounds that you find in those little cholesterol-lowering drinks. They have been shown clinically to reduce cholesterol, by blocking the absorption of cholesterol through the gut wall (similar to soluble fibre). Avocados are also very rich in vitamin E, which is a powerful antioxidant nutrient. Vitamin E can actually protect LDL cholesterol from oxidation. As we have explored earlier in the book, this can be one of the early factors that triggers endothelial damage, so any protection against this is a vital part of looking after your heart.\n\n##### BEETROOT\n\nOK, so I admit that beetroot is definitely one of those love\/hate foods. Personally I am a huge fan and can't get enough of the stuff. Luckily, in recent years it has been found to have many health benefits. One of the areas that has attracted a lot of attention is the effect beetroot has on blood pressure. It is very high in natural nitrates, a type of mineral salt. This is then converted by the body into nitric oxide, which is naturally produced to regulate blood pressure. Nitric oxide causes the smooth muscles in the blood vessel walls to relax, which widens the vessels and in turn reduces blood pressure within them. Some small-scale studies have confirmed this effect. This doesn't mean you can throw your medicine in the bin and eat beetroot all day, though, it just highlights a powerful ingredient that we can consume more of to benefit our heart health.\n\n##### BLACKBERRIES\n\nBlackberries are incredibly rich in the flavonoid compounds called anthocyanins. These potent compounds are responsible for their deep dark purple colour, and are one of the most bioactive flavonoids in terms of stimulating endothelial function. They are known to be taken up into the endothelium, where they can stimulate nitric oxide release.\n\n##### BLUEBERRIES\n\nBlueberries, like blackberries, are high in the antioxidant compounds anthocyanins. These are the compounds that give them their deep purple colour, and have been shown to cause relaxation of blood vessels, protect vessel walls against damage, even reduce cholesterol slightly. Many studies have shown significant benefits to patients with cardiovascular disease, even vascular dementia.\n\n##### BROWN RICE\n\nOK, it's a health food staple and a lot of people still see it as a bit hippyish, but brown rice has benefits for heart health. It is mostly the high fibre content that makes brown rice useful. It helps move cholesterol out of the digestive tract, reducing the amount absorbed into the bloodstream. It also contains a compound known as gamma-oryzanol, that is linked with reducing levels of bad (LDL) cholesterol.\n\n##### BULGAR WHEAT\n\nThe fibre content of bulgar wheat makes it an ideal ingredient for digestive and heart health, as high-fibre foods will help remove cholesterol from the digestive tract before it can be absorbed. There are also a lot of B vitamins and magnesium in bulgar wheat, which have a soothing and relaxing effect. This may have knock-on effects for stress-induced high blood pressure, for example. Magnesium also works against calcium in smooth muscle, aiding relaxation and therefore vasodilation.\n\n##### CACAO\/COCOA\n\nCacao is packed to the hilt with flavonoids. As we have seen, these compounds have been very widely researched and are known to cause the cells that line our blood vessels to release high levels of a compound called nitric oxide, which in turn causes the muscles in the blood vessel walls to relax. When they relax, the blood vessel widens, which reduces the pressure within it. Cacao has been the focus of a great deal of research here in the UK, with many studies confirming its benefits \u2013 albeit transient \u2013 for elevated blood pressure and enhanced peripheral circulation (a marker of increased vasodilation). Cacao is also very high in magnesium, which also encourages relaxation of the smooth muscle in vessel walls.\n\n##### CHILLIES\n\nChillies contain a phytochemical called capsaicin, which gives them their intense heat. Capsaicin causes the cells that line the inside of our blood vessels to secrete a chemical called nitric oxide, which as we have seen is naturally produced by these cells (chilli just gives them a kick in the right direction). Nitric oxide tells the muscles in the blood vessel walls to relax, so the vessel widens. This has two benefits: firstly, the wider the blood vessel, the lower the pressure within it; secondly, circulation to the extremities is improved. Have you (or anyone you know) turned red-faced after eating something particularly hot and spicy? Well, this is that very vasodilatory response in action!\n\n##### GARLIC\n\nGarlic has long been championed for keeping the heart healthy. It contains a potent compound \u2013 ajoene \u2013 which interacts with a compound in the body that regulates the rate and extent to which blood clots. As we have seen, excessive clotting can be a very high risk for cardiovascular incidents, while keeping clotting at a reasonable level may deliver several benefits. Some surgeons even advise their patients against eating garlic before surgery, just in case it increases their bleeding. On a day-to-day basis, it can protect from clotting, so is a weapon against strokes and heart attacks.\n\n##### GREEN TEA\n\nAnother of those healthy staples. I remember 10\u201315 years ago, when I would drink green tea, that friends, family, all and sundry looked at me like I'd just stepped out of a spaceship. Well, how times have changed. Green tea has quite the reputation these days as a healthy ingredient, and justifiably so in my view. Green tea has some potentially powerful benefits for the heart. This is thanks to the presence of a group of compounds called catechins. These have been shown to reduce platelet (thrombocyte) adhesion, so may offer protection against clots. There are also other flavonoids present in green tea that can stimulate nitric oxide release and therefore increase vasodilation.\n\n##### MACKEREL\n\nThe omega 3 fatty acids in mackerel have a very favourable effect upon cholesterol levels, and can also protect blood vessel walls from inflammatory damage. Omega 3 also delivers antithrombotic activity and can help to reduce blood pressure. What's not to like? Prolonged regular intake of oily fish, as well as fish oil supplements, has been shown in numerous studies to be associated with a decreased incidence of heart disease and has also been shown clinically to improve several of the clinical markers for cardiovascular disease.\n\n##### OATS\n\nOats have become one of the most famous of all 'heart healthy' foods today. They contain a soluble fibre called beta glucan. This has been clinically proven to reduce cholesterol in the digestive tract. It does this by forming a gel-like substance, which then binds to cholesterol that has been released from the liver. Once bound to it, it carries the cholesterol out the body through the bowel before it has had a chance to be absorbed back into the bloodstream.\n\n##### OLIVE OIL\n\nOlive oil has long been known to be beneficial to heart health. The Mediterranean diet is believed to be one of the healthiest ways to eat in the world, and has an exceptional track record for protecting the heart and circulatory system. One of the main protective elements within that diet is, of course, olive oil. The fatty acids in olive oil have been shown on many occasions to increase the levels of HDL cholesterol, and decrease LDL. Oleic acid, the most abundant fatty acid in olive oil, seems to have a beneficial effect upon blood pressure, with some subtle vasodilatory function.\n\n##### QUINOA\n\nAs I have explained earlier in the book, a high-GI diet is a fast track towards cardiovascular problems. Unlike many grains (which tend to be total starch bombs) quinoa is very, very low in carbohydrates and is very low GI. This means it will release its energy slowly and won't cause blood sugar spikes, making it a perfect alternative to rice for anyone wishing to stabilise their blood sugar more effectively. It also naturally has a high protein content which will aid satiety and slow down digestion of a meal, giving that all-important drip-feeding of blood sugar.\n\n##### RED LENTILS\n\nRed lentils are another ingredient with a high percentage of soluble fibre. I know I may sound like I am repeating myself a little bit, but I really want to drive the point home. This soluble fibre helps remove cholesterol from the gut, reducing the amount that gets absorbed into the bloodstream through the digestive tract.\n\n##### RED ONIONS\n\nAll onions are amazing for you, but red onions in particular are extra-special for the health of the heart. This is because they are particularly high in flavonoids, part of the cocktail of chemistry that gives them their deep purple colour. So, again, these will enter the endothelial cells in our vessels and increase their expression of nitric oxide, aiding vasodilation (widening of the blood vessels) and helping to protect the endothelium from damage.\n\n##### RED PEPPERS\n\nRed peppers are definitely up there with my favourite heart-healthy ingredients. Their deep red colour is given by a reasonably high concentration of flavonoids, offering protection to the endothelium and enhancing vasodilation again by \u2013 you guessed it \u2013 increasing nitric oxide expression by the endothelium.\n\n##### RED WINE\n\nAnd you thought it was all bad news, didn't you! Red wine consumption has been shown, in dozens of population studies, to be associated with reduced incidence of cardiovascular disease and many of the clinical markers associated with cardiovascular disease risk. It is believed that this is again due to the flavonoid content and also a compound called resveratrol. Both of these compounds are known to induce vasodilation, have anticoagulant properties, reduce inflammation and have positive effects upon cholesterol levels. The bad news is... only two glasses a day.\n\n##### SALMON\n\nOily fish are definitely at the top of the healthy heart food chain and are big players in my recipes, as you will see in the next section. Salmon is packed with omega 3 fatty acids, all-important good fats. These help maintain healthy cholesterol levels and protect blood vessels from long-term, persistent inflammatory damage, which can be the first step in the process that leads to heart attacks. Omega 3 is also beneficial for the rate and extent to which blood clots, offering a reduction in clotting.\n\n##### SWEET POTATOES\n\nAnother of my staple ingredients and rightly so, I think. These are packed with anti-inflammatory beta carotene. This is the thing that makes the flesh orange and which may offer some anti-inflammatory protection when consumed regularly. Sweet potatoes also give a much lower glycaemic response than the regular spud, so they are a perfect alternative to chips, mash, shepherd's pie, the lot!\n\n##### TROUT\n\nTrout is a fish that has very good levels of the anti-inflammatory omega 3 fatty acids.\n\n##### TUNA STEAK\n\nSeveral studies have found that tuna positively affects cholesterol levels. This is most likely due to the high omega 3 levels in fresh tuna. Canned tuna, although it's a great lean protein, is not a good source of omega 3, as all of the oils have already been pressed out and sold (ironically) to the nutritional supplements industry.\n\n# References, contacts and resources\n\n### REFERENCES\n\n### Omega 3:\n\n  Stone NJ. Fish consumption, fish oil, lipids, and coronary heart disease. _Circulation_. 1996; 94: 2337\u20132340\n\n  Hu FB, Bronner L, Willet WC. Fish and omega 3 fatty acid intake and risk of coronary heart disease in women. JAMA. 2002; 287: 1815\u20131821\n\n  Harris WS. N-3 fatty acids and serum lipoproteins: Human studies. _Am J Clin Nutr_. 1997; 65 (5 Suppl): 1645S\u20131654S\n\n  Roche HM, Gibney MJ. Postprandial triacylglycerolaemia: the effect of low-fat dietary treatment with and without fish oil supplementation. _Eur J Clin Nutr_. 1996; 50: 617\u2013624\n\n  Howe PR. Dietary fats and hypertension: focus on fish oil. _Ann N Y Acad Sci._ 1997; 827: 339\u2013352\n\n  Agren JJ, Vaisanen S, Hanninen O, et al. Hemostatic factors and platelet aggregation after a fish-enriched diet or fish oil or docosahexaenoic acid supplementation. _Prostaglandins Leukot Essent Fatty Acids._ 1997; 57: 419\u2013421\n\n### Magnesium:\n\n  Kass L, Weekes J, Carpenter L. Effect of magnesium supplementation on blood pressure: a meta-analysis. _Eur J Clin Nutr_ 2012; 66: 411\u20138\n\n### Flavonoids:\n\n  Peters U, Poole C, Arab L. Does tea affect cardiovascular disease? A meta-analysis. _Am J Epidemiol._ 2001; **154** : 495\u2013503.\n\n  Di Castelnuovo A, Rotondo S, Iacoviello L, Donati MB, DeGaetano G. Meta-analysis of wine and beer consumption in relation to vascular risk. _Circulation._ 2002; **105** : 2836\u201344\n\n  Renaud S, de Lorgeril M. Wine, alcohol, platelets, and the French paradox for coronary heart disease. _Lancet_. 1992; **339** : 1523\u20136\n\n  Fisher, Naomi DL; Hughes, Meghan; Gerhard-Herman, Marie; Hollenberg, Norman K. Flavanol-rich cocoa induces nitric-oxide-dependent vasodilation in healthy humans. _Journal of Hypertension._ 2003; 21 (12): 2281-2286\n\n### USEFUL CONTACTS AND RESOURCES\n\n### Organisations\n\n### British Heart Foundation\n\nProbably the best known organisation championing heart health. The British Heart Foundation offers a vast amount of information about heart health, keeping your heart healthy, heart disease, statistics, and everything in between. bhf.org.uk\n\n### Heart UK\n\nHeart UK have a big focus upon cholesterol. There is lots of interesting information on their website regarding cholesterol, medications, and diet and cholesterol. heartuk.org.uk\n\n### Blood Pressure UK\n\nAs the name suggests, Blood Pressure UK are a great resource for all things high blood pressure. Whether it is advice about knowing your numbers, or how your lifestyle may be affecting your blood pressure, their website has plenty on offer. bloodpressureuk.org\n\n### Nutritional resources\n\n### British Dietetic Association\n\nThe BDA have a series of fact sheets available on their website. The factsheet regarding blood pressure has some useful guidelines in it. bda.uk.com\/foodfacts\/hypertension\n\n### Nutritional supplements\n\n### Viridian Nutrition\n\nThis company make an extensive range of the cleanest supplements around. Over 180 products including vitamins, minerals, herbs, oils and specific formulae made from the purest ingredients, with no additives, nasty fillers or junk. viridian-nutrition.com\n\n# RECIPES\n\n# Breakfast\n\n######   VITAMIN E\n\nGARLIC (ANTICOAGULENT)  \nSOLUBLE FIBRE  \nLOW GI\n\n**Avocado and poached egg rye toast topper** I concocted this addictive dish one morning when faced with nothing but half an avocado and some eggs in the fridge. Oh, what a happy discovery it was!\n\n#### SERVES 1\n\n\u00bd ripe avocado\n\n1 garlic clove, finely chopped\n\njuice of \u00bd lemon\n\nlow-sodium salt and freshly ground black pepper\n\n1 slice of pumpernickel bread\n\n2 eggs\n\nScoop the avocado flesh into a bowl and add the garlic, lemon juice and low-sodium salt and pepper to taste. Mash the avocado mixture and mix well.\n\nToast the bread while you poach the eggs; the whites should be set but the yolks still runny.\n\nSpread the avocado mixture over the bread, top with the eggs and sprinkle on a little pepper.\n\n######   OMEGA 3 FATTY ACIDS\n\nMAGNESIUM  \nLOW GI\n\n**Salmon, pea and asparagus frittata** I am a real frittata freak. They are so satisfying when you are really hungry and are a great way to throw all manner of flavour combinations together. Use pre-cooked salmon (but not canned) from the supermarket, to save time. It's easy to scale up the recipe, as we have done in the photo, to serve more people.\n\n#### SERVES 1\n\n\u00bd tbsp coconut oil\n\n2 tbsp peas\n\n3\u20134 large asparagus stalks, each cut into 3 or halved lengthways\n\n2 eggs, lightly beaten\n\n1 small cooked salmon fillet, flaked\n\nlow-sodium salt and freshly ground black pepper\n\nPreheat the grill.\n\nHeat the coconut oil in a small ovenproof frying pan over a medium heat. Add the peas and asparagus and saut\u00e9 for four to five minutes, until the vegetables have turned a brighter green and are beginning to soften.\n\nAdd the eggs to the frying pan and cook for a couple of minutes, until the edges of the egg have started to cook well, but the middle is still raw. Add the salmon, low-sodium salt and pepper and cook for another minute.\n\nPlace under the grill until all the egg is cooked; this should take three or four minutes max. Ready to serve.\n\n######   FLAVONOIDS\n\nOMEGA 3 FATTY ACIDS  \nSOLUBLE FIBRE\n\n**Oat and berry layer** This is a gorgeous, speedy breakfast. I find it especially refreshing in the summer months.\n\n#### SERVES 1\n\n2 tbsp blueberries\n\n3 tbsp porridge oats\n\n2 tbsp blackberries\n\n1 tbsp natural live probiotic yogurt\n\n1 tsp flax seeds\n\nIn a tall glass tumbler, layer up the dish: begin with a layer of blueberries, then oats, then blackberries, then oats and so on. You should finish with a layer of oats.\n\nSpoon the yogurt on top, then finish with a sprinkling of flax seeds.\n\n######   FLAVONOIDS\n\nMAGNESIUM  \nOMEGA 3 FATTY ACIDS  \nSOLUBLE FIBRE\n\n**Mixed seed and blackberry bowl** This is a lovely refreshing breakfast. It's a really thick smoothie\/pudding\/parfait-type vibe.\n\n#### SERVES 1\n\n200g natural live probiotic yogurt\n\n2 tbsp blackberries, plus more for the top (optional)\n\n1 tbsp vanilla protein powder (optional)\n\n1 tsp ground flax seeds\n\n1 tsp sunflower seeds\n\n1 tsp pumpkin seeds\n\nPlace the yogurt, berries and protein powder into a food processor and blend into a thick, creamy, smoothie-type texture.\n\nTransfer to a serving bowl and sprinkle with the flax, sunflower and pumpkin seeds. You could also place a few whole berries on top for added colour, if you like.\n\n######   OMEGA 3 FATTY ACIDS\n\nFLAVONOIDS  \nMAGNESIUM\n\n**Kippers, boiled egg and watercress salad** OK, so I know having salad at breakfast may seem a bit alien. But in many parts of the world it is the norm and, on my travels, I have become very fond of the idea. Give it a try. Break the mould. You will soon see how refreshing it is, not to mention a great opportunity to get more of the good stuff into your body.\n\n#### SERVES 1\n\n1 kipper fillet\n\n2 large eggs\n\nsmall bunch of watercress\n\n1 tbsp olive oil\n\nFor packaged kippers, cook (usually boil) according to the manufacturer's instructions. If the kipper fillet is unpackaged from a fishmonger, grill it for eight to 10 minutes.\n\nHard-boil the eggs according to how you like them. I prefer an eight-minute egg that is still moist in the centre, but whatever floats your boat... Peel them, then slice.\n\nArrange the kipper and eggs on a plate, add the watercress and sprinkle over the olive oil.\n\n######   BETA GLUCAN\n\nLOW GI  \nMEDIUM CHAIN TRIGLYCERIDES\n\n**Creamy coconut porridge** Oats are a great ingredient for heart health, thanks to the presence of the soluble fibre beta glucan (see page ). Oats and coconut are a marriage made in heaven. Give this one a bash!\n\n#### SERVES 1\n\n50g porridge oats\n\n200ml coconut milk\n\n\u00bc tsp stevia\n\n3\u20134 drops vanilla extract\n\n1 tsp desiccated coconut\n\nPlace the oats, coconut milk and stevia into a saucepan, pour in 100ml of water and simmer for five to six minutes, until the oats are soft and a creamy texture has formed.\n\nAdd the vanilla extract and desiccated coconut and stir well, before serving.\n\n# Weekday lunches\n\n######   NITRATES\n\nFLAVONOIDS  \nSOLUBLE FIBRE  \nMAGNESIUM\n\n**Beetroot, bean and rocket salad with orange dressing** This may sound like a peculiar mish-mash of flavours... until you taste it. The orange and beetroot work beautifully together and the pepperiness of the rocket cuts straight through the middle. All this, plus it is a heart-healthy dynamo to boot. Magic!\n\n#### SERVES 1\n\n_For the salad_\n\n2 large or 3 medium cooked beetroot (not in vinegar)\n\n400g can of mixed beans, drained and rinsed\n\nlarge handful of rocket\n\n_For the dressing_\n\n1 tbsp orange juice\n\n1 tbsp olive oil\n\n1 tsp white wine vinegar\n\npinch of low-sodium salt\n\nAssemble all the salad ingredients in a bowl and mix well.\n\nWhisk the dressing ingredients thoroughly until emulsified.\n\nDress the salad and serve.\n\n######   FLAVONOIDS\n\nESSENTIAL FATTY ACIDS\n\n**Goat's cheese, pomegranate and olive salad** This just oozes Mediterranean delight, with a fresh but indulgent flavour. Nutrient-dense, flavour-packed and easy to make. Does it get much better? Pomegranate is now available pre-prepared, so is also hassle free.\n\n#### SERVES 1\n\n_For the salad_\n\n2 handfuls of mixed salad leaves\n\n2 tbsp kalamata olives\n\n\u00bd red pepper, finely chopped\n\n2 tbsp pomegranate seeds\n\n75\u201380g goat's cheese, crumbled\n\n_For the dressing_\n\n1 tbsp olive oil\n\n1 tsp balsamic vinegar\n\nlow-sodium salt and freshly ground black pepper\n\nCombine the leaves, olives, pepper and pomegranate in a salad bowl.\n\nWhisk the dressing ingredients thoroughly until emulsified, then pour the dressing over the salad and toss well.\n\nCrumble the cheese over the top.\n\n######   SOLUBLE FIBRE\n\nMAGNESIUM  \nFLAVONOIDS  \nLOW GI\n\n**Herbed chickpea salad with sun-dried tomatoes and spinach** This is such a flavourful little treat. Easy to prepare, filling and packed with the good stuff!\n\n#### SERVES 1\n\n\u00bd tbsp olive oil, plus more to dress\n\n3 handfuls of baby spinach\n\nleaves from a few sprigs of parsley\n\nleaves from a few sprigs of thyme\n\n400g can of chickpeas, drained and rinsed\n\n1 spring onion, finely chopped\n\n8 sun-dried tomatoes, chopped\n\njuice of \u00bd lemon\n\nfreshly ground black pepper\n\nPour the oil into a saucepan placed over a medium heat, then saut\u00e9 the spinach for one or two minutes, just until it wilts.\n\nMix the cooked spinach with the herbs, chickpeas, spring onion and sun-dried tomatoes. Add a little olive oil, the lemon juice and pepper and mix well.\n\n######   LYCOPENE\n\nFLAVONOIDS\n\n**Speedy tomato and paprika soup** This is a seriously speedy soup. Canned tomatoes really aren't that bad as long as they are pure and don't have added sugar (just read the label). And oddly enough, when tomatoes are cooked and processed, though the vitamin C may be destroyed the heart-healthy carotenoid lycopene actually becomes more bio-available to the body! This is a doddle to make and is a speedy lunchtime fix.\n\n#### SERVES 1\n\n1 tbsp olive oil\n\n1 red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\nlow-sodium salt and freshly ground black pepper\n\n400g can of chopped tomatoes\n\n1 tsp smoked paprika\n\nPour the olive oil into a saucepan placed over a medium heat. Saut\u00e9 the onion and garlic, with a good pinch of low-sodium salt, until the onion has softened and is turning translucent.\n\nAdd the tomatoes and paprika, bring to the boil, then reduce the heat and simmer for 10 minutes.\n\nPour into a blender (or use a hand-held blender) and blitz into a rich, smooth soup. Season to taste and serve.\n\n######   OMEGA 3 FATTY ACIDS\n\nCAROTENOIDS  \nSOLUBLE FIBRE\n\n**Spinach and anchovy pitta pizzas** Pitta pizzas are quick-fix gold. Out the pack, whack some bits on, under the grill, bang... Lunch. That's what you need!\n\n#### SERVES 1\n\n1 tsp tomato pur\u00e9e\n\n1 wholemeal pitta bread\n\n8 baby spinach leaves, torn\n\n4\u20135 anchovy fillets\n\n50g feta cheese\n\nPreheat the grill to its highest setting.\n\nSpread the tomato pur\u00e9e over the pitta. Add the baby spinach, scattering it over. Lay the anchovy fillets haphazardly on top, then crumble over the feta cheese.\n\nPlace under the grill for a few minutes, until the feta begins to brown at the edges, then serve.\n\n######   NITRATES\n\nOMEGA 3 FATTY ACIDS  \nSOLUBLE FIBRE\n\n**Smoked salmon, beetroot and minted yogurt wrap** This is a wonderful portable lunch and much lighter \u2013 with a lower GI \u2013 than your average sandwich.\n\n#### SERVES 1\n\n2 tbsp natural live probiotic yogurt\n\n6\u20137 mint leaves, shredded\n\n1 small cooked beetroot (not in vinegar), chopped\n\nlow-sodium salt and freshly ground black pepper\n\n1 wholemeal tortilla wrap\n\n3 slices of smoked salmon\n\na few rocket leaves (optional)\n\nYou choose how to assemble this; it's your lunch, after all. You can mix the yogurt, mint and beetroot together in a bowl and season to taste, or you can keep all the elements separate.\n\nPlace the wrap on a work top and add the salmon, yogurt, mint and beetroot in the centre, with the rocket leaves (if using), then roll it up.\n\n######   FLAVONOIDS\n\nSOLUBLE FIBRE  \nCAROTENOIDS  \nAJOENE\n\n**Roasted onion and cannellini bean houmous with vegetable crudit\u00e9s** This can be a super-quick option. The onions can be roasted the day before so it is quick to throw together. Or, if you have more time on your hands, they can be done there and then, giving a nice warmer houmous which is an interesting variation.\n\n#### SERVES 1\n\n_For the houmous_\n\n1 small red onion, thickly sliced\n\n1\u00bd tbsp olive oil\n\nlow-sodium salt\n\n1 garlic clove, finely chopped\n\n400g can of cannellini beans, drained\n\n_For the crudit\u00e9s_\n\n2 carrots, cut into batons\n\n1 celery stick, cut into batons\n\n4\u20135 whole radishes... or any combination of vegetable crudit\u00e9s you would like!\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the sliced onion in a small roasting tin and drizzle with about 2 tsp of the olive oil, with a pinch of low-sodium salt. Roast in the oven for 20\u201325 minutes, until the onions are soft and beginning to caramelise.\n\nPlace the roasted onion, garlic, cannellini beans, remaining oil and a pinch of low-sodium salt into a food processor and process into a thick houmous. Transfer to a serving bowl and set in the centre of a plate.\n\nSurround with the vegetable crudit\u00e9s and serve.\n\n######   FLAVONOIDS\n\nMAGNESIUM  \nCAROTENOIDS\n\n**Red cabbage and carrot salad with creamy orange dressing** This may sound really bizarre at first but believe me, when you taste it, all will make perfect sense. This is great just as a main course salad, as it's very dense, or is a wonderful side salad for things such as chicken or other white meats.\n\n#### SERVES 1\n\n_For the salad_\n\n\u00bc red cabbage, finely grated\n\n1 large carrot, finely grated\n\nleaves from a small bunch of flat-leaf parsley, torn\n\nhandful of baby spinach, torn\n\n_For the dressing_\n\n1 tbsp tahini\n\n2 tbsp fresh orange juice\n\n1 tsp cider vinegar\n\nlow-sodium salt\n\nCombine the grated vegetables, parsley and spinach and mix thoroughly.\n\nCombine all the dressing ingredients and mix well, before using to dress the salad.\n\n# Weekend lunches\n\n######   BETA CAROTENE\n\nOMEGA 3 FATTY ACIDS  \nMAGNESIUM\n\n**Roasted squash, rocket and sun-dried tomato salad** This is a gorgeous, colourful and nutrient-packed salad. It is a perfect lunch when you fancy lots of contrasts in flavour, yet still want something light.\n\n#### SERVES 1\n\n_For the salad_\n\n\u00bd small or \u00bc large butternut squash, chopped, skin left on\n\n\u00bd tbsp olive oil\n\n8 sun-dried tomatoes\n\nlarge handful of rocket\n\n1 tbsp walnuts\n\n_For the dressing_\n\n1 tbsp olive oil\n\n1 tsp balsamic vinegar\n\n\u00bc tsp ground cumin\n\nlow-sodium salt and freshly ground black pepper\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6. Place the squash on a baking tray, drizzle with olive oil and toss with your hands to coat. Bake at the top of the hot oven for about 30 minutes, stirring occasionally, until soft and roasted and the skin has turned crispy.\n\nCombine the squash with all the other salad ingredients.\n\nWhisk the dressing ingredients thoroughly until emulsified.\n\nDress the salad and toss well.\n\n######   NITRATES\n\nFLAVONOIDS  \nAJOENE\n\n**Bold beetroot and horseradish soup** This is an awesome soup with a real bolshy flavour.\n\n#### SERVES 1\u20132\n\n1 tbsp olive oil\n\n1 large red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\ngood pinch of low-sodium salt\n\n3 large raw beetroot, skins on, chopped\n\nup to 1 litre vegetable stock\n\n2 tbsp horseradish sauce\n\nPour the olive oil into a large saucepan placed over a medium heat. Saut\u00e9 the onion and garlic with the low-sodium salt, until the onion is nicely softened.\n\nAdd the beetroot and pour in just enough vegetable stock to cover. Allow to simmer for about 30 minutes, until the beetroot is tender to the point of a knife.\n\nTransfer to a blender (or use a hand-held blender). Add the horseradish sauce, then blend into a smooth soup.\n\n######   RUTIN\n\nERITADENINE  \nFLAVONOIDS  \nAJOENE\n\n**Soba noodle vegetable stir-fry** Soba noodles are an amazing source of the flavonoid rutin, which has been shown to be especially good for the health of blood vessels, protecting the walls from inflammatory damage.\n\n#### SERVES 1\n\n1 bundle of soba noodles (they come ready-portioned)\n\n1 tbsp olive oil\n\n1 large red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\n1 small chilli, finely chopped\n\n1 carrot, cut into thin julienne\n\npinch of low-sodium salt\n\n2 spring onions, chopped lengthways\n\n5 shiitake mushrooms, sliced\n\n2 handfuls of baby spinach\n\n3 tsp low-sodium soy sauce\n\n2 tsp sesame oil\n\nCook the noodles according to the packet instructions, then drain and set aside. Pour the olive oil into a small wok or saut\u00e9 pan set over a medium heat. Saut\u00e9 the onion, garlic, chilli and carrot, with the low-sodium salt, until the onion is soft and the carrot is beginning to soften.\n\nAdd the spring onions and shiitake mushrooms and saut\u00e9 for five to eight minutes, until the mushrooms are cooked. Throw in the baby spinach and saut\u00e9 just until it wilts.\n\nFinally, tip in the drained noodles and mix everything together well with the low-sodium soy sauce and sesame oil.\n\n######   BETA CAR OTENE\n\nFLAVONOIDS  \nAJOENE\n\n**Roasted sweet potato and coconut soup** This recipe is off the charts in the tasty spectrum. Deep, rich, creamy and decadent.\n\n#### SERVES 1\u20132\n\n1\u00bd large sweet potatoes, skin-on, chopped\n\n1 tbsp olive oil, plus more to serve (optional)\n\n1 large red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\nlow-sodium salt and freshly ground black pepper\n\n400g can of coconut milk\n\n500ml vegetable stock\n\ncoriander leaves, to serve (optional)\n\nslivers of red chilli, to serve (optional)\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6. Place the sweet potatoes on a baking tray and roast at the top of the oven for about 30 minutes, until they have started to soften and the skins are beginning to caramelise.\n\nPour the olive oil into a saucepan set over a medium heat. Saut\u00e9 the onion and garlic, with a good pinch of low-sodium salt, until the onion just softens.\n\nAdd the roasted sweet potato and pour in the coconut milk with enough of the vegetable stock to completely cover the sweet potatoes.\n\nSimmer for about 10 minutes, then blend into a luxurious soup. Serve scattered with coriander and chilli and\/or drizzled with a little more oil (if using).\n\n######   BETA CAROTENE\n\nLOW GI  \nOMEGA 3 FATTY ACIDS  \nMAGNESIUM\n\n**Black olive and anchovy-stuffed chicken breast, sweet potato mash and wilted greens** This is a lovely, strongly flavoured dish that is a dinner party favourite.\n\n#### SERVES 1\n\n1 large skinless chicken breast\n\n3 anchovy fillets\n\n4 kalamata olives, sliced\n\n\u00bd sweet potato, peeled and chopped\n\n\u00bd tbsp olive oil\n\nlow-sodium salt and freshly ground black pepper\n\nhandful of curly kale\n\nhandful of purple basil leaves (optional)\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nSlice a pocket into the chicken breast, cutting into the thickest part. Open up this pocket and add the anchovies and olives, then close and seal with cocktail sticks.\n\nPlace on a baking sheet and bake at the top of the oven for 25 minutes.\n\nMeanwhile, place the sweet potato in a pan and cover with just-boiled water. Simmer for 15 minutes, until tender. Drain and mash with the oil, low-sodium salt and pepper. Keep warm until the chicken is ready.\n\nFive minutes before you're ready to serve, cook the greens by lightly steaming them until they soften slightly and turn a brighter green. Serve with the chicken and sweet potato mash, sprinkled with purple basil (if using).\n\n######   LOW GI\n\nBETA CAROTENE  \nFLAVONOIDS  \nAJOENE\n\n**Roasted vegetables with quinoa salad** A gorgeous dish that is both filling and light, as well as nutrient packed.\n\n#### SERVES 1\u20132\n\n1 large courgette, sliced\n\n1 large red pepper, sliced\n\n1 large red onion, halved, then sliced\n\ndrizzle of olive oil\n\n1 tsp garlic powder\n\n1 tsp smoked paprika\n\nlow-sodium salt and freshly ground black pepper\n\n150g quinoa\n\nleaves from a few sprigs of parsley\n\n1 tsp capers, drained and rinsed\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the sliced vegetables in a roasting tin with the oil and mix well. Add the garlic powder, smoked paprika, a little low-sodium salt and pepper and mix again. Roast at the top of the hot oven for about 35 minutes, stirring occasionally so the edges don't catch.\n\nTip the quinoa into a saucepan and cover with boiling water. Simmer for about 20 minutes, until the grains have softened and what looks like a small 'tail' has appeared on the side of each. Drain.\n\nFinely chop the parsley and capers together and mix with the cooked quinoa.\n\nAdd the roasted vegetables. Ready to serve.\n\n######   B VITAMINS\n\nBETA CAROTENE  \nLYCOPENE  \nFLAVONOIDS  \nAJOENE\n\n**Mixed bean chilli with baked sweet potato** The classic(ish) chilli! This gorgeous dish is often served with rice, but following a low-GI diet means that you need to give white rice a really wide berth. (The odd bit of brown rice is fine.) This is a bit of a twist on the classic baked potato with chilli con carne. Sweet potatoes have a much lower glycaemic impact than regular potatoes, plus are packed with beta carotene, so are a great option.\n\n#### SERVES 1\n\n1 sweet potato\n\n\u00bd tbsp olive oil\n\n1 red onion, finely chopped\n\n1 garlic clove, finely chopped\n\n1 red chilli, finely chopped\n\n\u00bd red pepper, finely chopped\n\nlow-sodium salt and freshly ground black pepper\n\n400g can of mixed beans, drained and rinsed\n\n400g can of chopped tomatoes\n\n1 tsp ground cumin\n\n1 heaped tsp smoked paprika\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6. Make a few holes in the sweet potato with the tines of a fork and place in the top of the hot oven for about one hour. Keep checking on it, waiting until it has fully softened.\n\nPour the olive oil into a large saucepan set over a medium heat. Saut\u00e9 the onion, garlic, chilli and red pepper, with a little pinch of low-sodium salt, until the onion softens.\n\nTip in the beans and tomatoes and bring to the boil, then reduce the heat and simmer for about 10 minutes. Add the spices and simmer for a further 15 minutes, until the sauce has reduced and thickened. Season to taste.\n\nOpen up the baked sweet potato and spoon a generous amount of chilli over it.\n\n######   NITRATES\n\nAJOENE  \nFLAVONOIDS  \nSOLUBLE FIBRE\n\n**Baked beetroot wedges with white bean houmous** Baked beetroot has become like a slightly odd alternative to jacket potato or chips here at Pinnock HQ. It all stemmed from having a large amount of unused beetroot in the fridge that needed eating and a moment of creativity\/boredom. The result was very pleasing indeed. It is too firm to serve whole, but in big baked wedges it is pretty special.\n\n#### SERVES 1\n\n1 large beetroot, skin-on, cut into wedges\n\n2 tbsp olive oil, plus a tiny amount more for the beetroot\n\n400g can of cannellini beans, drained\n\njuice of \u00bd lemon\n\n1 garlic clove, finely chopped\n\nlow-sodium salt\n\nhandful of parsley leaves, chopped, to serve (optional)\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the beetroot on a baking sheet and drizzle with a tiny amount of olive oil. Toss well to coat the wedges. Bake at the top of the hot oven for about 40 minutes, until the wedges are soft, turning occasionally.\n\nPut the beans in a blender with the 2 tbsp of olive oil, the lemon juice, garlic and low-sodium salt. Blend into a thick houmous.\n\nPlate up the beetroot wedges, add a generous helping of the houmous and sprinkle with parsley (if using). Serve with a green salad.\n\n######   CAROTENOIDS\n\nAJOENE  \nFLAVONOIDS\n\n**Squash, goji berry and red onion soup** OK, fruit in a savoury soup. That sounds like I have finally tipped over the edge. But trust me, there is something so special about squash and goji berries. They intensify each other's flavour beautifully. Give it a go. You'll be glad you did!\n\n#### SERVES 2\n\n1 large red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\n\u00bd tbsp olive oil\n\nlow-sodium salt\n\n1 small butternut squash, chopped, skin-on\n\n2 handfuls of goji berries\n\nup to 500ml vegetable stock\n\nSaut\u00e9 the onion and garlic in the olive oil, with a pinch of low-sodium salt, until the onion is nice and soft. Add the squash and goji berries.\n\nAdd enough vegetable stock to just cover all of the ingredients, then simmer until the squash is soft and falls apart when prodded.\n\nBlend into a thick, bright orange soup.\n\n######   FLAVONOIDS\n\nAJOENE  \nCAROTENOIDS\n\n**Balsamic caramelised pepper soup** This one is just a bit special. It takes a little time to make but is seriously worth it for the deep, lingering flavour you get in return.\n\n#### SERVES 1\u20132\n\n2 red peppers, deseeded and sliced\n\n2 yellow peppers, deseeded and sliced\n\n1\u00bd tbsp olive oil\n\n2 tbsp balsamic vinegar\n\n1 large onion, finely chopped\n\n1 garlic clove, finely chopped\n\n\u00bd small sweet potato, peeled and chopped\n\n200\u2013300ml vegetable stock, plus more if needed\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the peppers in a roasting tin and drizzle \u00bd tbsp each of the olive oil and balsamic vinegar over them. Roast in the oven for 30\u201340 minutes. Every 10 minutes, take them out, add another \u00bd tbsp of the balsamic vinegar, stir, then return to the oven. By 40 minutes, the balsamic vinegar should have caramelised around the peppers and the smell will be divine.\n\nMeanwhile, saut\u00e9 the onion and garlic in the remaining 1 tbsp of olive oil, just until the onion has softened.\n\nTransfer the caramelised peppers to the cooked onion, add the sweet potato, then enough vegetable stock to half-cover all the ingredients. Simmer until the sweet potato has softened.\n\nBlend into a smooth soup. If you find it needs thinning out slightly, add a little more stock.\n\n# Quick dinners\n\n######   BETA CAROTENE\n\nFLAVONOIDS\n\n**Sweet potato wedges with red pepper-walnut dip** An absolute flavour bomb and, though it sounds simple, even light, its nutritional density means it will seriously fill you up. We're talking for hours.\n\n#### SERVES 1\n\n1 large sweet potato, skin-on, cut into wedges\n\n2 tbsp olive oil, plus a drizzle for the sweet potatoes\n\n1\u00bd large red peppers, roughly chopped\n\n80g walnuts\n\n1 garlic clove\n\nlow-sodium salt\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the sweet potato wedges on a baking sheet and drizzle with a little olive oil. Stir so all of the wedges are coated with oil. Bake at the top of the hot oven for about 20 minutes, until the wedges are soft but with crispy skins, turning them over occasionally.\n\nAt the same time, roast the peppers in the hot oven for about 12 minutes. I like to roast them without oil so the skins get a bit charred on the edges and give a beautiful char-grilled flavour. Once they are turning and beginning to soften, remove them from the oven.\n\nPlace the roast peppers, walnuts, garlic, the 2 tbsp of olive oil and a good pinch of low-sodium salt in a blender or food processor and blend at full power to make a houmous-like dip.\n\nDip the wedges into the walnut mixture, it is heaven! Serve with a good side salad.\n\n######   FLAVONOIDS\n\nAJOENE  \nBETA CAROTENE  \nLYCOPENE  \nSOLUBLE FIBRE\n\n**Stuffed aubergine** This is such a treat, I love all the flavours. Filling, sumptuous and easy to make. Doesn't get much better if you ask me!\n\n#### SERVES 1\u20132\n\n1 tbsp olive oil\n\n1 large red onion, halved, then sliced\n\n2 garlic cloves, finely chopped\n\n1 large red pepper, deseeded and chopped\n\n1 large courgette, sliced\n\nlow-sodium salt and freshly ground black pepper\n\n400g can of chopped tomatoes\n\n1 large aubergine\n\n2 tbsp porridge oats\n\n3 tsp grated Parmesan\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPour the olive oil into a saucepan set over a medium heat. Saut\u00e9 the onion, garlic, red pepper and courgette, with a good pinch of low-sodium salt, for about eight minutes, until they all begin to soften.\n\nAdd the tomatoes and simmer for 15\u201320 minutes, until the tomatoes have reduced right down and you have a thick ratatouille. Season further, if desired.\n\nCut the aubergine in half. Scoop out the flesh from each half, leaving a rim of about 0.5cm of flesh. Lay the aubergine halves face down on a baking tray and pour in a little water. Bake for about 12 minutes, until they start to soften. Turn over and bake for another five minutes.\n\nMix the oats and Parmesan together and season to taste. Spoon the ratatouille mixture into the aubergine halves, pressing it down firmly. Divide the Parmesan topping between them.\n\nReturn to the oven for another 12 minutes. Serve with a side salad.\n\n######   BETA CAROTENE\n\nFLAVONOIDS  \nAJOENE  \nLOW GI\n\n**Chicken and tarragon-stuffed peppers with greens** This super-tasty and unusual dish is set to become a favourite. It can work as a lighter dish with a side salad, or as a heartier dinner with sweet potato mash and greens.\n\n#### SERVES 1\n\n1 large skinless chicken breast\n\n\u00bd tbsp olive oil\n\n1 garlic clove, finely chopped\n\npinch of low-sodium salt\n\n1 heaped tsp soft cheese\n\nleaves from 2\u20133 sprigs of tarragon, roughly chopped\n\n1 large red pepper, halved and deseeded\n\nlarge handful of curly kale\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the chicken in a food processor and process on a low speed to create coarsely minced meat.\n\nPour the olive oil into a saucepan set over a medium heat. Saut\u00e9 the garlic, with a pinch of low-sodium salt, for two or three minutes. Add the chicken and continue to cook, stirring and turning the meat, for about 12 minutes, until thoroughly cooked.\n\nMix in the soft cheese and tarragon and use the mixture to stuff the pepper halves. Place on a baking sheet. Add a small amount of water around the pepper, then bake at the top of the hot oven for 15\u201320 minutes, until the pepper has softened and there is a light golden crust on top of the stuffing.\n\nFive minutes before you're ready to serve, cook the greens by lightly steaming them until they soften slightly and turn a brighter green. Serve with the stuffed peppers.\n\n######   MAGNESIUM\n\nFLAVONOIDS  \nAJOENE  \nCAPSAICIN\n\n**Chicken and green vegetable nutty stir-fry** This is a great super-quick fix after a long day. A quick-fire, nutrient-dense, one-pot wonder. Almond butter is available from most health food stores and some larger supermarkets. If you can't find it, peanut butter will do fine.\n\n#### SERVES 1\n\n1 tbsp olive oil\n\n2 garlic cloves, finely chopped\n\n1 large leek, sliced\n\n1 red chilli, finely chopped\n\n1 large skinless chicken breast, chopped\n\n1 small courgette, sliced handful of curly kale\n\n2 handfuls of baby spinach\n\n1 heaped tbsp almond butter\n\n2 tsp soy sauce\n\n1 tsp honey\n\n1 tbsp flaked almonds\n\nPour the oil into a saucepan set over a medium heat. Saut\u00e9 the garlic, leek and chilli for about five minutes. Add the chicken and stir-fry for eight to 10 minutes, until it is cooked. (You can cut one of the large pieces in half to check, if you want to be sure; you should see no trace of pink.)\n\nAdd the courgette, kale and spinach and stir-fry for a further five minutes, then measure in the almond butter, soy sauce and honey. Mix well. Serve sprinkled with the flaked almonds.\n\n######   B VITAMINS\n\nFLAVONOIDS  \nAJOENE  \nSOLUBLE FIBRE\n\n**Peppered king prawn skewers with tarka dal** I'm a complete freak for Indian flavours. I find it some of the most divinely flavoured food on the planet and, when you push aside those weird takeaway staples that have been invented for the British palate (such as chicken tikka masala), you'll find it some of the healthiest in the world, too. The combination of vegetables, pulses and antioxidant-dense spices create dishes that are an edible medicine chest.\n\n#### SERVES 1\n\n1 tbsp olive oil\n\n\u00bd red onion, finely chopped\n\n1 large garlic clove, finely chopped\n\nlow-sodium salt and freshly cracked black pepper\n\n75g red lentils\n\n500ml vegetable stock (you may not need it all)\n\n\u00bd tsp ground cumin\n\n\u00bd tsp turmeric\n\n12 king prawns, shelled and deveined\n\n3 wooden skewers, soaked for 30 minutes\n\nPour the oil into a saucepan over a medium heat. Saut\u00e9 the onion and garlic, with a good pinch of low-sodium salt, until the onion softens.\n\nAdd the lentils and a small amount of vegetable stock and simmer. As if you were making a risotto, keep adding stock as the liquid reduces, until the lentils are cooked. The finished texture should be like a thin porridge. Stir in the cumin and turmeric, mixing well.\n\nPlace a griddle pan over a medium-high heat. Thread four prawns on to each skewer, sprinkle with cracked black pepper and place in the griddle pan for three minutes each side.\n\nServe the dal in a bowl with the skewers.\n\n######   NITRATES\n\nOMEGA 3 FATTY ACIDS  \nFLAVONOIDS\n\n**Salmon and beetroot wasabi stacks** This is a rather odd but incredible (and stunning looking) combination that is fantastic as a summer evening dish, because it is served cold. You could also have it as a starter.\n\n#### SERVES 1\n\n2 small cooked beetroot (not in vinegar), finely chopped\n\n1 tbsp mayonnaise\n\n2 tsp wasabi\n\n4 slices of smoked salmon, cut into small pieces\n\njuice of \u00bd lemon\n\nfreshly ground black pepper\n\nhandful of rocket leaves\n\nMix the beetroot, mayonnaise and wasabi in a small bowl.\n\nIn a separate bowl, mix the salmon, lemon juice and black pepper.\n\nTo assemble, place a ring mould in the centre of a plate. Put the beetroot mix in first and push it down well so it is pressed into the shape of the mould. Top with a layer of the salmon, again pushing down well so the salmon takes the shape of the mould. Or you could make more, thinner layers, if you want.\n\nCarefully lift off the ring mould and top the stack with a few rocket leaves.\n\n######   OMEGA 3 FATTY ACIDS\n\nSOLUBLE FIBRE  \nFLAVONOIDS  \nAJOENE\n\n**Tapenade salmon with borlotti bean crush** This is a seriously filling dinner in a hurry, if you use canned beans. It is perfect after a long day at work, when you could eat anything that stays still for long enough. Find black olive tapenade in any supermarket.\n\n#### SERVES 1\n\n1 salmon fillet\n\n1 garlic clove, finely chopped\n\n1\u00bd red onions, finely chopped\n\n\u00bd tbsp olive oil\n\nlow-sodium salt and freshly ground black pepper\n\n400g can of borlotti beans, drained\n\n1 tsp capers\n\n\u00bd tbsp black olive tapenade\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPut the salmon fillet on a baking tray and place in the oven for around 10 minutes.\n\nMeanwhile, saut\u00e9 the garlic and onions in the olive oil, with a pinch of low-sodium salt, until the onion has softened. Add the beans to the onion and garlic and saut\u00e9 for another minute or two. Using a potato masher, roughly crush the beans; they should be semi-mashed. Add the capers and mix well.\n\nRemove the salmon from the oven, top with the tapenade, then return to the oven for a final 10 minutes, until the edges of the tapenade get firmer and almost crisp up.\n\nPlace the bean crush in the centre of the serving plate, then top with the salmon.\n\n# Fancy dinners\n\n######   OMEGA 3 FATTY ACIDS\n\nMAGNESIUM  \nAJOENE  \nOLEIC ACID  \nNITRATES  \nSOLUBLE FIBRE\n\n**Grilled trout with root vegetables and salsa verde** This is such a vibrant dish and is awash with fresh flavours and beautiful colours.\n\n#### SERVES 1\n\n\u00bd raw beetroot, cut into wedges\n\n1 large carrot, cut into wedges, or a handful of baby carrots\n\n1 small parsnip, cut into wedges\n\n2 tbsp olive oil, or more to taste, plus more for the root vegetables\n\nlow-sodium salt and freshly ground black pepper\n\nsmall bunch of parsley\n\nsmall bunch of mint\n\nsmall bunch of basil\n\n1 garlic clove, finely chopped\n\n2 tsp capers, drained and rinsed\n\n1 tsp white wine vinegar\n\n1 large trout fillet\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the chopped root vegetables into a roasting tin. Drizzle with a little olive oil, add a generous pinch of low-sodium salt and pepper and mix well. Roast in the top of the hot oven for about 30 minutes, until they are all soft and beginning to turn golden.\n\nMeanwhile, tip the parsley, mint, basil, garlic, capers, vinegar and the 2 tbsp of olive oil into a blender and blend at a slow speed to maintain a coarse texture. Add more oil, if you prefer. Preheat the grill. Place the trout under the hot grill for 15 minutes, turning occasionally, until a golden crispiness begins to form on the fillet.\n\nStack the root vegetables in the centre of a plate. Top with the trout fillet (or just serve the trout and vegetables alongside), then drizzle a generous amount of salsa verde over the top.\n\n######   LOW GI\n\nB VITAMINS  \nBETA CAROTENE  \nFLAVONOIDS  \nSOLUBLE FIBRE\n\n**Mediterranean brown rice risotto** This is real comfort food and a great way to get the heft and substance you need on a cold winter's evening, without it sticking to your waistline!\n\n#### SERVES 2\u20133\n\n1 tbsp olive oil\n\n1 large red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\nlow-sodium salt\n\n60g sun-dried tomatoes\n\n250g short-grain brown rice\n\n400g can of chopped tomatoes\n\n1 litre vegetable stock (you may not need it all, but it's always best to have plenty)\n\n1 courgette, sliced\n\n1 red pepper, sliced\n\nPour the olive oil into a large saucepan set over a medium heat. Saut\u00e9 the onion and garlic with a pinch of low-sodium salt, until the onion starts to soften.\n\nAdd the sun-dried tomatoes, rice and canned tomatoes. Simmer until the liquid is notably reducing, stirring very frequently.\n\nAt this stage, begin adding stock little and often, topping it up when you notice the liquid beginning to reduce. Keep this up until the rice is virtually cooked.\n\nNow add the courgette and red pepper and continue pouring in the stock until the rice is cooked and the vegetables have softened.\n\n######   LOW GI\n\nFLAVONOIDS  \nSOLUBLE FIBRE\n\n**Wholewheat pasta with roasted pepper sauce** OK, so as you have probably gathered by now, I'm not a massive fan of heavy amounts of carbs. But we all crave these foods from time to time. Rather than depriving ourselves, we may as well make the best version of these treats that we can. This is a prime example and it just so happens that this sauce tastes awesome! Just saying...\n\n#### SERVES 1\n\n1 red pepper, deseeded and sliced\n\n1 yellow pepper, deseeded and sliced\n\n1\u00bd tbsp olive oil\n\nlow-sodium salt\n\n1 large red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\n65g (dry weight) wholewheat fusili pasta\n\n50g feta cheese\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the peppers in a roasting tin, drizzle with \u00bd tbsp of the oil and a pinch of low-sodium salt. Roast in the oven for about 30 minutes, turning occasionally. This may seem a long time but you want some of the edges to char slightly, as this will give amazing flavour later on. Meanwhile, saut\u00e9 the onion and garlic in the remaining 1 tbsp of olive oil, with a pinch of low-sodium salt, until the onion has softened.\n\nTip the pasta into a pan, cover with boiling water and boil for 10\u201312 minutes, or according to the packet instructions. Meanwhile, place the peppers and the onion mixture into a food processor and process into a smooth sauce.\n\nDrain the pasta and stir the sauce through it. Finally, top with the crumbled feta.\n\n######   OMEGA 3 FATTY ACIDS\n\nBETA CAROTENE  \nLOW GI  \nMAGNESIUM\n\n**Salmon with pea pur\u00e9e and roasted butternut squash** When I first discovered a simply seasoned pea pur\u00e9e it blew my mind. So simple but a real treat. This combination is a regular feature at Pinnock HQ.\n\n#### SERVES 1\n\n\u00bc large butternut squash, skin-on, chopped\n\n\u00bd tbsp olive oil\n\nlow-sodium salt and freshly ground black pepper\n\n160g frozen peas\n\n1 salmon fillet\n\nmixed salad leaves, to serve\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the squash in a roasting tin and drizzle with a little olive oil, a pinch of low-sodium salt and pepper and mix well. Roast at the top of the hot oven for 20\u201325 minutes, until it has softened and the skins are turning golden and crispy.\n\nPlace the peas in boiling water and simmer until soft, but still bright green. If they are dull they are dead! You need them soft enough to semipur\u00e9e. Drain and mash with a potato masher, or put them into a food processor and process on a low setting to get a rough, chunky pur\u00e9e.\n\nSeason the salmon with a little low-sodium salt and pepper, place on a baking sheet and bake at the top of the oven for about 20 minutes, until well-cooked with a crispy skin and marginally crisped edges.\n\nPut a dollop of the pea pur\u00e9e, off centre, on the plate, then arrange a stack of roasted squash next to it. Place the salmon on the pea pur\u00e9e and top with salad leaves.\n\n######   B VITAMINS\n\nLYCOPENE  \nCURCUMINOIDS  \nAJOENE  \nLOW GI\n\n**King prawn and spinach curry with herby brown rice** A quick, simple curry. It isn't particularly fiery and is very straightforward.\n\n#### SERVES 2\n\n150g brown rice\n\n1 tbsp coconut oil\n\n1 red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\n2cm piece of root ginger, peeled and very finely chopped\n\n1 cinnamon stick, broken\n\nlow-sodium salt\n\n\u00bd tsp turmeric\n\n\u00bd tsp ground coriander\n\n200g (\u00bd can) of chopped tomatoes\n\n\u00bd tsp garam masala\n\n\u00bd tsp chilli flakes\n\n150g raw king prawns, shelled and deveined\n\n3 handfuls of baby spinach\n\nsmall bunch of chopped coriander leaves\n\nsmall bunch of chopped parsley leaves, plus more to serve (optional)\n\njuice of \u00bd lime, plus lime wedges to serve\n\nIn a saucepan, cover the rice with just-boiled water and simmer for 25\u201330 minutes.\n\nHeat the coconut oil in a large saucepan set over a medium heat. Cook the onion, garlic, ginger and cinnamon with a good pinch of low-sodium salt, until the onion has softened and the flavour of the ginger has died down a little.\n\nTip in the turmeric and ground coriander and cook for two minutes, stirring continuously. Add the tomatoes and simmer for 10\u201315 minutes, until the sauce thickens considerably.\n\nAdd the garam masala, chilli flakes and prawns and cook for about five minutes, until the prawns are cooked. Throw in the spinach and cook just until it wilts.\n\nDrain the rice, add the herbs and lime juice and mix. Serve with the curry, scattered with more herbs and lime wedges if you like.\n\nWe've shown it here served with a king prawn in its shell, which notches the presentation up a gear for a really fancy affair!\n\n######   OMEGA 3 FATTY ACIDS\n\nB VITAMINS  \nMAGNESIUM  \nLOW GI\n\n**Tuna steak with mango salsa, wilted greens and quinoa verde** A seriously nutrient-packed, fresh, vibrant and very satisfying dinner. For some reason it reminds me of holidays in far-off places. Maybe that's just me!\n\n#### SERVES 1\n\n\u00bc mango, finely chopped\n\n\u00bc small red onion, very finely chopped\n\n\u00bc small red chilli (deseeded if you want it less hot), very finely chopped\n\n1 tsp white wine vinegar\n\n70g quinoa\n\nleaves from a few sprigs of flat-leaf parsley, chopped\n\n1 tsp chopped capers\n\n\u00bd tbsp olive oil\n\n1 tuna steak\n\nlarge handful of spring greens, or similar\n\nCombine the mango, onion, chilli and vinegar, mix well and set aside.\n\nPlace the quinoa in a saucepan and cover with just-boiled water. Simmer for about 20 minutes, until the grains have softened and what looks like a little 'tail' has formed on the side of each. Drain and stir in the parsley and capers.\n\nSet a griddle pan over a high heat and add the oil. Place the tuna steak on the hot, oiled griddle pan and griddle for about three minutes on either side to get a pink middle. If you prefer it more well done, cook for a little longer.\n\nMeanwhile, cook the greens by lightly steaming them until they soften slightly and turn a brighter green.\n\nPlate up the quinoa first, top with the steamed greens, then finish with the tuna and salsa.\n\n######   OMEGA 3 FATTY ACIDS\n\nB VITAMINS  \nSOLUBLE FIBRE  \nFLAVONOIDS\n\n**Grilled salmon with red barlotto** Barlotto is basically a risotto made from pearl barley. Barley is a very nutrient-rich grain that is incredibly low GI and full of B vitamins.\n\n#### SERVES 1\n\n1 tbsp olive oil\n\n\u00bd red onion, finely chopped\n\n1 garlic clove, finely chopped\n\n\u00bd red pepper, finely chopped\n\nlow-sodium salt and freshly ground black pepper\n\n75g pearl barley\n\n500ml vegetable stock (you may not need all of this)\n\n1 salmon fillet\n\njuice of \u00bd lemon\n\nPour the olive oil into a saucepan set over a medium heat. Saut\u00e9 the onion, garlic and red pepper with a good pinch of low-sodium salt until the onion and pepper have softened.\n\nAdd the barley and a little vegetable stock. Simmer until the stock begins to reduce, then stir in a little more. Repeat this over and over until the barley is cooked and a creamy risotto-like texture has been reached.\n\nMeanwhile, preheat the grill. Season the salmon with low-sodium salt, black pepper and a squeeze of lemon juice and place under the hot grill for 10\u201315 minutes, turning halfway through. This should give you salmon that is still a little soft in the middle. If you prefer it more well done, simply cook it for a little longer.\n\n######   MAGNESIUM\n\nSOLUBLE FIBRE  \nLOW GI\n\n**Sea bass with salsa verde and tabbouleh** Fresh, herby and wholesome. This dish is equally at home on a summer afternoon or a winter day.\n\n#### SERVES 1\n\n40g bulgar wheat\n\n15g flat-leaf parsley leaves\n\n3\u20134 mint leaves\n\n5\u20136 basil leaves\n\n1 tbsp capers, drained and rinsed\n\n1\u00bd tbsp olive oil\n\n1 sea bass fillet\n\nlow-sodium salt and freshly ground black pepper\n\nPlace the bulgar wheat in a pan and cover with boiling water. Simmer for around 20 minutes, until it swells and softens.\n\nPlace one-third of the parsley, the mint, basil and capers into a food processor, along with 1 tbsp of the olive oil, and process in bursts to create a coarse salsa.\n\nGently fry the sea bass in the remaining \u00bd tbsp of olive oil for five to seven minutes, turning occasionally.\n\nDrain the bulgar wheat, add the remaining parsley, roughly chopped, a pinch of low-sodium salt, and some black pepper and mix well.\n\nPlace the bulgar in the centre of the plate, lay the fish on top, then drizzle over the salsa verde.\n\n######   SOLUBLE FIBRE\n\nBETA CAROTENE  \nFLAVONOIDS  \nAJOENE\n\n**Chickpea and red pepper stew with sweet potato mash** This flavoursome, filling and wholly satisfying dish is super-convenient and nutrient-dense, with a great depth of flavour.\n\n#### SERVES 2\n\n1 large sweet potato, skin-on, chopped\n\nlow-sodium salt and freshly ground black pepper\n\n1 tbsp olive oil\n\n1 large red onion, finely chopped\n\n2 garlic cloves, finely chopped\n\n1 red pepper, finely chopped\n\n400g can of chickpeas, drained\n\n400g can of chopped tomatoes\n\n1 tsp ground cinnamon\n\n1 tsp smoked paprika\n\nhandful of coriander leaves, to serve (optional)\n\nPlace the sweet potato in a pan and cover with boiling water. Simmer for 15\u201320 minutes, until the potatoes are soft and almost falling apart. Perfect for mashing! Drain, mash and season.\n\nMeanwhile, pour the olive oil into a saucepan set over a medium heat. Saut\u00e9 the onion, garlic and red pepper with a pinch of low-sodium salt, until the onion and pepper start to soften.\n\nTip in the chickpeas and tomatoes and simmer for about 15 minutes, until the sauce reduces. Add the cinnamon and paprika and season further if required. Simmer for another five to eight minutes.\n\nServe a dollop of the mash with a generous helping of the stew poured over it. Sprinkle with coriander leaves (if using).\n\n######   FLAVONOIDS\n\nOMEGA 3 FATTY ACIDS  \nAJOENE\n\n**Tuna steak with chilli-blueberry compote and roasted celeriac** I love this. Tuna steak and fruity sauces are a match made in heaven. Mango is a traditional pairing, but I have made blueberries the star of the show here because of their high concentration of flavonoids.\n\n#### SERVES 1\n\n\u00bc small celeriac, peeled and chopped\n\n1 tbsp olive oil\n\nlow-sodium salt\n\n150g blueberries\n\n\u00bd garlic clove, finely chopped\n\n\u00bd red chilli (deseeded if you want it less hot) finely chopped\n\n1 tuna steak\n\nPreheat the oven to 200\u00b0C\/400\u00b0F\/gas mark 6.\n\nPlace the celeriac in a roasting tin, drizzle over \u00bd tbsp of the oil and season with a little lowsodium salt. Roast for 20\u201325 minutes, until soft and golden.\n\nMeanwhile, put the blueberries, garlic and chilli in a saucepan with 1 tbsp of water, add a good pinch of low-sodium salt and simmer for about 12 minutes, until the blueberries burst and the sauce starts to resemble a thin jam.\n\nPan-fry the tuna steak in the remaining oil for one or two minutes max on each side, or more if you don't want it too pink.\n\nPlace the celeriac in the centre of the serving plate, place the tuna on top, then drizzle the spicy blueberry compote over the fish.\n\n# Drinks, desserts and snacks\n\n######   FLAVONOIDS\n\n**Berry protein smoothie** I have mixed feelings about fruit smoothies. Most of those you can buy are essentially just sugar bombs and can cause many of the issues we covered earlier, when blood sugar levels get too high. But there is a way around that: add protein to the equation. The added protein will slow down the release of the sugars, drip-feeding your blood sugar rather than carpet-bombing it.\n\n#### SERVES 1\n\n\u00bd punnet mixed summer berries (such as blackberries, raspberries or blueberries)\n\nlarge scoop of vanilla protein powder\n\nPlace the berries and protein powder into a blender and pour in 150ml of cold water.\n\nBlend on full speed into a thick smoothie.\n\n######   NITRATES\n\nFLAVONOIDS  \nPOTASSIUM\n\n**Beetroot, blackberry, celery and ginger juice** This slightly weird-sounding combination works a treat from both a flavour perspective and also from a nutritional one.\n\n#### MAKES 1\n\n1 large raw beetroot, washed, skin left on\n\n2 celery stalks\n\n3 tbsp blackberries\n\n3cm piece of root ginger\n\nRun all the ingredients through a juicer.\n\n######   MAGNESIUM\n\nFLAVONOIDS  \nLOW GI\n\n**Nutty chocolate smoothie** This simple smoothie has a lovely luxurious flavour, so much so that you may take some convincing that it is actually really rather good for you!\n\n#### SERVES 1\n\n150ml coconut water\n\n1 heaped tbsp cocoa powder\n\n1 scoop of low-carb chocolate whey protein powder\n\n1 heaped tsp peanut butter\n\nPlace all the ingredients into a blender, and blitz for about one minute.\n\nI suggest this much time just make sure all the peanut butter is fully broken down. Blenders vary in power, so this amount of time should cover everyone.\n\n######   OMEGA 3 FATTY ACIDS\n\nFLAVONOIDS  \nCAROTENOIDS  \nSOLUBLE FIBRE\n\n**Pomegranate goji omega smoothie** This is a great smoothie for days when you want to go a little lighter but don't want to skimp on nutrition. This one is nutrient-dense. I know that pomegranate juice can be a bit pricey in some places, but market demand is pushing the cost down. Shop around and you will get it at a reasonable price.\n\n#### SERVES 1\n\n150ml pomegranate juice (not anything labelled 'juice drink')\n\n1 tbsp frozen blueberries\n\n2 tbsp goji berries, soaked in water for 30 minutes to soften, water reserved\n\n1 tbsp ground flax seeds\n\nPlace all the ingredients into a food processor \u2013 including the goji berry soaking water \u2013 and blitz on full power until all the ingredients have blended well.\n\n######   VITAMIN E\n\nMAGNESIUM\n\n**Nutty chocolate avocado pots** OK, I know avocado and dessert don't seem as though they belong in the same sentence, but trust me. When making healthy desserts, avocados can be your best friend. They provide a creamy texture without the need to add any nasties... and happen to be packed with heart-healthy nutrients to boot!\n\n#### SERVES 2\n\n1 very ripe avocado\n\n1 tbsp almond butter\n\n1 tbsp maple syrup, or \u00bd tsp stevia if you want to keep the sugar down\n\n1\u20132 tbsp cocoa powder, to taste, plus more to serve (optional)\n\nScoop the avocado flesh into a blender or food processor. Add the remaining ingredients with 1\u20132 tbsp of cold water.\n\nProcess on full speed until all the ingredients have mixed into a smooth chocolatey dessert.\n\nSpoon the mixture into ramekins and chill in the fridge for two to three hours before serving, sprinkled with cocoa powder, if you like.\n\n######   FLAVONOIDS\n\nCAROTENOIDS\n\n**Tonic tipple** Surprise... it's not all about staying on your best behaviour. Sometimes we need a little treat. When it comes to heart health, a bit of red wine here and there can be your friend. This summery drink is very refreshing and full of important compounds for heart health, too.\n\n#### SERVES 1\n\npomegranate juice (not anything labelled 'juice drink')\n\nblood orange juice\n\nred wine\n\nTake a red wine glass, fill one-quarter with pomegranate juice, one-quarter with blood orange juice, then top up with a red wine of your choice.\n\nYou can add a little ice, too, if you like.\n\n######   BETA GLUCAN\n\nFLAVONOIDS  \nOMEGA 3 FATTY ACIDS\n\n**Oaty flax berry crumble** This is a tasty and simple dessert that takes very little time and is a perfect piece of guilt-free indulgence.\n\n#### SERVES 1\n\n200g mixed berries\n\n3 tbsp porridge oats\n\n1 tbsp ground flax seeds\n\n\u00bd tsp ground cinnamon\n\nPreheat the grill on its highest setting.\n\nPlace the berries and 1 tbsp of water in a saucepan and set over a high heat; the maximum the hottest ring will go on. Stew the berries until they start to burst and, before long, a thicker jam-like texture will form. Place in an oven\u2013 and flameproof serving bowl.\n\nSprinkle the oats, ground flax and cinnamon evenly over the top, then place the bowl under the grill for a few minutes until the oaty topping begins to turn golden.\n\n######   FLAVONOIDS\n\nSOLUBLE FIBRE\n\n**Pears poached in spiced red wine** This is a lovely recipe that has a great seasonal festive vibe to it, but is just as at home served cold in the summer.\n\n#### SERVES 3\n\n250ml red wine\n\n3 ripe pears, peeled\n\n1 large cinnamon stick\n\n4\u20135 cloves\n\n2 slices of root ginger\n\n1 tsp vanilla extract\n\n\u00bd tsp stevia, or honey if you prefer, to taste\n\nPlace all the ingredients in a saucepan and bring to a gentle simmer (not a boil). Cook for 25\u201330 minutes. The pears should be tender to the point of a knife.\n\nFish out the pears and place in a serving bowl, one per person. Strain the wine through a sieve over the fruits and serve.\n\n######   OMEGA 3 FATTY ACIDS\n\nMAGNESIUM\n\n**Mackerel and caper p\u00e2t\u00e9** This is a gorgeous snack. Spread on an oatcake or use it as a dip for raw veggies such as carrots and celery.\n\n#### SERVES 1\n\n2 smoked mackerel fillets\n\n4 tbsp natural live probiotic yogurt\n\n1 tbsp extra virgin olive oil\n\njuice of \u00bd lemon\n\n2 tsp capers, drained and rinsed\n\nlow-sodium salt and freshly ground black pepper\n\nPlace all the ingredients into a food processor and process at full power until a smooth p\u00e2t\u00e9 has been formed.\n\nPlace in a bowl and snack at will.\n\n###### FLAVONOIDS  \nMAGNESIUM  \nVITAMIN E  \nSTEROLS  \nOMEGA 3 FATTY ACIDS\n\n**Heart-healthy trail mix** One thing that I hear very often from friends or clients is that they wish they had healthier snacks to hand when they are sitting at their desk. Workplace vending machines are kryptonite to many people, dangling temptation before us, so making your own snacks to take with you is an obvious solution. This little trail mix is tasty, portable and \u2013 most importantly \u2013 contains a broad array of heart-healthy nutrients. This makes enough for at least three or four days. Remember, this is for between-meal nibbling!\n\n#### MAKES 3\u20134 SNACKS\n\n1 tbsp pumpkin seeds\n\n1 tbsp sunflower seeds\n\n1 tbsp flax seeds\n\n1 tbsp goji berries\n\n1 tbsp dried blueberries\n\n1 tbsp dark chocolate chips\n\nCombine all the ingredients together and store in a sealable plastic container.\n\n# INDEX\n\n  1. ajoene  1\n  2. anchovies: black olive and anchovy-stuffed chicken breast  1\n    1. spinach and anchovy pitta pizzas  1\n  3. anthocyanins  1\n  4. apples  1\n  5. arteries  1,  2\n  6. arterioles  1\n  7. asparagus: salmon, pea and asparagus frittata  1\n  8. atherosclerosis  1,  2\n  9. ATP  1\n  10. aubergine, stuffed  1\n  11. avocados  1\n    1. avocado and poached egg rye toast topper  1\n  12. nutty chocolate avocado pots  1\n\n  1. barlotto, grilled salmon with red  1\n  2. beans: beetroot, bean and rocket salad  1\n    1. mixed bean chilli  1\n  3. beetroot  1\n    1. baked beetroot wedges with white bean houmous  1\n    2. beetroot, bean and rocket salad  1\n    3. beetroot, blackberry, celery and ginger juice  1\n    4. bold beetroot and horseradish soup  1\n    5. salmon and beetroot wasabi stacks  1\n    6. smoked salmon, beetroot and minted yogurt wrap  1\n  4. berries: berry protein smoothie  1\n    1. oat and berry layer  1\n    2. oaty flax berry crumble  1\n  5. beta carotene  1\n  6. beta glucan  1\n  7. blackberries 53 \n    1. beetroot, blackberry, celery and ginger juice  1\n    2. mixed seed and blackberry bowl  1\n  8. blood  1,  2,  3,  4,  5\n  9. blood clotting  1,  2,  3,  4\n  10. blood pressure  1,  2,  3,  4,  5\n  11. blood vessels  1,  2,  3,  4,  5\n  12. blueberries  1\n    1. chilli-blueberry compote  1\n  13. borlotti bean crush, tapenade salmon with  1\n  14. bread: avocado and poached egg rye toast topper  1\n  15. bulgar wheat  1\n    1. sea bass with salsa verde and tabbouleh  1\n\n  1. cabbage: red cabbage and carrot salad  1\n  2. cacao  1\n  3. calcium  1,  2,  3\n  4. cannellini beans: roasted onion and cannellini bean houmous  1\n    1. white bean houmous  1\n  5. capers: mackerel and caper p\u00e2t\u00e9  1\n  6. capillaries  1\n  7. capsaicin  1\n  8. carbohydrates  1,  2\n  9. cardiovascular system  1\n  10. carrot salad, red cabbage and  1\n  11. catechins  1\n  12. celery: beetroot, blackberry, celery and ginger juice  1\n  13. cheese: goat's cheese, pomegranate and olive salad  1\n  14. chicken: black olive and anchovy-stuffed chicken breast  1\n    1. chicken and green vegetable nutty stir-fry  1\n    2. chicken and tarragon-stuffed peppers with greens  1\n  15. chickpeas: chickpea and red pepper stew  1\n    1. herbed chickpea salad  1\n  16. chillies  1\n    1. chilli-blueberry compote  1\n    2. mixed bean chilli  1\n  17. chlorophyll  1\n  18. chocolate: heart-healthy trail mix  1\n    1. nutty chocolate avocado pots  1\n    2. nutty chocolate smoothie  1\n  19. cholesterol  1,  2,  3,  4\n    1. food that reduces  1,  2,  3,  4\n  20. clotting factors  1,  2,  3,  4\n  21. cocoa  1\n  22. coconut milk: creamy coconut porridge  1\n    1. roasted sweet potato and coconut soup  1\n  23. coconut oil  1\n  24. compote, chilli-blueberry  1\n  25. curry, king prawn and spinach  1\n\n  1. de novo lipogenesis  1\n  2. diet  1\n  3. dietary fibre  1,  2\n  4. digestion  1\n  5. dip, red pepper-walnut  1\n  6. dressings: creamy orange  1\n    1. orange  1\n\n  1. eggs: avocado and poached egg rye toast topper  1\n    1. kippers, boiled egg and watercress salad  1\n  2. endothelium  1,  2,  3,  4,  5,  6\n    1. endothelial damage  1\n    2. endothelial dysfunction  1,  2\n    3. and flavonoids  1,  2,  3\n  3. erythrocytes  1\n\n  1. fats  1,  2,  3,  4,  5\n  2. fatty acids  1,  2,  3,  4\n  3. fibre  1,  2\n  4. fibrin  1,  2,  3\n  5. fish  1,  2,  3,  4,  5\n    1. see also mackerel; salmon, etc\n  6. flavonoids  1,  2\n  7. flax seeds: oaty flax berry crumble  1\n  8. frittata, salmon, pea and asparagus  1\n\n  1. gamma-oryzanol  1\n  2. garlic  1\n  3. ginger: beetroot, blackberry, celery and ginger juice  1\n  4. glucagon  1\n  5. glucose  1\n  6. glycaemic response of foods  1\n  7. goji berries: pomegranate goji omega smoothie  1\n    1. squash, goji berry and red onion soup  1\n  8. green tea  1\n\n  1. haemoglobin  1\n  2. HDL cholesterol  1,  2\n  3. heart attacks  1\n  4. horseradish: bold beetroot and horseradish soup  1\n  5. houmous: roasted onion and cannellini  1\n    1. white bean  1\n\n  1. infarction  1\n  2. inflammation  1,  2,  3\n  3. ingredients  1\n  4. insulin  1,  2,  3\n  5. iron  1\n\n  1. juice, beetroot, blackberry, celery and ginger  1\n\n  1. Keys, Ancel  1,  2\n  2. kippers, boiled egg and watercress  1\n\n  1. LDL cholesterol  1,  2,  3,  4,  5,  6\n  2. lentils  1\n    1. tarka dal  1\n  3. leukocytes  1,  2\n  4. lipogenesis  1\n  5. lipoprotein  1\n\n  1. mackerel  1\n    1. mackerel and caper p\u00e2t\u00e9  1\n  2. magnesium  1,  2\n  3. mango salsa, tuna steak with  1\n  4. Mediterranean brown rice risotto  1\n  5. minerals  1\n  6. muscles  1\n\n  1. nitric acid  1\n  2. nitric oxide  1,  2,  3,  4,  5\n  3. nuts: chicken and green vegetable nutty stir-fry  1\n    1. nutty chocolate avocado pots  1\n    2. nutty chocolate smoothie  1\n\n  1. oats  1,  2\n    1. creamy coconut porridge  1\n    2. oat and berry layer  1\n    3. oaty flax berry crumble  1\n  2. occlusions  1\n  3. olive oil  1,  2\n  4. olives: black olive and anchovy-stuffed chicken breast  1\n    1. goat's cheese, pomegranate and olive salad  1\n  5. omega 3  1,  2,  3\n  6. omega 6  1,  2,  3\n  7. onions  1\n    1. roasted onion and cannellini bean houmous  1\n    2. squash, goji berry and red onion soup  1\n  8. oranges: creamy orange dressing  1\n    1. orange dressing  1\n\n  1. pasta: wholewheat pasta with roasted pepper sauce  1\n  2. p\u00e2t\u00e9, mackerel and caper  1\n  3. pearl barley: grilled salmon with red barlotto  1\n  4. pears poached in spiced red wine  1\n  5. peas: salmon, pea and asparagus frittata  1\n    1. salmon with pea pur\u00e9e and roasted butternut squash  1\n  6. pectin  1\n  7. peppers  1\n    1. balsamic caramelised pepper soup  1\n    2. chicken and tarragon-stuffed peppers  1\n    3. chickpea and red pepper stew  1\n    4. red pepper-walnut dip  1\n    5. roasted pepper sauce  1\n    6. stuffed aubergine  1\n  8. phytochemicals  1,  2\n  9. phytosterols  1\n  10. pitta pizzas, spinach and anchovy  1\n  11. plaque  1,  2,  3\n  12. plasma  1,  2,  3\n  13. platelets  1,  2,  3\n  14. pomegranate: goat's cheese, pomegranate and olive salad  1\n    1. pomegranate goji omega smoothie  1\n    2. tonic tipple  1\n  15. porridge, creamy coconut  1\n  16. post-prandial lipaemia  1\n  17. post-prandial triglyceridemia  1\n  18. potassium  1\n  19. prawns: king prawn and spinach curry  1\n    1. peppered king prawn skewers  1\n  20. processed foods  1\n  21. prostaglandins  1\n  22. protein  1,  2\n\n  1. quinoa  1\n    1. roasted vegetables with quinoa salad  1\n    2. tuna steak with quinoa verde  1\n\n  1. red blood cells  1\n  2. resveratrol  1\n  3. rice  1\n    1. king prawn and spinach curry with herby brown rice  1\n    2. Mediterranean brown rice risotto  1\n  4. rocket: beetroot, bean and rocket salad  1\n    1. roasted squash, rocket and sun-dried tomato salad  1\n  5. rye bread: avocado and poached egg rye toast topper  1\n\n  1. salads: beetroot, bean and rocket  1\n    1. goat's cheese, pomegranate and olive  1\n    2. herbed chickpea  1\n    3. kippers, boiled egg and watercress  1\n    4. red cabbage and carrot  1\n    5. roasted squash, rocket and sun-dried tomato  1\n    6. roasted vegetables with quinoa  1\n  2. salmon  1\n    1. grilled salmon with red barlotto  1\n    2. salmon and beetroot wasabi stacks  1\n    3. salmon, pea and asparagus frittata  1\n    4. salmon with pea pur\u00e9e and roasted butternut squash  1\n    5. smoked salmon, beetroot and minted yogurt wrap  1\n    6. tapenade salmon with borlotti crush  1\n  3. salsa, mango  1\n  4. salsa verde: grilled trout with root vegetables and salsa verde  1\n    1. sea bass with salsa verde and tabbouleh  1\n  5. salt  1\n  6. sea bass with salsa verde and tabbouleh  1\n  7. seeds: heart-healthy trail mix  1\n    1. mixed seed and blackberry bowl  1\n  8. skewers: peppered king prawn skewers with tarka dal  1\n  9. smooth muscle  1,  2,  3,  4,  5\n  10. smoothies: berry protein  1\n    1. nutty chocolate  1\n    2. pomegranate goji omega  1\n  11. soba noodle vegetable stir-fry  1\n  12. sodium  1\n  13. soups: balsamic caramelised pepper  1\n    1. bold beetroot and horseradish  1\n    2. roasted sweet potato and coconut  1\n    3. speedy tomato and paprika  1\n    4. squash, goji berry and red onion  1\n  14. spinach: herbed chickpea salad with sun-dried tomatoes and spinach  1\n    1. king prawn and spinach curry  1\n    2. spinach and anchovy pitta pizzas  1\n  15. squash: roasted squash, rocket and sun-dried tomato salad  1\n    1. salmon with pea pur\u00e9e and roasted butternut squash  1\n    2. squash, goji berry and red onion soup  1\n  16. starchy foods  1\n  17. stew, chickpea and red pepper  1\n  18. stir-fries: chicken and green vegetable nutty stir-fry  1\n    1. soba noodle vegetable stir-fry  1\n  19. stress  1,  2\n  20. strokes  1\n  21. sweet potatoes  1\n    1. roasted sweet potato and coconut soup  1\n    2. sweet potato wedges with red pepper-walnut dip  1\n\n  1. tabbouleh, sea bass with salsa verde and  1\n  2. tarka dal  1\n  3. tea  1\n  4. thrombocytes  1,  2\n  5. thrombus formation  1,  2\n  6. tomatoes: herbed chickpea salad with sun-dried tomatoes and spinach  1\n    1. roasted squash, rocket and sun-dried tomato salad  1\n    2. speedy tomato and paprika soup  1\n  7. tonic tipple  1\n  8. trail mix, heart-healthy  1\n  9. triacylglycerol  1\n  10. triglycerides  1,  2,  3\n  11. trout  1\n    1. grilled trout with root vegetables and salsa verde  1\n  12. tryptophan  1\n  13. tuna  1\n    1. tuna steak with chilli-blueberry compote and roasted celeriac  1\n    2. tuna steak with mango salsa, wilted greens and quinoa verde  1\n\n  1. vasoconstriction  1,  2,  3\n  2. vasodilation  1,  2,  3,  4,  5,  6\n  3. vegetable oils  1\n  4. vegetables: chicken and green vegetable nutty stir-fry  1\n    1. grilled trout with root vegetables and salsa verde  1\n    2. roasted vegetables with quinoa salad  1\n    3. soba noodle vegetable stir-fry  1\n    4. vegetable crudit\u00e9s  1\n  5. vitamin C  1\n  6. vitamin D  1\n  7. vitamin E  1\n\n  1. walnuts: red pepper-walnut dip  1\n  2. watercress: kippers, boiled egg and watercress salad  1\n  3. white blood cells  1,  2\n  4. wine  1,  2\n    1. pears poached in spiced red wine  1\n    2. tonic tipple  1\n\n  1. yogurt: mixed seed and blackberry bowl  1\n    1. oat and berry layer  1\n    2. smoked salmon, beetroot and minted yogurt wrap  1\n\n# Copyright\n\nClare Hulton \u2013 we are really cooking on gas now! Amazing work. Thank you! Jenny Liddle \u2013 you are tireless at what you do! Tanya Murkett \u2013 as always, supporting me and putting up with me no matter what! A big thank you to all the team at Quadrille, Smith & Gilmour, Martin Poole, and Aya Nishimura. Catherine Tyldesley, Gaby Roslin, and all of the wonderful people that have supported my work and career. Ramsay and Candy. Mum and Dad.\n\nEditorial director: Anne Furniss  \nCreative director: Helen Lewis  \nProject editor: Lucy Bannell  \nArt direction and design: Smith & Gilmour  \nPhotography: Martin Poole  \nIllustration: Blindsalida  \nFood stylist: Aya Nishimura  \nProps stylists: Polly Webb-Wilson & Wei Tang  \nProduction: Tom Moore\n\nFirst published in 2015 by Quadrille Publishing Limited  \nwww.quadrille.co.uk\n\nQuadrille is an imprint of Hardie Grant.  \nwww.hardiegrant.com.au\n\nText \u00a9 2015 Dale Pinnock  \nPhotography \u00a9 2015 Martin Poole  \nDesign and layout \u00a9 2015 Quadrille Publishing Limited\n\nThe rights of the author have been asserted. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, electrostatic, magnetic tape, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publisher.\n\nCataloguing in Publication Data: a catalogue record for this book is available from the British Library.\n\n978 184949 658 2\n","meta":{"redpajama_set_name":"RedPajamaBook"}}