Western tattooists work with a special electrical instrument, something like a dentist’s drill. It holds a number of very fine needles which, for the purpose of reproducing the approved drawing, are dipped in black ink. When the current is switched on, and the instrument passed rapidly over the outline, the action of the needles drives the ink into the skin. The tattooist is constantly wiping away excess ink as he works. This is where skill is so important, for the speed of the instrument means that he must work rapidly over lines which are almost permanently covered over.

The basic drawing then has to be coloured in, using the same method but with non-poisonous paint now replacing the ink. The average tattoo contains four or five colours, each injected with a separate instrument. How many needles are used each time will depend on the area to be covered, but it is possible to use as many as ten or twelve, giving up to 3, 000 injections a minute. Filling-in is a lengthier process than outlining, and since most people find half an hour under the needles quite enough, a major tattoo can take a number of visits to complete. Every visit will leave the skin sore and stinging, and to prevent infection the area is finally treated with an antiseptic cream and covered with a dressing. After a few days it finally heals over, leaving the new tattoo clearly visible under the skin.

And there it stays, as those who get tattooed and think better of it soon discover that getting rid of the tattoo is a far more difficult business than getting it. The tattooist is powerless to undo what he has done and can only refer unhappy customers to their doctors who, no matter how sympathetic, are able to offer little encouragement. Removing a tattoo, if it can be done at all, has to be by one of two methods, neither of them pleasant or even completely satisfactory. The first is by surgery and skin replacement, all operation which leaves permanent marks. The other possibility is to re-tattoo over the offending design with a special acid-based substance which absorbs the colours as it goes. This is a painful and lengthy process which, though less expensive than private surgery, is still quite costly.

It is such a common event that responsible tattooists refuse to work on areas which cannot normally be covered up. “The trouble is that most people don’t think about it until it’s too late,” says one tattooist who had his own hands tattooed some years ago, and freely admits to regretting it. “I realize now that it looks in bad taste.”

To paraphrase 18th-century statesman Edmund Burke, “All that is needed for the triumph of a misguided cause is that good people do nothing.” One such cause now seeks to end biomedical research because of the theory that animals have rights ruling out their use in research. Scientists need to respond forcefully to animal rights advocates, whose arguments are confusing the public and thereby threatening advances in health knowledge and care. Leaders of the animal rights movement target biomedical research because it depends on public funding, and few people understand the process of health care research. Hearing allegations of cruelty to animals in research settings, many are perplexed that anyone would deliberately harm an animal.

For example, a grandmotherly woman staffing an animal rights booth at a recent street fair was distributing a brochure that encouraged readers not to use anything that comes from or is tested in animals — no meat, no fur, no medicines. Asked if she opposed immunizations, she wanted to know if vaccines come from animal research. When assured that they do, she replied, “Then I would have to say yes.” Asked what will happen when epidemics return, she said, “Don’t worry. Scientists will find some way of using computers.” Such well-meaning people just don’t understand.

Scientists must communicate their message to the public in a compassionate, understandable way — in human terms, not in the language of molecular biology. We need to make clear the connection between animal research and a grandmother’s hip replacement, a father’s bypass operation, a baby’s vaccinations, and even a pet’s shots. To those who are unaware that animal research was needed to produce these treatments, as well as new treatments and vaccines, animal research seems wasteful at best and cruel at worst.

Much can be done. Scientists could “adopt” middle school classes and present their own research. They should be quick to respond to letters to the editor, lest animal rights misinformation go unchallenged and acquire a deceptive appearance of truth. Research institutions could be opened to tours, to show that laboratory animals receive humane care. Finally, because the ultimate stakeholders are patients, the health research community should actively recruit to its cause not only well-known personalities such as Stephen Cooper, who has made courageous statements about the value of animal research, but all who receive medical treatment. If good people do nothing there is a real possibility that an uninformed citizenry will extinguish the precious embers of medical progress.

In recent years, railroads have been combining with each other, merging into super systems, causing heightened concerns about monopoly. As recently as 1995, the top four railroads accounted for under 70 percent of the total ton-miles moved by rails. Next year, after a series of mergers is completed, just four railroads will control well over 90 percent of all the freight moved by major rail carriers.

Supporters of the new super systems argue that these mergers will allow for substantial cost reductions and better coordinated service. Any threat of monopoly, they argue, is removed by fierce competition from trucks. But many shippers complain that for heavy bulk commodities traveling long distances, such as coal, chemicals, and grain, trucking is too costly and the railroads therefore have them by the throat.

The vast consolidation within the rail industry means that most shippers are served by only one rail company. Railroads typically charge such “captive” shippers 20 to 30 percent more than they do when another railroad is competing for the business. Shippers who feel they are being overcharged have the right to appeal to the federal government’s Surface Transportation Board for rate relief, but the process is expensive, time-consuming, and will work only in truly extreme cases.

Railroads justify rate discrimination against captive shippers on the grounds that in the long run it reduces everyone’s cost. If railroads charged all customers the same average rate, they argue, shippers who have the option of switching to trucks or other forms of transportation would do so, leaving remaining customers to shoulder the cost of keeping up the line. It’s the theory to which many economists subscribe, but in practice it often leaves railroads in the position of determining which companies will flourish and which will fail. “Do we really want railroads to be the arbiters of who wins and who loses in the marketplace?” asks Martin Bercovici, a Washington lawyer who frequently represents shippers.

Many captive shippers also worry they will soon be hit with a round of huge rate increases. The railroad industry as a whole, despite its brightening fortunes, still does not earn enough to cover the cost of the capital it must invest to keep up with its surging traffic. Yet railroads continue to borrow billions to acquire one another, with Wall Street cheering them on. Consider the 1.02 billion bid by Norfolk Southern and CSX to acquire Conrail this year. Conrail’s net railway operating income in 1996 was just 427 million, less than half of the carrying costs of the transaction. Who’s going to pay for the rest of the bill? Many captive shippers fear that they will, as Norfolk Southern and CSX increase their grip on the market.

It is said that in England death is pressing, in Canada inevitable and in California optional. Small wonder. Americans’ life expectancy has nearly doubled over the past century. Failing hips can be replaced, cataracts removed in a 30-minute surgical procedure. Such advances offer the aging population a quality of life that was unimaginable when I entered medicine 50 years ago. But not even a great health-care system can cure death, and our failure to confront that reality now threatens this greatness of ours.

Death is normal; we are genetically programmed to disintegrate and perish, even under ideal conditions. We all understand that at some level, yet as medical consumers we treat death as a problem to be solved. Shielded by third-party payers from the cost of our care, we demand everything that can possibly be done for us, even if it’s useless. The most obvious example is late-stage cancer care. Physicians — frustrated by their inability to cure the disease and fearing loss of hope in the patient—too often offer aggressive treatment far beyond what is scientifically justified.

In 1950, the U.S. spent $12.7 billion on health care. In 2002, the cost will be $1,540 billion. Anyone can see this trend is unsustainable. Yet few seem willing to try to reverse it. Some scholars conclude that a government with finite resources should simply stop paying for medical care that sustains life beyond a certain age — say 83 or so. Former Colorado governor Richard Lamm has been quoted as saying that the old and infirm “have a duty to die and get out of the way”, so that younger, healthier people can realize their potential.

I would not go that far. Energetic people now routinely work through their 60s and beyond, and remain dazzlingly productive. At 78, Viacom chairman Sumner Redstone jokingly claims to be 53. Supreme Court Justice Sandra Day O’Connor is in her 70s, and former surgeon general C. Everett Koop chairs an Internet start-up in his 80s. These leaders are living proof that prevention works and that we can manage the health problems that come naturally with age. As a mere 68-year-old, I wish to age as productively as they have.

Yet there are limits to what a society can spend in this pursuit. As a physician, I know the most costly and dramatic measures may be ineffective and painful. I also know that people in Japan and Sweden, countries that spend far less on medical care, have achieved longer, healthier lives than we have. As a nation, we may be overfunding the quest for unlikely cures while underfunding research on humbler therapies that could improve people’s lives.

1. What is implied in the first sentence?