V

Emilia Reggio

The Reggio Emilia Approach is an educational philosophy focused on preschool and primary education. It was started by the parents of the villages around Reggio Emilia in Italy after World War II. The city of Reggio Emilia in Italy is recognized worldwide for its innovative approach to education. Its signature educational philosophy has become known as the Reggio Emilia Approach. And many American preschool programs have adopted it. The Reggio Emilia philosophy is based upon the following set of principles: Children must have some control over the direction of their learning; children must be able to learn through experiences of touching, moving, listening, seeing, and hearing; children have a relationship with other children and with material items in the world that children must be allowed to explore; and children must have endless ways and opportunities to express themselves.

The Reggio Emilia approach to teaching young children puts the natural development of children as well as the close relationships that they share with their environment at the center of its philosophy. Early childhood programs that have successfully adapted to this educational philosophy share that they are attracted to Reggio because of the way it views and respects the child. They believe that the central reason that a child must have control over his or her day-to-day activity is that learning must make sense from the child's point of view.

Parents are a vital component to the Reggio Emilia philosophy. Parents are viewed as partners, collaborators and advocates for their children. Teachers respect parents as each child's first teacher and involve parents in every aspect of the curriculum. It is not uncommon to see parents volunteering within Reggio Emilia classrooms throughout the school. This philosophy does not end when the child leaves the classroom. Most parents who choose to send their children to a Reggio Emilia program incorporate many of the principles within their parenting and home life. Even with this bridge between school and home, many people wonder what happens to Reggio children when they make the transition from this style of education to a non Reggio Emilia school. The answer is that there is some adjustment that must take place. In most school environments, intellectual curiosity is rewarded, so students continue to reap the benefits of Reggio after they've left the program.

Community support and parental involvement

Reggio Emilia's tradition of community support for families with young children expands on a view, more strongly held in Emilia Romagna and Tuscany, of children as the collective responsibility of the local community. In Reggio Emilia, the infant/toddler and pre-primary program is a vital part of the community, as reflected in the high level of financial support. Community involvement is also apparent in citizen membership in La Consulta, a school committee that exerts significant influence over local government policy.

The parents' role mirrors the community's, at both the schoolwide and the classroom level. Parents are expected to take part in discussions about school policy, child development concerns, and curriculum planning and evaluation. Because a majority of parents--including mothers--are employed, meetings are held in the evenings so that all who wish to participate can do so.

Teachers as learners

Teachers' long-term commitment to enhancing their understanding of children is at the crux of the Reggio Emilia approach. Their resistance to the American use of the term model to describe their program reflects the continuing evolution of their ideas and practices. They compensate for the meager preservice training of Italian early childhood teachers by providing extensive staff development opportunities, with goals determined by the teachers themselves. Teacher autonomy is evident in the absence of teacher manuals, curriculum guides, or achievement tests. The lack of externally imposed mandates is joined by the imperative that teachers become skilled observers of children in order to inform their curriculum planning and implementation.

Teachers routinely divide responsibilities in the class so that one can systematically observe, take notes, and record conversations between children. These observations are shared with other teachers and a specialized teacher called the atelierista who uses a space in the school called an atelier -or studio- to use art as an integrated way for children's symbolic expression. Parents are also involved in curriculum planning and evaluation. Teachers of several schools often work and learn together under the leadership of the pedagogista as they explore ways of expanding on children's spontaneous activities..

The role of the environment

The organization of the physical environment is crucial to Reggio Emilia's early childhood program, and is often referred to as the child's "third teacher." Major aims in the planning of new spaces and the remodeling of old ones include the integration of each classroom with the rest of the school, and the school with the surrounding community. The preschools are generally filled with indoor plants and vines, and awash with natural light. Classrooms open to a center piazza, kitchens are open to view, and access to the surrounding community is assured through wall-size windows, courtyards, and doors to the outside in each classroom. Entries capture the attention of both children and adults through the use of mirrors (on the walls, floors, and ceilings), photographs, and children's work accompanied by transcriptions of their discussions. These same features characterize classroom interiors, where displays of project work are interspersed with arrays of found objects and classroom materials. In each case, the environment informs and engages the viewer.

Other supportive elements of the environment include ample space for supplies, frequently rearranged to draw attention to their aesthetic features. In each classroom there are studio spaces in the form of a large, centrally located atelier and a smaller mini-atelier, and clearly designated spaces for large- and small-group activities. Throughout the school, there is an effort to create opportunities for children to interact. Thus, the single dress-up area is in the center piazza; classrooms are connected with telephones, passageways or windows; and lunchrooms and bathrooms are designed to encourage community.

Long-term projects as vehicles for learning

The curriculum is characterized by many features advocated by contemporary research on young children, including real-life problem-solving among peers, with numerous opportunities for creative thinking and exploration. Teachers often work on projects with small groups of children, while the rest the class engages in a wide variety of self-selected activities typical of preschool classrooms.

The projects that teachers and children engage in are distinct in a number of ways from those that characterize American teachers' conceptions of unit or thematic studies. The topic of investigation may derive directly from teacher observations of children's spontaneous play and exploration. Project topics are also selected on the basis of an academic curiosity or social concern on the part of teachers or parents, or serendipitous events that direct the attention of the children and teachers. Reggio teachers place a high value on their ability to improvise and respond to children's predisposition to enjoy the unexpected. Regardless of their origins, successful projects are those that generate a sufficient amount of interest and uncertainty to provoke children's creative thinking and problem-solving and are open to different avenues of exploration. Because curriculum decisions are based on developmental and sociocultural concerns, small groups of children of varying abilities and interests, including those with special needs, work together on projects.

Projects begin with teachers observing and questioning children about the topic of interest. Based on children's responses, teachers introduce materials, questions, and opportunities that provoke children to further explore the topic. While some of these teacher provocations are anticipated, projects often move in unanticipated directions as a result of problems children identify. Thus, curriculum planning and implementation revolve around open-ended and often long-term projects that are based on the reciprocal nature of teacher-directed and child-initiated activity.

The hundred languages of children

As children proceed in an investigation, generating and testing their hypotheses, they are encouraged to depict their understanding through one of many symbolic languages, including drawing, sculpture, dramatic play, and writing. They work together toward the resolution of problems that arise. Teachers facilitate and then observe debates regarding the extent to which a child's drawing or other form of representation lives up to the expressed intent. Revision of drawings (and ideas) is encouraged, and teachers allow children to repeat activities and modify each other's work in the collective aim of better understanding the topic. Teachers foster children's involvement in the processes of exploration and evaluation, acknowledging the importance of their evolving products as vehicles for exchange.

Conclusion

Reggio Emilia's approach to early education reflects a theoretical kinship with John Dewey, Jean Piaget, Vygotsky and Jerome Bruner, among others. Much of what occurs in the class reflects a constructivist approach to early education. Reggio Emilia's approach does challenge some conceptions of teacher competence and developmentally appropriate practice. For example, teachers in Reggio Emilia assert the importance of being confused as a contributor to learning; thus a major teaching strategy is purposely to allow mistakes to happen, or to begin a project with no clear sense of where it might end. Another characteristic that is counter to the beliefs of many Western educators is the importance of the child's ability to negotiate in the peer group.

One of the most challenging aspects of the Reggio Emilia approach is the solicitation of multiple points of view regarding children's needs, interests, and abilities, and the concurrent faith in parents, teachers, and children to contribute in meaningful ways to the determination of school experiences. Teachers trust themselves to respond appropriately to children's ideas and interests, they trust children to be interested in things worth knowing about, and they trust parents to be informed and productive members of a cooperative educational team. The result is an atmosphere of community and collaboration that is developmentally appropriate for adults and children alike.

Pathways

Crap Economy

Casinos, generally seen as recession-proof, are beginning to feel the pain of the slowing U.S. economy.

The gambling industry has expanded rapidly in recent years, as more U.S. states allowed casinos and existing gaming parlors expanded. Casino gambling revenue, the amount lost by players, doubled between 1995 and 2006 to $32 billion, according to the American Gaming Association.

But with the U.S. economy slowing, there are signs that Americans, especially patrons of local casinos, are not in a betting mood.

"Competitive pressures in several markets do not appear likely to lessen in the near term," Oppenheimer analyst David Katz said in a report released Wednesday.

Harrah's Entertainment, the world's largest casino company, and Boyd Gaming both posted weaker quarterly earnings Wednesday and both described the economic environment as "challenging."

Their weaker earnings come a day after Pinnacle Entertainment, which operates casinos in regional U.S. markets, posted a wider fourth-quarter loss, mainly because of costs related to opening a new casino. The company said progress on other projects hinged on improved access to credit financing.

Harrah's, which operates Las Vegas Strip resorts like Caesars Palace and the Flamingo, posted a fourth-quarter loss, burdened by impairment charges and losses at its properties in Illinois and Indiana.

Gary Loveman, Harrah's chief executive, said during a conference call that results at regional casinos were "mixed," while in Las Vegas "the gaming business has held up well, but room rates are off a bit."

Boyd Gaming, which owns and operates 17 casinos in seven states, posted a 45 percent drop in fourth-quarter profit.

Boyd, which is building a casino resort called Echelon on the Las Vegas Strip, said net income fell to $31.2 million, or 35 cents per share, from $56.3 million, or 64 cents per share, a year earlier. Revenue fell 8.1 percent to $478.6 million, Boyd said.

The chief executive of Boyd, Keith Smith, said that the company experienced "some softness or weaknesses in the business" in late November through January, but that trends improved in February and that the company was "cautiously optimistic" for this quarter.

Fourth-quarter earnings at its downtown Las Vegas properties, aimed at tourists, posted a 13.8 percent profit drop, while profit fell 13.2 percent at Boyd casinos in the U.S. Midwest and South, as its Blue Chip casino in Michigan City, Indiana, suffered from new competition.

At the same time, profit from Borgata in Atlantic City, New Jersey, a joint venture with MGM Mirage, was essentially flat as it faced competition from video lottery terminals added in nearby Pennsylvania and New York.

Boyd's earnings at its casinos catering to Las Vegas locals rose 3.3 percent as the company overcame a 1.5 percent dip in revenue.

Harrah's, which was acquired last month by the private equity funds Apollo Global Management and TPG Capital, posted a net loss of $47.8 million, compared with a profit of $47.6 million in the same quarter a year earlier.

Abstract

Hedged Out

Peloton Partners LLP, the London- based hedge fund manager being forced to liquidate a $1.8 billion asset-backed fund, said it's a victim of Wall Street's reduced lending.

``Credit providers have been severely tightening terms without regard to the creditworthiness or track record of individual firms, which has compounded our difficulties and made it impossible to meet margin calls,'' Peloton co-founders Ron Beller and Geoff Grant said in a letter yesterday to clients.

Peloton joins Thornburg Mortgage Inc. and Sailfish Capital Partners LLC on the growing list of funds and companies that have had to sell securities or shut down after banks restricted how much they could borrow, or demanded more collateral as values of securities backed by mortgages slumped. The world's biggest financial institutions are cutting off lines of credit to hedge funds after at least $163 billion of asset writedowns and market losses.

``More hedge funds will blow up this year than ever before,'' said Michael Hennessy, who helps oversee $10 billion of hedge fund investments at Morgan Creek Capital Management in Chapel Hill, North Carolina. ``Financing is much harder to get. The bubble has burst.''

UBS AG, Goldman Sachs Group Inc., Merrill Lynch & Co. and Deutsche Bank AG were among the firms that lent money to Peloton, said people with knowledge of the matter, who declined to be identified. Officials at the banks declined to comment.

Freeze on Redemptions

Peloton said yesterday in a separate letter to investors that it froze customer redemptions from its $1.6 billion Multi- Strategy Fund, which has a ``very large position'' in the ABS fund.

Beller and Grant, who founded their firm in 2005, are seeking buyers for mortgage securities held by the ABS fund. The fund provided clients with an 87 percent return last year after the managers bet on a surge in delinquencies on loans to homeowners in the riskiest subprime category. Beller said in a Jan. 25 telephone interview that the firm bought securities backed by mortgages that are safer than subprime.

The price of top-rated Alt-A securities, which rank above subprime, dropped 10 percent to 15 percent this month, according to Thornburg Mortgage, the Santa Fe, New Mexico-based finance company which yesterday said it may sell securities to meet further margin calls, after burning through cash.

``Risk managers everywhere are revisiting how collateral is being priced so you're seeing margin calls,'' said Kenneth Hackel, managing director of fixed-income strategy at RBS Greenwich Capital Markets in Greenwich, Connecticut. ``As risk appetites decline, the price of assets that are used as collateral decline.''

Sailfish Fund

Beller, 45, led Goldman's fixed-income currency and commodity sales group in London before leaving in 2001 to reorganize New York City's school system. Grant, 47, was co-head of New York-based Goldman's so-called macro proprietary trading group. Grant, who works in Santa Barbara, California, declined to comment.

Sailfish's Multi-Strat Fixed Income fund, which had $1.9 billion in July, collapsed as credit bets went sour and the Stamford, Connecticut-based firm unwound positions into a declining market.

The average price of an actively traded high-yield, high- risk loan tumbled this month to a record low of 86.28 cents on the dollar from 100 cents last July.

Margin Calls

The extra yield, or spread, investors demand to own high- yield, high-risk, or junk, bonds instead of Treasuries widened to 718 basis points from 592 basis points in December, according to data compiled by Merrill Lynch & Co. in New York. A basis point is 0.01 percentage point. Junk debt is rated below Baa3 by Moody's Investors Service and less than BBB- by Standard & Poor's.

Morgan Stanley predicts that the ``substantial and sharp moves in the credit markets'' will lead to the closures of several credit hedge funds, which could put further pressure on prices of mortgage-related securities and derivatives.

Particularly at risk of further credit losses is UBS, which has so far written down $19 billion, according to Huw Van Steenis, a Morgan Stanley analyst in London.

``We feel that UBS has been consistently behind the curve in marks and, worryingly, the worst may not be over,'' he wrote in a report yesterday.

UBS needs to reduce its balance sheet from 2.3 trillion francs ($2.2 trillion) to less than 1.7 trillion francs ($1.63 trillion), and reducing relationships with hedge funds is a likely lever, Van Steenis wrote in an e-mail today.

An increase in margin calls may drive prices even lower, RBS's Hackel said.

``I feel like so many shoes have already dropped, the shoe store should be empty by now,'' he said. ``I'd like to think we're pretty close to the end of the game, but I can't say that with any degree of confidence.''

Time

Building Blocks

Carl and Oliver, both 8-year-olds in our after-school program, huddled over piles of Legos. They carefully assembled them to add to a sprawling collection of Lego houses, grocery stores, fish-and-chips stands, fire stations, and coffee shops. They were particularly keen to find and use "cool pieces," the translucent bricks and specialty pieces that complement the standard-issue red, yellow, blue, and green Lego bricks.

"I'm making an airport and landing strip for my guy's house. He has his own airplane," said Oliver.

"That's not fair!" said Carl. "That takes too many cool pieces and leaves not enough for me."

"Well, I can let other people use the landing strip, if they have airplanes," said Oliver. "Then it's fair for me to use more cool pieces, because it's for public use."

Discussions like the one above led to children collaborating on a massive series of Lego structures we named Legotown. Children dug through hefty-sized bins of Legos, sought "cool pieces," and bartered and exchanged until they established a collection of homes, shops, public facilities, and community meeting places. We carefully protected Legotown from errant balls and jump ropes, and watched it grow day by day.

After nearly two months of observing the children's Legotown construction, we decided to ban the Legos.

The Investigation Begins

Our school-age childcare program — the "Big Kids" — involves 25 children and their families. The children, ages 5 through 9, come to Hilltop after their days in elementary school, arriving around 3:30 and staying until 5:30 or 6:00. Hilltop is located in an affluent BlueMint neighborhood; the families are upper-middle class and socially liberal. Kendra is the lead teacher for the Big Kid program; two additional teachers, Erik and Harmony, staff the program. Ann is the mentor teacher at Hilltop, working closely with teachers to study and plan curriculum from children's play and interactions.

A group of about eight children conceived and launched Legotown. Other children were eager to join the project, but as the city grew — and space and raw materials became more precious — the builders began excluding other children.

Occasionally, Legotown leaders explicitly rebuffed children, telling them that they couldn't play. Typically the exclusion was more subtle, growing from a climate in which Legotown was seen as the turf of particular kids. The other children didn't complain much about this; when asked about Legos, they'd often comment vaguely that they just weren't interested in playing with Legos anymore. As they closed doors to other children, the Legotown builders turned their attention to complex negotiations among themselves about what sorts of structures to build, whether these ought to be primarily privately owned or collectively used, and how "cool pieces" would be distributed and protected. These negotiations gave rise to heated conflict and to insightful conversation. Into their coffee shops and houses, the children were building their assumptions about ownership and the social power it conveys — assumptions that mirrored those of a class-based, capitalist society — a society that we teachers believe to be unjust and oppressive. As we watched the children build, we became increasingly concerned.

Then, tragedy struck Legotown and we saw an opportunity to take strong action.

Hilltop is housed in a church, and over a long weekend, some children in the congregation who were playing in our space accidentally demolished Legotown.

When the children discovered the decimated Legotown, they reacted with shock and grief. Children moaned and fell to their knees to inspect the damage; many were near tears. The builders were devastated, and the other children were deeply sympathetic. We gathered as a full group to talk about what had happened; at one point in the conversation, Kendra suggested a big cleanup of the loose Legos on the floor. The Legotown builders were fierce in their opposition. They explained that particular children "owned" those pieces and it would be unfair to put them back in the bins where other children might use them. As we talked, the issues of ownership and power that had been hidden became explicit to the whole group.

We met as a teaching staff later that day. We saw the decimation of Lego-town as an opportunity to launch a critical evaluation of Legotown and the inequities of private ownership and hierarchical authority on which it was founded. Our intention was to promote a contrasting set of values: collectivity, collaboration, resource-sharing, and full democratic participation. We knew that the examination would have the most impact if it was based in engaged exploration and reflection rather than in lots of talking. We didn't want simply to step in as teachers with a new set of rules about how the children could use Legos, exchanging one set of authoritarian rules with another. Ann suggested removing the Legos from the classroom. This bold decision would demonstrate our discomfort with the issues we saw at play in Legotown. And it posed a challenge to the children: How might we create a "community of fairness" about Legos?

Out with the Legos

Taking the Legos out of the classroom was both a commitment and a risk. We expected that looking frankly at the issues of power and inequity that had shaped Legotown would hold conflict and discomfort for us all. We teachers talked long and hard about the decision. We shared our own perspectives on issues of private ownership, wealth, and limited resources. One teacher described her childhood experience of growing up without much money and her instinctive critical judgments about people who have wealth and financial ease. Another teacher shared her allegiance to the children who had been on the fringes of Legotown, wanting more resources but not sure how to get them without upsetting the power structure. We knew that our personal experiences and beliefs would shape our decision-making and planning for the children, and we wanted to be as aware as we could about them.

We also discussed our beliefs about our role as teachers in raising political issues with young children. We recognized that children are political beings, actively shaping their social and political understandings of ownership and economic equity — whether we interceded or not. We agreed that we want to take part in shaping the children's understandings from a perspective of social justice. So we decided to take the Legos out of the classroom.

We had an initial conversation with the children about our decision. "We're concerned about what was happening in Legotown, with some kids feeling left out and other kids feeling in charge," Kendra explained. "We don't want to rebuild Legotown and go back to how things were. Instead, we want to figure out with you a way to build a Legotown that's fair to all the kids."

Naturally the children had big feelings and strong opinions to share. During that first day's discussion, they laid out the big issues that we would pursue over the months to come.

Several times in the discussion, children made reference to "giving" Lego pieces to other children. Kendra pointed out the understanding behind this language: "When you say that some kids ‘gave' pieces to other kids, that sounds like there are some kids who have most of the power in Legotown — power to decide what pieces kids can use and where they can build." Kendra's comment sparked an outcry by Lukas and Carl, two central figures in Legotown:

Carl: "We didn't ‘give' the pieces, we found and shared them."

Lukas: "It's like giving to charity."

Carl: "I don't agree with using words like ‘gave.' Because when someone wants to move in, we find them a platform and bricks and we build them a house and find them windows and a door."

These children seemed to squirm at the implications of privilege, wealth, and power that "giving" holds. The children denied their power, framing it as benign and neutral, not something actively sought out and maintained. This early conversation helped us see more clearly the children's contradictory thinking about power and authority, laying the groundwork for later exploration.

Issues of fairness and equity also bubbled to the surface during the animated discussion about the removal of the Legos:

Lukas: "I think every house should be average, and not over-average like Drew's, which is huge."

Aidan: "But Drew is special."

Drew: "I'm the fire station, so I have to have room for four people."

Lukas: "I think that houses should only be as big as 16 bumps one way, and 16 bumps the other way. That would be fair." ["Bumps" are the small circles on top of Lego bricks.]

This brief exchange raised issues that we would revisit often in the weeks ahead. What is a fair distribution of resources? Does fairness mean that everyone has the same number of pieces? What about special rights: Who might deserve extra resources, and how are those extra resources allotted?

After nearly an hour of passionate exchange, we brought the conversation to a close, reminding the children that we teachers didn't have an answer already figured out about Legotown. We assured them that we were right there with them in this process of getting clearer about what hadn't worked well in Legotown, and understanding how we could create a community of fairness about Legos.

We'd audiotaped the discussion so that we'd be able to revisit it during our weekly teaching team meeting to tease out important themes and threads. The children's thoughts, questions, and tensions would guide us as we planned our next steps. We weren't working from carefully sequenced lessons on ownership, resource sharing, and equity. Instead, we committed to growing an investigation into these issues, one step at a time. Our planning was guided by our goals for social justice learning, and by the pedagogy our school embraces, inspired by schools in Reggio Emilia, Italy. In this approach, teachers offer children a provocation and listen carefully to the children's responses. These responses help teachers plan the next provocation to challenge or expand the children's theories, questions, and cognitive challenges.

What Does Power Look Like?

A few days after we'd removed the Legos, we turned our attention to the meaning of power. During the boom days of Legotown, we'd suggested to the key Lego players that there was an unequal distribution of power giving rise to conflict and tension. Our suggestions were met with deep resistance. Children denied any explicit or unfair power, making comments like "Some-body's got to be in charge or there would be chaos," and "The little kids ask me because I'm good at Legos." They viewed their power as passive leadership, benignly granted, arising from mastery and long experience with Legos, as well as from their social status in the group.

Now, with Legotown dismantled and the issues of equity and power squarely in front of us, we took up the idea of power and its multiple meanings. We began by inviting the children to draw pictures of power, knowing that when children represent an idea in a range of "languages" or art media, their understandings deepen and expand. "Think about power," said Kendra. "What do you think ‘power' means? What does power look like? Take a few minutes to make a drawing that shows what power is."

As children finished their drawings, we gathered for a meeting to look at the drawings together. The drawings represented a range of understandings of power: a tornado, love spilling over as hearts, forceful and fierce individuals, exclusion, cartoon superheroes, political power.

During our meeting, children gave voice to the thinking behind their drawings.

Marlowe: "If your parents say you have to eat pasta, then that's power."

Lukas: "You can say no."

Carl: "Power is ownership of something."

Drew: "Sometimes I like power and sometimes I don't. I like to be in power because I feel free. Most people like to do it, you can tell people what to do and it feels good."

Drew's comment startled us with its raw truth. He was a member of the Legotown inner circle, and had been quite resistant to acknowledging the power he held in that role. During this discussion, though, he laid his cards on the table. Would Drew's insight break open new understandings among the other members of the inner circle?

Exploring Power

To build on Drew's breakthrough comment about the pleasure and unease that comes with wielding power, and to highlight the experience of those who are excluded from power, we designed a Lego trading game with built-in inequities. We developed a point system for Legos, then skewed the system so that it would be quite hard to get lots of points. And we established just one rule: Get as many points as possible. The person with the most points would create the rules for the rest of the game. Our intention was to create a situation in which a few children would receive unearned power from sheer good luck in choosing Lego bricks with high point values, and then would wield that power with their peers. We hoped that the game would be removed enough from the particulars and personalities of Legotown that we could look at the central Legotown issues from a fresh perspective.

This was a simple game about complicated issues.

We introduced the Lego trading game to the children by passing a bin of Legos around the circle, asking each child to choose 10 Legos; we didn't say anything about point values or how we'd use the bricks. Most children chose a mix of colored Lego bricks, though a few chose 10 of one color. Liam took all eight green Legos, explaining that green is his favorite color; this seemingly straightforward choice altered the outcome of the game.

When everyone had their Legos, the teachers announced that each color had a point value: The more common the brick color, the fewer the points it was worth, while the scarcest brick color, green, was worth a whopping five points.

Right away, there were big reactions.

Liam: "I have all the green! I have 40 points because I have all the green!"

Drew: "This isn't fair! Liam won't trade any green, I bet, so what's the point? What if you just want to quit?"

Carl: "I don't want to play this game. I'll just wait for Liam to give me a green. If he doesn't, it's hopeless."

We didn't linger with the children's reactions, but carried on with the game, explaining that the object of the game was to trade Lego pieces in an effort to get the most points. Kids immediately began to calculate how they'd trade their pieces, and dove into trading. Several children shadowed Liam, pleading with him to give them a green — but he refused.

After a few minutes of trading, we rang a bell and children added up their scores. Liam and Kyla had scores that far out-totaled those of the other children. Kendra asked them each to create a rule, explaining that we'd play another round of the game, following the new rules and aiming for the same goal: to get the most points possible.

We expected that the winners would make rules to ensure that they would win the next round — for instance, "All greens are worth 50 points," or, "You can only win if your name starts with a K." We were surprised at what happened.

Liam instituted this rule: "You have to trade at least one piece. That's a good rule because if you have a high score at the beginning, you wouldn't have to trade, and that's not fair."

Kyla added this rule to the game: "If you have more than one green, you have to trade one of them."

With these new rules on the books, we held a second short round of trading, then rang the bell and added up points. Liam, Kyla, and Lukas won this round. The three winners grinned at each other as we gathered in a circle to debrief the game. Before we could launch a conversation as teachers, the children's raw emotion carried us into a passionate exchange.

Drew: "Liam, you don't have to brag in people's faces."

Carl: "The winner would stomp his feet and go ‘Yes' in the face of people. It felt kind of mean."

Liam: "I was happy! I wasn't trying to stomp in people's faces."

Carl: "I don't like that winners make new rules. People make rules that are only in their advantage. They could have written it simpler that said, ‘Only I win.'"

Juliet: "Because they wanted to win and make other people feel bad."

Kyla: "I wasn't trying to make other people feel bad. I felt bad when people felt bad, so I tried to make a rule that would make them feel better. It was fun to make up the rule — like a treat, to be one of only three people out of the whole group."

When the teaching staff met to reflect on the Lego trading game, we were struck by the ways the children had come face-to-face with the frustration, anger, and hopelessness that come with being on the outside of power and privilege. During the trading game, a couple of children simply gave up, while others waited passively for someone to give them valuable pieces. Drew said, "I stopped trading because the same people were winning. I just gave up." In the game, the children could experience what they'd not been able to acknowledge in Legotown: When people are shut out of participation in the power structure, they are disenfranchised — and angry, discouraged, and hurt.

To make sense of the sting of this disenfranchisement, most of the children cast Liam and Kyla as "mean," trying to "make people feel bad." They were unable or unwilling to see that the rules of the game — which mirrored the rules of our capitalist meritocracy — were a setup for winning and losing. Playing by the rules led to a few folks winning big and most folks falling further and further behind. The game created a classic case of cognitive disequilibrium: Either the system is skewed and unfair, or the winners played unfairly. To resolve this by deciding that the system is unfair would call everything into question; young children are committed to rules and rule-making as a way to organize a community, and it is wildly unsettling to acknowledge that rules can have built-in inequities. So most of the children resolved their disequilibrium by clinging to the belief that the winners were ruthless — despite clear evidence of Liam and Kyla's compassionate generosity.

In Legotown, the children had constructed a social system of power where a few people made the important decisions and the rest of the participants did the grunt work — much like the system in the trading game. We wanted children to critique the system at work in Legotown, not to critique the children at the top of the Legotown hierarchy. At the same time, we wanted them to see that the Legotown system was created by people, and, as such, could be challenged and reformulated. The children's reaction to the winners of the trading game was a big warning flag for us: We clearly had some repair work to do around relationships, as well as some overt teaching about systemic fallibility. The Lego trading game presented core issues that would be our focus for the months to come. Our analysis of the game, as teachers, guided our planning for the rest of the investigation into the issues of power, privilege, and authority that spanned the rest of the year.

Rules and Ownership

In the weeks after the trading game, we explored questions about how rules are made and enforced, and when they ought to be followed or broken. We aimed to help children see that all rules (including social structures and systems) are made by people with particular perspectives, interests, and experiences that shape their rule-making. And we wanted to encourage them to consider that there are times when rules ought to be questioned or even broken — sharing stories of people who refused to "play by the rules" when the rules were unjust, people like Rosa Parks and Cesar Chavez.

We added another thread to our investigation of power, as well, by turning our attention to issues related to ownership. In Legotown, the builders "owned" sections of Legotown and protected them fiercely from encroachment. We were curious to explore with the children their beliefs about how ownership happens: How does a person come to own something? How is ownership maintained or transferred? Are there situations in which ownership ought to be challenged or denied? What are the distinctions between private and public ownership?

We looked at ownership through several lenses. With the children, we created an "ownership museum," where children displayed possessions they brought from home — a Gameboy, a special blanket, a bike helmet, a baseball card, jewelry, dolls — and described how they came to own them. And we visited Pike Place Market, the farmers and artisans market in downtown Seattle, and asked questions to provoke kids to think about ownership: Does a farmer own her produce? Or does the consumer own it?

In their reflections, the children articulated several shared theories about how ownership is conferred.

If I buy it, I own it:
Sophia: "She owns the lavender balls because she makes them, but if I buy it, then it's mine."

If I receive it as a gift, I own it:
Marlowe: "My mom bought this book for me because she thought it would be a good reading book for me. I know I own it because my mom bought it and she's my mom and she gave it to me."

If I make it myself, I own it:
Sophie: "I sewed this pillow myself with things that my teacher gave me, like stuffing and fabric. I sewed it and it turned into my pillow because it's something I made instead of something I got at the store."

If it has my name on it, I own it:
Alex: "My teacher made this pillow for me and it has my name on it."

Kendra: "If I put my name on it, would I own it?"

Alex: "Well, Miss S. made it for me... but if your name was on it, then you would own it."

Sophie: "Kendra, don't put your name on it, OK?"

If I own it, I make the rules about it:
Alejandro: "I own this computer, because my grandpa gave it to me. I lend it to my friends so that they can play with it. But I make the rules about it."

The Return of the Legos

Throughout the investigation, the staff continued to meet weekly to study our notes about the activities we took up with the children, watching for moments when children identified contradictions in their own thinking, took on new perspectives, or questioned their own assumptions. In late spring, we decided it was time to challenge the children to wrestle their theoretical understandings into practical shape and apply their analysis of individual and collective ownership to a concrete project. After five months of naming and investigating the issues of power, rules, ownership, and authority, we were ready to reconstruct Legotown in a new way.

We invited the children to work in small, collaborative teams to build Pike Place Market with Legos. We set up this work to emphasize negotiated decision-making, collaboration, and collectivity. We wanted the children to practice the big ideas we'd been exploring. We wanted Lego Pike Place Market to be an experience of group effort and shared ownership: If Legotown was an embodiment of individualism, Lego Pike Place Market would be an experiment in collectivity and consensus.

We offered the children some guidelines to steer them into a new way of interacting with each other and with the Legos: "Create teams of two or three people, decide as a team on some element of Pike Place Market that you'll build, and then start constructing." The first day or two, children created signs warning the other teams "Do Not Touch" their collaboratively constructed vegetable, fruit, and crafts stands. As they settled into this construction project, though, the teams softened the rigid boundaries around their work and began to leave notes for each other describing their work and proposing next steps for Pike Place Market. We celebrated this shift, seeing it as a sign that the children were beginning to integrate the thinking of the last months into their interactions.

A New Ethics for Legotown

This "practice" round of Lego construction served as a foundation for a full-fledged return of Legos to their front-and-center place in the classroom, but with a new location in the consciousness of the group. In preparation for bringing Legos back, we held several meetings with the children to generate a set of key principles for Lego play. We met with small groups of children over snack or as we walked to and from the park, posing questions like "If you were going to play with Legos, what would be important to you?" "What would be different if we bring the Legos back to the classroom? How could we make it different?" "What could we do if we fall into old habits with the Legos?" From our conversations, several themes emerged.

Collectivity is a good thing:
"You get to build and you have a lot of fun and people get to build onto your structure with you, and it doesn't have to be the same way as when you left it.... A house is good because it is a community house."

Personal expression matters:
"It's important that the little Lego plastic person has some identity. Lego houses might be all the same except for the people. A kid should have their own Lego character to live in the house so it makes the house different."

Shared power is a valued goal:
"It's important to have the same amount of power as other people over your building. And it's important to have the same priorities."

"Before, it was the older kids who had the power because they used Legos most. Little kids have more rights now than they used to and older kids have half the rights."

Moderation and equal access to resources are things to strive for:
"We should have equal houses. They should be standard sizes.... We should all just have the same number of pieces, like 15 or 28 pieces."

As teachers, we were excited by these comments. The children gave voice to the value that collectivity is a solid, energizing way to organize a community — and that it requires power-sharing, equal access to resources, and trust in the other participants. They expressed the need, within collectivity, for personal expression, for being acknowledged as an individual within the group. And finally, they named the deep satisfaction of shared engagement and investment, and the ways in which the participation of many people deepens the experience of membership in community for everyone.

From this framework, the children made a number of specific proposals for rules about Legos, engaged in some collegial debate about those proposals, and worked through their differing suggestions until they reached consensus about three core agreements:

All structures are public structures. Everyone can use all the Lego structures. But only the builder or people who have her or his permission are allowed to change a structure.

Lego people can be saved only by a "team" of kids, not by individuals.

All structures will be standard sizes.

With these three agreements — which distilled months of social justice exploration into a few simple tenets of community use of resources — we returned the Legos to their place of honor in the classroom.

Children absorb political, social, and economic worldviews from an early age. Those worldviews show up in their play, which is the terrain that young children use to make meaning about their world and to test and solidify their understandings. We believe that educators have a responsibility to pay close attention to the themes, theories, and values that children use to anchor their play. Then we can interact with those worldviews, using play to instill the values of equality and democracy.

Nothing

Crap

The risk of a dollar ``downside overshoot'' is growing as the Federal Reserve's interest-rate cuts leave it ``out of sync'' with other central banks seeking to temper inflation, according to Bank of America Corp.

The dollar touched $1.5229 per euro today, the weakest since the common currency began trading in January 1999. It has tumbled about 5 percent in the past three weeks as speculation mounted the Fed will lower borrowing costs again next month for the sixth time since September. It was at $1.5218 per euro at 3:07 p.m. in New York, from $1.5120 yesterday.

``Fed easing policy that is out of sync with other central banks is not supportive of'' the dollar, Robert Sinche, Bank of America's head of global currency strategy in New York, wrote in a research note dated today.

The dollar's decline gained momentum this week after Fed Vice Chairman Donald Kohn said on Feb. 26 that turmoil in credit markets and the possibility of a slower economy pose a ``greater threat'' than inflation. The Fed's benchmark rate is 3 percent.

In contrast, European Central Bank President Jean-Claude Trichet today said ``price stability is a necessary condition'' for ongoing economic expansion and employment. The ECB next meets on March 6 to decide on the main rate, which is at 4 percent.

A euro rally to a range of $1.55 to $1.57 is now ``increasingly likely,'' Sinche said in the note.

Some central banks, including China's and Hungary's, may also allow their currencies to appreciate versus the dollar as a way to reduce inflation pressure from rising commodity prices, which are often priced in dollars, Sinche wrote.

Road To?

Peak All

Our peak oil thesis gained some new respect last week as oil prices hit yet another record, the first close over US$100 per barrel. Demand fluctuates, but it is all about supply, and supply concerns this week showed how tight the market really is.

Peak oil has lots of press, but what about peak copper? Peak zinc? Peak gold? Sounds preposterous, but maybe it's not so far-fetched. Nearly every commodity is experiencing some supply issues, for a host of reasons. Add it all up, and it means potential supply shortages in the future. Demand may slacken this year, but in the next 10 years today's high commodity prices may actually look like a bargain.

Let's take a look at some of the issues facing commodity projects today, and give some examples of companies that have already been impacted by them.

Cost overruns: Inflation, equipment shortages, and labour issues have combined to wreak havoc on so many new commodity projects that long-term supply issues may result.

Simply put, because of inflation, a commodity project that appeared economical two years ago may no longer be viable. Case in point: Novagold's (NG/TSX) Galore Creek project in British Columbia.

Costs estimated at $2.5-billion a year or so ago escalated to more than $4-billion. The cost overruns have put the project on hold despite high copper and gold prices. That means an expected 432 million pounds of copper production a year is not going to hit the market anytime soon.

Newmont (NMC/TSX) earlier this month said its Boddington gold mine in Australia was experiencing 77% cost overruns.

Petaquilla's (PTC/TSX) copper project in Panama is in a similar situation, with costs soaring to $3.5-billion.

Political issues: Too many examples to list here, but ask any mining company based in Ecuador, Venezuela, Mongolia or the Democratic Republic of Congo (DRC) how easy it is to get a project started. It's practically impossible. For commodity supplies, that's too bad, because some of the best remaining projects in the world are in some of the most politically unfriendly jurisdictions. Once again, future world supply will not be helped. Power shortages: If you were the president of a country, and your people had no electricity, what would be the first thing you would do? How about shutting down a gold mine? Gold is not actually used for anything, yet gold mines suck out massive amounts of power. Would you rather provide energy for your constituents or produce a bar of gold?

The answer is obvious, and so we see countries such as South Africa institute rolling blackouts for mines -- resulting in record high platinum and gold prices. We expect ongoing power issues to becoming even more prevalent in the future, with serious implications to future supplies of many commodities.

Financing: We all know credit is much harder to come by these days. For large-scale projects, it's even harder for banks to part with cash. Look at Skye Resources (SKR/TSX). It has an attractive nickel project in Guatemala, but in early February the company said credit market turmoil has delayed its financing plans for the project. This is a theme being reflected worldwide, and it means that many of the best commodity projects in the world will be delayed, resulting in more supply issues years from now.

Environmental issues: Rightly so, countries are getting more stringent about the projects they approve, with a view to protecting the environment. Environmental permits are not quite as easy to obtain any more, and governments have shifted their priorities away from the jobs projects create to a focus on environmental factors.

Australia recently rejected Rio Tinto's (RPT/NYSE) proposed iron mine because the environmental protection agency there determined five species of troglobitic animals would be killed by the project. For those who skipped biology, a troglobitic animal is one that lives in total darkness.

Mother Nature: Coal prices and agricultural product prices have soared this year. One reason? The weather. The worst snow storms in China in decades have impacted rail lines and production. The result: China had to import huge amounts of commodities that it used to export.

The rest of the world has to pay the price. Just ask Cameco Corp. (CCO/TSX) how nature can impact production, with its Cigar Lake mine beset by flooding problems. Weather issues world wide only highlight how tight supply is in numerous commodities.

All being said, it seems like there is a potential perfect storm brewing on the commodity front over the next five to 10 years. If the world keeps up its insatiable demand for commodities, watch out -- there won't be much left of anything.

DR

Greenscam - Blowing With The Wind

Former Federal Reserve Chairman Alan Greenspan said on Monday near-record Gulf Arab inflation would fall "significantly" were the oil producers to drop their dollar pegs, in contradiction to Saudi policy.

The pegs restrict the Gulf's ability to fight inflation by forcing them to shadow U.S. monetary policy at a time when the Fed is cutting rates to ward off recession and Gulf economies are surging on a near five-fold jump in oil prices since 2002.

Rifts are growing across the world's top oil-exporting region on how to tackle inflation which hit a 27-year peak of 7 percent in Saudi Arabia in January and a 19-year peak of 9.3 percent in the United Arab Emirates in 2006, the most recent figure.

"In the short term free floating ... will not fully dissipate inflationary pressure, although it would significantly do so," Greenspan told an investment conference in Jeddah, Saudi Arabia's second-largest city.

Saudi and UAE central bank chiefs spoke in favor on Monday of retaining dollar pegs, while Qatar's prime minister advocated regional currency reform to avert possible unilateral revaluations designed to curb inflation.

"The economies of the Gulf and the United States are completely out of sync and that is exposing the shortcomings of the dollar peg," said Simon Williams, Middle East economist at HSBC Holdings Plc in Dubai.

"Against a backdrop of inflation, high oil prices and low interest rates the debate over currency reform has to take on greater urgency," he said.

Floating the Saudi riyal would not be appropriate for an economy that relies on oil exports, Saudi Central Bank Governor Hamad Saud al-Sayyari told Arabiya Television in response to Greenspan's suggestion.

"Floating is beneficial when the economy and exports are diverse ... as for the kingdom it remains reliant on the export of a single commodity," Sayyari said.

Dollar pegs were helping Gulf states attract foreign investments, UAE Central Bank Governor Sultan Nasser al-Suweidi added during a speech in the UAE capital, Abu Dhabi.

"They did very well for our economies because it has led to more capital flows," Suweidi said on Monday.

Still, "Gulf governments should consider the implication of such a move in the long term," Greenspan said of the idea of floating their currencies.

QATAR'S CALL

Qatar, contending with the region's highest inflation, is studying revaluing its riyal among options to combat inflation that hit 13.74 percent in the fourth quarter, Sheikh Hamad bin Jassim bin Jabr al-Thani told Reuters late on Saturday.

The exchange rate contributes to about 40 percent of inflation in Qatar, where the riyal is 30 percent undervalued, Hamad said.

"We prefer always to act with all the GCC countries," Sheikh Hamad, whose country currently chairs the six nation-Gulf Cooperation Council, said.

"It's now time for the Gulf to have its own currency," he said, adding the Gulf currency should be "like the Japanese yen or other currencies."

Both Qatar and the UAE would likely sever their links to the U.S. dollar this year and track currency baskets as Kuwait did last May, Deutsche Bank said last month.

Divergence in Gulf monetary policy widened last May when Kuwait broke ranks with its neighbors by severing its link to the dollar in favor of a basket of currencies, saying a weak dollar was driving imported inflation.

Oman has said it will not join a single currency at all, and Suweidi said in November he was under mounting social and economic pressure to drop the peg.

He has since backtracked, mirroring the position of Saudi Arabia, which has in the last month introduced public sector wage increases, welfare payments and subsidies to offset the impact of inflation.

Inflation in the UAE last year likely rose to 10.9 percent, National Bank of Abu Dhabi said on Sunday.

DR

Tsunami Visible

The Federal Deposit Insurance Corp. is taking steps to brace for an increase in failed financial institutions as the nation's housing and credit markets continue to worsen.

The FDIC is looking to bring back 25 retirees from its division of resolutions and receiverships. Many of these agency veterans likely worked for the FDIC during the late 1980s and early 1990s, when more than 1,000 financial institutions failed amid the savings-and-loan crisis.

FDIC spokesman Andrew Gray said the agency was looking to bulk up "for preparedness purposes." The division now has 223 employees, mostly based in Dallas.

The agency, which insures accounts at more than 8,000 financial institutions, is also seeking to hire an outside firm that would help manage mortgages and other assets at insolvent banks, according to a newspaper advertisement.

In public, policy makers are debating what role the government should play in trying to stabilize the housing market and minimize foreclosures. Meanwhile, regulators have worked discreetly behind the scenes to closely monitor the growing number of troubled banks and thrifts considered at risk.

"Regulators are bracing for well over 100 bank failures in the next 12 to 24 months, with concentrations in Rust Belt states like Michigan and Ohio, and the states that are suffering severe housing-market problems like California, Florida, and Georgia," said Jaret Seiberg, Washington policy analyst for financial-services firm Stanford Group.

In job postings on its Web site, the FDIC said it is looking for people with "skill in performing duties associated with a financial-institution closing, such as receivership management, resolutions and/or asset disposition; knowledge of the resolutions process as it relates to complex financial institutions." Such positions would require "very frequent overnight travel," the posting said, and would pay up to $180,770.

"The notion of bringing back some people who have been through it before is very smart," said William Isaac, who was FDIC chairman from 1981 until 1985. All told, the FDIC has roughly 4,600 employees, far fewer than the about 15,000 it had as recently as 1992.

On Sunday, the FDIC ran a newspaper ad seeking companies that could service commercial loans, mortgages and student loans in the event of a bank failure. It didn't say how much a company could earn in this area.

The FDIC rated 65 banks and thrifts as "problem" institutions at the end of the third quarter of 2007, up from 47 institutions a year earlier. Both figures are low by historical standards. At the end of 1993, there were 572 "problem" banks and thrifts. The FDIC is expected to update its data on "problem" institutions today.

Before the housing market soured, the banking industry was enjoying one of its most profitable stretches in U.S. history. There wasn't a single bank failure from July 2005 through January 2007, an unprecedented span.

There have only been four bank failures in the past 12 months, a rate the FDIC has easily been able to handle.

In many parts of the country, the housing-market decline has hamstrung banks, and regulators have reported weakening performance of commercial real estate, small business and credit-card loans. Exacerbating the situation is a cash-flow crunch, which makes it harder for banks to obtain funding to originate new loans.

FDIC Chairman Sheila Bair, Comptroller of the Currency John Dugan and Office of Thrift Supervision Director John Reich have warned of a pickup in bank failures. Last week, Mr. Reich reported that the thrift industry lost a record $5.2 billion in the fourth quarter.

The FDIC was created by Congress in the 1930s after a series of bank runs during the Great Depression. At the end of 2007, it had $52.4 billion in its fund that backstops the nation's insured deposits.

Fleet

United Slums Of America

Strange days are upon the residents of many a suburban cul-de-sac. Once-tidy yards have become overgrown, as the houses they front have gone vacant. Signs of physical and social disorder are spreading.

At Windy Ridge, a recently built starter-home development seven miles northwest of Charlotte, North Carolina, 81 of the community’s 132 small, vinyl-sided houses were in foreclosure as of late last year. Vandals have kicked in doors and stripped the copper wire from vacant houses; drug users and homeless people have furtively moved in. In December, after a stray bullet blasted through her son’s bedroom and into her own, Laurie Talbot, who’d moved to Windy Ridge from New York in 2005, told The Charlotte Observer, “I thought I’d bought a home in Pleasantville. I never imagined in my wildest dreams that stuff like this would happen.”

In the Franklin Reserve neighborhood of Elk Grove, California, south of Sacramento, the houses are nicer than those at Windy Ridge—many once sold for well over $500,000—but the phenomenon is the same. At the height of the boom, 10,000 new homes were built there in just four years. Now many are empty; renters of dubious character occupy others. Graffiti, broken windows, and other markers of decay have multiplied. Susan McDonald, president of the local residents’ association and an executive at a local bank, told the Associated Press, “There’s been gang activity. Things have really been changing, the last few years.”

In the first half of last year, residential burglaries rose by 35 percent and robberies by 58 percent in suburban Lee County, Florida, where one in four houses stands empty. Charlotte’s crime rates have stayed flat overall in recent years—but from 2003 to 2006, in the 10 suburbs of the city that have experienced the highest foreclosure rates, crime rose 33 percent. Civic organizations in some suburbs have begun to mow the lawns around empty houses to keep up the appearance of stability. Police departments are mapping foreclosures in an effort to identify emerging criminal hot spots.

The decline of places like Windy Ridge and Franklin Reserve is usually attributed to the subprime-mortgage crisis, with its wave of foreclosures. And the crisis has indeed catalyzed or intensified social problems in many communities. But the story of vacant suburban homes and declining suburban neighborhoods did not begin with the crisis, and will not end with it. A structural change is under way in the housing market—a major shift in the way many Americans want to live and work. It has shaped the current downturn, steering some of the worst problems away from the cities and toward the suburban fringes. And its effects will be felt more strongly, and more broadly, as the years pass. Its ultimate impact on the suburbs, and the cities, will be profound.

Arthur C. Nelson, director of the Metropolitan Institute at Virginia Tech, has looked carefully at trends in American demographics, construction, house prices, and consumer preferences. In 2006, using recent consumer research, housing supply data, and population growth rates, he modeled future demand for various types of housing. The results were bracing: Nelson forecasts a likely surplus of 22 million large-lot homes (houses built on a sixth of an acre or more) by 2025—that’s roughly 40 percent of the large-lot homes in existence today.

For 60 years, Americans have pushed steadily into the suburbs, transforming the landscape and (until recently) leaving cities behind. But today the pendulum is swinging back toward urban living, and there are many reasons to believe this swing will continue. As it does, many low-density suburbs and McMansion subdivisions, including some that are lovely and affluent today, may become what inner cities became in the 1960s and ’70s—slums characterized by poverty, crime, and decay.

The suburban dream began, arguably, at the New York World’s Fair of 1939 and ’40. “Highways and Horizons,” better known as “Futurama,” was overwhelmingly the fair’s most popular exhibit; perhaps 10 percent of the American population saw it. At the heart of the exhibit was a scale model, covering an area about the size of a football field, that showed what American cities and towns might look like in 1960. Visitors watched matchbox-sized cars zip down wide highways. Gone were the crowded tenements of the time; 1960s Americans would live in stand-alone houses with spacious yards and attached garages. The exhibit would not impress us today, but at the time, it inspired wonder. E. B. White wrote in Harper’s, “A ride on the Futurama … induces approximately the same emotional response as a trip through the Cathedral of St. John the Divine … I didn’t want to wake up.”

The suburban transformation that began in 1946, as GIs returned home, took almost half a century to complete, as first people, then retail, then jobs moved out of cities and into new subdivisions, malls, and office parks. As families decamped for the suburbs, they left behind out-of-fashion real estate, a poorer residential base, and rising crime. Once-thriving central-city retail districts were killed off by the combination of regional suburban malls and the 1960s riots. By the end of the 1970s, people seeking safety and good schools generally had little alternative but to move to the suburbs. In 1981, Escape From New York, starring Kurt Russell, depicted a near future in which Manhattan had been abandoned, fenced off, and turned into an unsupervised penitentiary.

Cities, of course, have made a long climb back since then. Just nine years after Russell escaped from the wreck of New York, Seinfeld—followed by Friends, then Sex and the City—began advertising the city’s renewed urban allure to Gen-Xers and Millennials. Many Americans, meanwhile, became disillusioned with the sprawl and stupor that sometimes characterize suburban life. These days, when Hollywood wants to portray soullessness, despair, or moral decay, it often looks to the suburbs—as The Sopranos and Desperate Housewives attest—for inspiration.

In the past decade, as cities have gentrified, the suburbs have continued to grow at a breakneck pace. Atlanta’s sprawl has extended nearly to Chattanooga; Fort Worth and Dallas have merged; and Los Angeles has swung a leg over the 10,000-foot San Gabriel Mountains into the Mojave Desert. Some experts expect conventional suburbs to continue to sprawl ever outward. Yet today, American metropolitan residential patterns and cultural preferences are mirror opposites of those in the 1940s. Most Americans now live in single-family suburban houses that are segregated from work, shopping, and entertainment; but it is urban life, almost exclusively, that is culturally associated with excitement, freedom, and diverse daily life. And as in the 1940s, the real-estate market has begun to react.

Pent-up demand for urban living is evident in housing prices. Twenty years ago, urban housing was a bargain in most central cities. Today, it carries an enormous price premium. Per square foot, urban residential neighborhood space goes for 40 percent to 200 percent more than traditional suburban space in areas as diverse as New York City; Portland, Oregon; Seattle; and Washington, D.C.

It’s crucial to note that these premiums have arisen not only in central cities, but also in suburban towns that have walkable urban centers offering a mix of residential and commercial development. For instance, luxury single-family homes in suburban Westchester County, just north of New York City, sell for $375 a square foot. A luxury condo in downtown White Plains, the county’s biggest suburban city, can cost you $750 a square foot. This same pattern can be seen in the suburbs of Detroit, or outside Seattle. People are being drawn to the convenience and culture of walkable urban neighborhoods across the country—even when those neighborhoods are small.

Builders and developers tend to notice big price imbalances, and they are working to accommodate demand for urban living. New lofts and condo complexes have popped up all over many big cities. Suburban towns built in the 19th and early 20th centuries, featuring downtown street grids at their core, have seen a good deal of “in-filling” in recent years as well, with new condos and town houses, and renovated small-lot homes just outside their downtowns. And while urban construction may slow for a time because of the present housing bust, it will surely continue. Sprawling, large-lot suburbs become less attractive as they become more densely built, but urban areas—especially those well served by public transit—become more appealing as they are filled in and built up. Crowded sidewalks tend to be safe and lively, and bigger crowds can support more shops, restaurants, art galleries.

But developers are also starting to find ways to bring the city to newer suburbs—and provide an alternative to conventional, car-based suburban life. “Lifestyle centers”—walkable developments that create an urban feel, even when built in previously undeveloped places—are becoming popular with some builders. They feature narrow streets and small storefronts that come up to the sidewalk, mixed in with housing and office space. Parking is mostly hidden underground or in the interior of faux city blocks.

The granddaddy of all lifestyle centers is the Reston Town Center, located between Virginia’s Dulles International Airport and Washington, D.C. Since it opened in 1990, it has become the “downtown” for western Fairfax and eastern Loudoun counties; a place for the kids to see Santa and for teenagers to ice skate. People living in the town can stroll from the movie theater to restaurants and then back home. A 2006 study by the Brookings Institution showed that Reston’s apartments, condominiums, and office and retail space were all commanding about a 50 percent rent or price premium over the typically suburban houses, office parks, and strip malls nearby.

Housing at Belmar, the new “downtown” in Lakewood, Colorado, a middle-income inner suburb of Denver, commands a 60 percent premium per square foot over the single-family homes in the neighborhoods around it. The development covers about 20 small blocks in all. What’s most noteworthy is its history: it was built on the site of a razed mall.

Building lifestyle centers is far more complex than building McMansion developments (or malls). These new, faux-urban centers have many moving parts, and they need to achieve critical mass quickly to attract buyers and retailers. As a result, during the 1990s, lifestyle centers spread slowly. But real-estate developers are gaining more experience with this sort of building, and it is proliferating. Very few, if any, regional malls are being built these days—lifestyle centers are going up instead.

In most metropolitan areas, only 5 to 10 percent of the housing stock is located in walkable urban places (including places like downtown White Plains and Belmar). Yet recent consumer research by Jonathan Levine of the University of Michigan and Lawrence Frank of the University of British Columbia suggests that roughly one in three homeowners would prefer to live in these types of places. In one study, for instance, Levine and his colleagues asked more than 1,600 mostly suburban residents of the Atlanta and Boston metro areas to hypothetically trade off typical suburban amenities (such as large living spaces) against typical urban ones (like living within walking distance of retail districts). All in all, they found that only about a third of the people surveyed solidly preferred traditional suburban lifestyles, featuring large houses and lots of driving. Another third, roughly, had mixed feelings. The final third wanted to live in mixed-use, walkable urban areas—but most had no way to do so at an affordable price. Over time, as urban and faux-urban building continues, that will change.

Demographic changes in the United States also are working against conventional suburban growth, and are likely to further weaken preferences for car-based suburban living. When the Baby Boomers were young, families with children made up more than half of all households; by 2000, they were only a third of households; and by 2025, they will be closer to a quarter. Young people are starting families later than earlier generations did, and having fewer children. The Boomers themselves are becoming empty-nesters, and many have voiced a preference for urban living. By 2025, the U.S. will contain about as many single-person households as families with children.

Because the population is growing, families with children will still grow in absolute number—according to U.S. Census data, there will be about 4 million more households with children in 2025 than there were in 2000. But more than 10 million new single-family homes have already been built since 2000, most of them in the suburbs.

If gasoline and heating costs continue to rise, conventional suburban living may not be much of a bargain in the future. And as more Americans, particularly affluent Americans, move into urban communities, families may find that some of the suburbs’ other big advantages—better schools and safer communities—have eroded. Schooling and safety are likely to improve in urban areas, as those areas continue to gentrify; they may worsen in many suburbs if the tax base—often highly dependent on house values and new development—deteriorates. Many of the fringe counties in the Washington, D.C., metropolitan area, for instance, are projecting big budget deficits in 2008. Only Washington itself is expecting a large surplus. Fifteen years ago, this budget situation was reversed.

The U.S. grows its total stock of housing and commercial space by, at most, 3 percent each year, so the imbalance between the supply of urban living options and the demand for them is not going to disappear overnight. But over the next 20 years, developers will likely produce many, many millions of new and newly renovated town houses, condos, and small-lot houses in and around both new and traditional downtowns.

As conventional suburban lifestyles fall out of fashion and walkable urban alternatives proliferate, what will happen to obsolete large-lot houses? One might imagine culs-de-sac being converted to faux Main Streets, or McMansion developments being bulldozed and reforested or turned into parks. But these sorts of transformations are likely to be rare. Suburbia’s many small parcels of land, held by different owners with different motivations, make the purchase of whole neighborhoods almost unheard-of. Condemnation of single-family housing for “higher and better use” is politically difficult, and in most states it has become almost legally impossible in recent years. In any case, the infrastructure supporting large-lot suburban residential areas—roads, sewer and water lines—cannot support the dense development that urbanization would require, and is not easy to upgrade. Once large-lot, suburban residential landscapes are built, they are hard to unbuild.

The experience of cities during the 1950s through the ’80s suggests that the fate of many single-family homes on the metropolitan fringes will be resale, at rock-bottom prices, to lower-income families—and in all likelihood, eventual conversion to apartments.

This future is not likely to wear well on suburban housing. Many of the inner-city neighborhoods that began their decline in the 1960s consisted of sturdily built, turn-of-the-century row houses, tough enough to withstand being broken up into apartments, and requiring relatively little upkeep. By comparison, modern suburban houses, even high-end McMansions, are cheaply built. Hollow doors and wallboard are less durable than solid-oak doors and lath-and-plaster walls. The plywood floors that lurk under wood veneers or carpeting tend to break up and warp as the glue that holds the wood together dries out; asphalt-shingle roofs typically need replacing after 10 years. Many recently built houses take what structural integrity they have from drywall—their thin wooden frames are too flimsy to hold the houses up.

As the residents of inner-city neighborhoods did before them, suburban homeowners will surely try to prevent the division of neighborhood houses into rental units, which would herald the arrival of the poor. And many will likely succeed, for a time. But eventually, the owners of these fringe houses will have to sell to someone, and they’re not likely to find many buyers; offers from would-be landlords will start to look better, and neighborhood restrictions will relax. Stopping a fundamental market shift by legislation or regulation is generally impossible.

Of course, not all suburbs will suffer this fate. Those that are affluent and relatively close to central cities—especially those along rail lines—are likely to remain in high demand. Some, especially those that offer a thriving, walkable urban core, may find that even the large-lot, residential-only neighborhoods around that core increase in value. Single-family homes next to the downtowns of Redmond, Washington; Evanston, Illinois; and Birmingham, Michigan, for example, are likely to hold their values just fine.

On the other hand, many inner suburbs that are on the wrong side of town, and poorly served by public transport, are already suffering what looks like inexorable decline. Low-income people, displaced from gentrifying inner cities, have moved in, and longtime residents, seeking more space and nicer neighborhoods, have moved out.

But much of the future decline is likely to occur on the fringes, in towns far away from the central city, not served by rail transit, and lacking any real core. In other words, some of the worst problems are likely to be seen in some of the country’s more recently developed areas—and not only those inhabited by subprime-mortgage borrowers. Many of these areas will become magnets for poverty, crime, and social dysfunction.

Despite this glum forecast for many swaths of suburbia, we should not lose sight of the bigger picture—the shift that’s under way toward walkable urban living is a healthy development. In the most literal sense, it may lead to better personal health and a slimmer population. The environment, of course, will also benefit: if New York City were its own state, it would be the most energy-efficient state in the union; most Manhattanites not only walk or take public transit to get around, they unintentionally share heat with their upstairs neighbors.

Perhaps most important, the shift to walkable urban environments will give more people what they seem to want. I doubt the swing toward urban living will ever proceed as far as the swing toward the suburbs did in the 20th century; many people will still prefer the bigger houses and car-based lifestyles of conventional suburbs. But there will almost certainly be more of a balance between walkable and drivable communities—allowing people in most areas a wider variety of choices.

By the estimate of Virginia Tech’s Arthur Nelson, as much as half of all real-estate development on the ground in 2025 will not have existed in 2000. It’s exciting to imagine what the country will look like then. Building and residential migration seem to progress slowly from year to year, yet then one day, in retrospect, the landscape seems to have been transformed in the blink of an eye. Unfortunately, the next transformation, like the ones before it, will leave some places diminished. About 25 years ago, Escape From New York perfectly captured the zeitgeist of its moment. Two or three decades from now, the next Kurt Russell may find his breakout role in Escape From the Suburban Fringe.

Escape

Death By Medicine - The Drug Pushers

Back in the old days, long before drug companies started making headlines in the business pages, doctors were routinely called upon by company representatives known as “detail men.” To “detail” a doctor is to give that doctor information about a company’s new drugs, with the aim of persuading the doctor to prescribe them. When I was growing up, in South Carolina in the 1970s, I would occasionally see detail men sitting patiently in the waiting room outside the office of my father, a family doctor. They were pretty easy to spot. Detail men were usually sober, conservatively dressed gentlemen who would not have looked out of place at the Presbyterian church across the street. Instead of Bibles or hymn books, though, they carried detail bags, which were filled with journal articles, drug samples, and branded knickknacks for the office.

Today detail men are officially known as “pharmaceutical sales representatives,” but everyone I know calls them “drug reps.” Drug reps are still easy to spot in a clinic or hospital, but for slightly different reasons. The most obvious is their appearance. It is probably fair to say that doctors, pharmacists, and medical-school professors are not generally admired for their good looks and fashion sense. Against this backdrop, the average drug rep looks like a supermodel, or maybe an A-list movie star. Drug reps today are often young, well groomed, and strikingly good-looking. Many are women. They are usually affable and sometimes very smart. Many give off a kind of glow, as if they had just emerged from a spa or salon. And they are always, hands down, the best-dressed people in the hospital.

Drug reps have been calling on doctors since the mid-nineteenth century, but during the past decade or so their numbers have increased dramatically. From 1996 to 2001 the pharmaceutical sales force in America doubled, to a total of 90,000 reps. One reason is simple: good reps move product. Detailing is expensive, but almost all practicing doctors see reps at least occasionally, and many doctors say they find reps useful. One study found that for drugs introduced after 1997 with revenues exceeding $200 million a year, the average return for each dollar spent on detailing was $10.29. That is an impressive figure. It is almost twice the return on investment in medical-journal advertising, and more than seven times the return on direct-to-consumer advertising.

But the relationship between doctors and drug reps has never been uncomplicated, for reasons that should be obvious. The first duty of doctors, at least in theory, is to their patients. Doctors must make prescribing decisions based on medical evidence and their own clinical judgment. Drug reps, in contrast, are salespeople. They swear no oaths, take care of no patients, and profess no high-minded ethical duties. Their job is to persuade doctors to prescribe their drugs. If reps are lucky, their drugs are good, the studies are clear, and their job is easy. But sometimes reps must persuade doctors to prescribe drugs that are marginally effective, exorbitantly expensive, difficult to administer, or even dangerously toxic. Reps that succeed are rewarded with bonuses or commissions. Reps that fail may find themselves unemployed.

Most people who work in health care, if they give drug reps any thought at all, regard them with mixed feelings. A handful avoid reps as if they were vampires, backing out of the room when they see one approaching. In their view, the best that can be said about reps is that they are a necessary by-product of a market economy. They view reps much as NBA players used to view Michael Jordan: as an awesome, powerful force that you can never really stop, only hope to control.

Yet many reps are so friendly, so easygoing, so much fun to flirt with that it is virtually impossible to demonize them. How can you demonize someone who brings you lunch and touches your arm and remembers your birthday and knows the names of all your children? After awhile even the most steel-willed doctors may look forward to visits by a rep, if only in the self-interested way that they look forward to the UPS truck pulling up in their driveway. A rep at the door means a delivery has arrived: take-out for the staff, trinkets for the kids, and, most indispensably, drug samples on the house. Although samples are the single largest marketing expense for the drug industry, they pay handsome dividends: doctors who accept samples of a drug are far more likely to prescribe that drug later on.

Drug reps may well have more influence on prescriptions than anyone in America other than doctors themselves, but to most people outside the drug industry their jobs are mysterious. What exactly do they do every day? Where do they get their information? What do they say about doctors when the doctors are not around? Reps can be found in hospitals, waiting rooms, and conference halls all over the country, yet they barely register on the collective medical consciousness. Many doctors notice them only in the casual, utilitarian way that one might notice a waitress or a bartender. Some doctors look down on them on ethical grounds. “Little Willy Lomans,” they say, “only in it for the money.” When I asked my friends and colleagues in medicine to suggest some reps I could talk to about detailing, most could not come up with a single name.

These doctors may be right about reps. It is true that selling pharmaceuticals can be a highly lucrative job. But in a market-based medical system, are reps really so different from doctors? Most doctors in the United States now work, directly or indirectly, for large corporations. Like reps, many doctors must answer to managers and bureaucrats. They are overwhelmed by paperwork and red tape. Unlike my father, who would have sooner walked to Charleston barefoot than take out an ad for his practice, many doctors now tout their services on roadside billboards. My medical-school alumni magazine recently featured the Class of 1988 valedictorian, who has written a diet book, started her own consulting firm, and become the national spokesperson for a restaurant chain. For better or worse, America has turned its health-care system over to the same market forces that transformed the village hardware store into Home Depot and the corner pharmacy into a strip-mall CVS. Its doctors are moving to the same medical suburb where drug reps have lived for the past 150 years. If they want to know what life is like there, perhaps they should talk to their neighbors.

The King of Happy Hour

Gene Carbona was almost a criminal. I know this because, thirty minutes into our first telephone conversation, he told me, “Carl, I was almost a criminal.” I have heard ex–drug reps speak bluntly about their former jobs, but never quite so cheerfully and openly. These days Carbona works for The Medical Letter, a highly respected nonprofit publication (Carbona stresses that he is speaking only for himself), but he was telling me about his twelve years working for Merck and then Astra Merck, a firm initially set up to market the Sweden-based Astra’s drugs in the United States. Carbona began training as a rep in 1988, when he was only eleven days out of college. He detailed two drugs for Astra Merck. One was a calcium-channel blocker he calls “a dog.” The other was the heartburn medication Prilosec, which at the time was available by prescription only.

Prilosec is the kind of drug most reps can only dream about. The industry usually considers a drug to be a blockbuster if it reaches a billion dollars a year in sales. In 1998 Prilosec became the first drug in America to reach $5 billion a year. In 2000 it made $6 billion. Prilosec’s success was not the result of a massive heartburn epidemic. It was based on the same principle that drove the success of many other 1990s blockbusters, from Vioxx to Viagra: the restoration of an ordinary biological function that time and circumstance had eroded. In the case of Prilosec, the function was digestion. Many people discovered that the drug allowed them to eat the burritos and curries that their gastrointestinal systems had placed off-limits. So what if Prilosec was $4 a pill, compared with a quarter or so for a Tagamet? Patients still begged for it. Prilosec was their savior. Astra Merck marketed Prilosec as the “purple pill,” but, according to Carbona, many patients called it “purple Jesus.”

How did Astra Merck do it? Prilosec was the first proton pump inhibitor (a drug that inhibits the production of stomach acid) approved by the Food and Drug Administration, and thus the first drug available in its class. By definition this gave it a considerable head start on the competition. In the late 1990s Astra Merck mounted a huge direct-to-consumer campaign; ads for the purple pill were ubiquitous. But consumer advertising can do only so much for a drug, because doctors, not patients, write the prescriptions. This is where reps become indispensable.

Many reps can tell stories about occasions when, in order to move their product, they pushed the envelope of what is ethically permissible. I have heard reps talk about scoring sports tickets for their favorite doctors, buying televisions for waiting rooms, and arranging junkets to tropical resorts. One rep told me he set up a putting green in a hospital and gave a putter to any doctor who made a hole-in-one. A former rep told me about a colleague who somehow managed to persuade a pharmacist to let him secretly write the prescribing protocol for antibiotic use at a local hospital.

But Carbona was in a class of his own. He had access to so much money for doctors that he had trouble spending it all. He took residents out to bars. He distributed “unrestricted educational grants.” He arranged to buy lunch for the staff of certain private practices every day for a year. Often he would invite a group of doctors and their guests to a high-end restaurant, buy them drinks and a lavish meal, open up the club in back, and party until 4:00 a.m. “The more money I spent,” Carbona says, “the more money I made.” If he came back to the restaurant later that week with his wife, everything would be on the house. “My money was no good at restaurants,” he told me, “because I was the King of Happy Hour.”

My favorite Carbona story, the one that left me shaking my head in admiration, took place in Tallahassee. One of the more important clinics Carbona called on was a practice there consisting of about fifty doctors. Although the practice had plenty of patients, it was struggling. This problem was not uncommon. When the movement toward corporate-style medicine got under way, in the 1980s and 1990s, many doctors found themselves ill-equipped to run a business; they didn’t know much about how to actually make money. (“That’s why doctors are such great targets for Ponzi schemes and real-estate scams,” Carbona helpfully points out.) Carbona was detailing this practice twice a week and had gotten to know some of the clinicians pretty well. At one point a group of them asked him for help. “Gene, you work for a successful business,” Carbona recalls them saying. “Is there any advice you could give us to help us turn the practice around?” At this point he knew he had stumbled upon an extraordinary opportunity.

Carbona decided that the clinic needed a “practice- management consultant.” And he and his colleagues at Astra Merck knew just the man: a financial planner and accountant with whom they were very friendly. They wrote up a contract. They agreed to pay the consultant a flat fee of about $50,000 to advise the clinic. But they also gave him another incentive. Carbona says, “We told him that if he was successful there would be more business for him in the future, and by ‘successful,’ we meant a rise in prescriptions for our drugs.”

The consultant did an extremely thorough job. He spent eleven or twelve hours a day at the clinic for months. He talked to every employee, from the secretaries to the nurses to the doctors. He thought carefully about every aspect of the practice, from the most mundane administrative details to big-picture matters such as bill collection and financial strategy. He turned the practice into a profitable, smoothly running financial machine. And prescriptions for Astra Merck drugs soared.

When I asked Carbona how the consultant had increased Astra Merck’s market share within the clinic so dramatically, he said that the consultant never pressed the doctors directly. Instead, he talked up Carbona. “Gene has put his neck on the line for you guys,” he would tell them. “If this thing doesn’t work, he might get fired.” The consultant emphasized what a remarkable service the practice was getting, how valuable the financial advice was, how everything was going to turn around for them—all courtesy of Carbona. The strategy worked. “Those guys went berserk for me,” Carbona says. Doctors at the newly vitalized practice prescribed so many Astra Merck drugs that he got a $140,000 bonus. The scheme was so successful that Carbona and his colleagues at Astra Merck decided to duplicate it in other practices.

I got in touch with Carbona after I learned that he was giving talks on the American Medical Student Association lecture circuit about his experiences as a rep. At that point I had read a fair bit of pharmaceutical sales literature, and most of it had struck me as remarkably hokey and stilted. Merck’s official training materials, for example, instruct reps to say things like, “Doctor, based on the information we discussed today, will you prescribe Vioxx for your patients who need once-daily power to prevent pain due to osteoarthritis?” So I was unprepared for a man with Carbona’s charisma and forthright humor. I could see why he had been such an excellent rep: he came off as a cross between a genial con artist and a comedic character actor. After two hours on the phone with him I probably would have bought anything he was selling.

Most media accounts of the pharmaceutical industry miss this side of drug reps. By focusing on scandals—the kickbacks and the fraud and the lavish gifts—they lose sight of the fact that many reps are genuinely likeable people. The better ones have little use for the canned scripts they are taught in training. For them, effective selling is all about developing a relationship with a doctor. If a doctor likes a rep, that doctor is going to feel bad about refusing to see the rep, or about taking his lunches and samples but never prescribing his drugs. As Jordan Katz, a rep for Schering-Plough until two years ago, says, “A lot of doctors just write for who they like.”

A variation on this idea emerges in Side Effects, Kathleen Slattery-Moschkau’s 2005 film about a fictional fledgling drug rep. Slattery-Moschkau, who worked for nine years as a rep for Bristol-Myers Squibb and Johnson & Johnson, says the carefully rehearsed messages in the corporate training courses really got to her. “I hated the crap I had to say to doctors,” she told me. The heroine of Side Effects eventually decides to ditch the canned messages and stop spinning her product. Instead, she is brutally honest. “Bottom line?” she says to one doctor. “Your patients won’t shit for a week.” To her amazement, she finds that the blunter she is, the higher her market share rises. Soon she is winning sales awards and driving a company BMW.

For most reps, market share is the yardstick of success. The more scripts their doctors write for their drugs, the more the reps make. Slattery-Moschkau says that most of her fellow reps made $50,000 to $90,000 a year in salary and another $30,000 to $50,000 in bonuses, depending on how much they sold. Reps are pressured to “make quota,” or meet yearly sales targets, which often increase from year to year. Reps who fail to make quota must endure the indignity of having their district manager frequently accompany them on sales calls. Those who meet quota are rewarded handsomely. The most successful reps achieve minor celebrity within the company.

One perennial problem for reps is the doctor who simply refuses to see them at all. Reps call these doctors “No Sees.” Cracking a No See is a genuine achievement, the pharmaceutical equivalent of a home run or a windmill dunk. Gene Carbona says that when he came across a No See, or any other doctor who was hard to influence, he used “Northeast-Southwest” tactics. If you can’t get to a doctor, he explains, you go after the people surrounding that doctor, showering them with gifts. Carbona might help support a Little League baseball team or a bowling league. After awhile, the doctor would think, Gene is doing such nice things for all these people, the least I can do is give him ten minutes of my time. At that point, Carbona says, the sale was as good as made. “If you could get ten minutes with a doctor, your market share would go through the roof.”

For decades the medical community has debated whether gifts and perks from reps have any real effect. Doctors insist that they do not. Studies in the medical literature indicate just the opposite. Doctors who take gifts from a company, studies show, are more likely to prescribe that company’s drugs or ask that they be added to their hospital’s formulary. The pharmaceutical industry has managed this debate skillfully, pouring vast resources into gifts for doctors while simultaneously reassuring them that their integrity prevents them from being influenced. For example, in a recent editorial in the journal Health Affairs, Bert Spilker, a vice president for PhRMA, the pharmaceutical trade group, defended the practice of gift-giving against critics who, he scornfully wrote, “fear that physicians are so weak and lacking in integrity that they would ‘sell their souls’ for a pack of M&M candies and a few sandwiches and doughnuts.”

Doctors’ belief in their own incorruptibility appears to be honestly held. It is rare to hear a doctor—even in private, off-the-record conversation—admit that industry gifts have made a difference in his or her prescribing. In fact, according to one small study of medical residents in the Canadian Medical Association Journal, one way to convince doctors that they cannot be influenced by gifts may be to give them one; the more gifts a doctor takes, the more likely that doctor is to believe that the gifts have had no effect. This helps explain why it makes sense for reps to give away even small gifts. A particular gift may have no influence, but it might make a doctor more apt to think that he or she would not be influenced by larger gifts in the future. A pizza and a penlight are like inoculations, tiny injections of self-confidence that make a doctor think, I will never be corrupted by money.

Gifts from the drug industry are nothing new, of course. William Helfand, who worked in marketing for Merck for thirty-three years, told me that company representatives were giving doctors books and pamphlets as early as the late nineteenth century. “There is nothing new under the sun,” Helfand says. “There is just more of it.” The question is: Why is there so much more of it just now? And what changed during the past decade to bring about such a dramatic increase in reps bearing gifts?

An ethic of salesmanship

One morning last year I had breakfast at the Bryant-Lake Bowl, a diner in Minneapolis, with a former Pfizer rep named Michael Oldani. Oldani grew up in a working-class family in Kenosha, Wisconsin. Although he studied biochemistry in college, he knew nothing about pharmaceutical sales until he was recruited for Pfizer by the husband of a woman with whom he worked. Pfizer gave him a good salary, a company car, free gas, and an expense account. “It was kind of like the Mafia,” Oldani told me. “They made me an offer I couldn’t refuse.” At the time, he was still in college and living with his parents. “I knew a good ticket out of Kenosha when I saw one,” he says. He carried the bag for Pfizer for nine years, until 1998.

Today Oldani is a Princeton-trained medical anthropologist teaching at the University of Wisconsin at Whitewater. He wrote his doctoral dissertation on the anthropology of pharmaceutical sales, drawing not just on ethnographic fieldwork he did in Manitoba as a Fulbright scholar but also on his own experience as a rep. This dual perspective—the view of both a detached outsider and a street-savvy insider—gives his work authority and a critical edge. I had invited Oldani to lecture at our medical school, the University of Minnesota, after reading his work in anthropology journals. Although his writing is scholarly, his manner is modest and self-effacing, more Kenosha than Princeton. This is a man who knows his way around a diner.

Like Carbona, Oldani worked as a rep in the late 1980s and the 1990s, a period when the drug industry was undergoing key transformations. Its ethos was changing from that of the country-club establishment to the aggressive, new-money entrepreneur. Impressed by the success of AIDS activists in pushing for faster drug approvals, the drug industry increased pressure on the FDA to let companies bring drugs to the market more quickly. As a result, in 1992 Congress passed the Prescription Drug User Fee Act, under which drug companies pay a variety of fees to the FDA, with the aim of speeding up drug approval (thereby making the drug industry a major funder of the agency set up to regulate it). In 1997 the FDA dropped most restrictions on direct-to-consumer advertising of prescription drugs, opening the gate for the eventual Levitra ads on Super Bowl Sunday and Zoloft cartoons during daytime television shows. The drug industry also became a big political player in Washington: by 2005, according to the Center for Public Integrity, its lobbying organization had become the largest in the country.

Many companies started hitting for the fences, concentrating on potential blockbuster drugs for chronic illnesses in huge populations: Claritin for allergies, Viagra for impotence, Vioxx for arthritis, Prozac for depression. Successful drugs were followed by a flurry of competing me-too drugs. For most of the 1990s and the early part of this decade, the pharmaceutical industry was easily the most profitable business sector in America. In 2002, according to Public Citizen, a nonprofit watchdog group, the combined profits of the top ten pharmaceutical companies in the Fortune 500 exceeded the combined profits of the other 490 companies.

During this period reps began to feel the influence of a new generation of executives intent on bringing market values to an industry that had been slow to embrace them. Anthony Wild, who was hired to lead Parke-Davis in the mid-1990s, told the journalist Greg Critser, the author of Generation Rx, that one of his first moves upon his appointment was to increase the incentive pay given to successful reps. Wild saw no reason to cap reps’ incentives. As he said to the company’s older executives, “Why not let them get rich?” Wild told the reps about the change at a meeting in San Francisco. “We announced that we were taking off the caps,” he told Critser, “and the sales force went nuts!”

It was not just the industry’s ethos that was changing; the technology was changing, too. According to Oldani, one of the most critical changes came in the way that information was gathered. In the days before computers, reps had to do a lot of legwork to figure out whom they could influence. They had to schmooze with the receptionists, make friends with the nurses, and chat up the pharmacists in order to learn which drugs the local doctors were prescribing, using the right incentives to coax what they needed from these informants. “Pharmacists are like pigeons,” Jamie Reidy, a former rep for Pfizer and Eli Lilly, told me. “Only instead of bread crumbs, you toss them pizzas and sticky notes.”

But in the 1990s, new information technology made it much simpler to track prescriptions. Market-research firms began collecting script-related data from pharmacies and hospitals and selling it to pharmaceutical companies. The American Medical Association collaborated by licensing them information about doctors (including doctors who do not belong to the AMA), which it collects in its “Physician Masterfile.” Soon reps could find out exactly how many prescriptions any doctor was writing and exactly which drugs those prescriptions were for. All they had to do was turn on their laptops and download the data.

What they discovered was revelatory. For one thing, they found that a lot of doctors were lying to them. Doctors might tell a rep that they were writing prescriptions for, say, Lipitor, when they weren’t. They were just being polite, or saying whatever they thought would get the rep off their backs. Now reps could detect the deception immediately. (Even today many doctors do not realize that reps have access to script-tracking reports.)

More important, script-tracking helped reps figure out which doctors to target. They no longer had to waste time and money on doctors with conservative prescribing habits; they could head straight to the “high prescribers,” or “high writers.” And they could get direct feedback on which tactics were working. If a gift or a dinner presentation did not result in more scripts, they knew to try another approach.

But there was a rub: the data was available to every rep from every company. The result was an arms race of pharmaceutical gift-giving, in which reps were forced to devise ever-new ways to exert influence. If the Eli Lilly rep was bringing sandwiches to the office staff, you brought Thai food. If GSK flew doctors to Palm Springs for a conference, you flew them to Paris. Oldani used to take residents to Major League Baseball games. “We did beer bongs, shots, and really partied,” he told me. “Some of the guys were incredibly drunk on numerous occasions. I used to buy half barrels for their parties, almost on a retainer-like basis. I never talked product once to any of these residents, and they took care of me in their day-to-day practice. I never missed quota at their hospital.”

Oldani says that script-tracking data also changed the way that reps thought about prescriptions. The old system of monitoring prescriptions was very inexact, and the relationship between a particular doctor’s prescriptions and the work of a given rep was relatively hard to measure. But with precise script-tracking reports, reps started to feel a sense of ownership about prescriptions. If their doctors started writing more prescriptions for their drugs, the credit clearly belonged to them. However, more precise monitoring also invited micromanagement by the reps’ bosses. They began pressuring reps to concentrate on high prescribers, fill out more paperwork, and report more frequently back to management.

“Script-tracking, to me at least, made everyone a potentially successful rep,” Oldani says. Reps didn’t need to be nearly as resourceful and street savvy as in the past; they just needed the script-tracking reports. The industry began hiring more and more reps, many with backgrounds in sales (rather than, say, pharmacy, nursing, or biology). Some older reps say that during this period the industry replaced the serious detail man with “Pharma Barbie” and “Pharma Ken,” whose medical knowledge was exceeded by their looks and catering skills. A newer, regimented style of selling began to replace the improvisational, more personal style of the old-school reps. Whatever was left of an ethic of service gave way to an ethic of salesmanship.

Doctors were caught in a bind. Many found themselves being called on several times a week by different reps from the same company. Most continued to see reps, some because they felt obligated to get up to speed with new drugs, some because they wanted to keep the pipeline of free samples open. But seeing reps has a cost, of course: the more reps a doctor sees, the longer the patients sit in the waiting room. Many doctors began to feel as though they deserved whatever gifts and perks they could get because reps were such an irritation. At one time a few practices even charged reps a fee for visiting.

Professional organizations made some efforts to place limits on the gifts doctors were allowed to accept. But these efforts were halfhearted, and they met with opposition from indignant doctors ridiculing the idea that their judgment could be bought. One doctor, in a letter to the American Medical News, confessed, “Every time a discussion comes up on guidelines for pharmaceutical company gifts to physicians, I feel as if I need to take a blood pressure medicine to keep from having a stroke.” In 2001 the AMA launched a campaign to educate doctors about the ethical perils of pharmaceutical gifts, but it undercut its message by funding the campaign with money from the pharmaceutical industry.

Of course, most doctors are never offered free trips to Monaco or even a weekend at a spa; for them an industry gift means a Cialis pen or a Lexapro notepad. Yet it is a rare rep who cannot tell a story or two about the extravagant gifts doctors have requested. Oldani told me that one doctor asked him to build a music room in his house. Phyllis Adams, a former rep in Canada, was told by a doctor that he would not prescribe her product unless her company made him a consultant. (Both said no.) Carbona arranged a $35,000 “unrestricted educational grant” for a doctor who wanted a swimming pool in his back yard. “It was the Wild West,” says Jamie Reidy, whose frank memoir about his activities while working for Pfizer in the 1990s, Hard Sell: The Evolution of a Viagra Salesman, recently got him fired from Eli Lilly. “They cashed the check, and that was it. And hopefully they remembered you every time they turned on the TV, or bought a drink on the cruise, or dived into the pool.”

The trick is to give doctors gifts without making them feel that they are being bought. “Bribes that aren’t considered bribes,” Oldani says. “This, my friend, is the essence of pharmaceutical gifting.” According to Oldani, the way to make a gift feel different from a bribe is to make it personal. “Ideally, a rep finds a way to get into a scriptwriter’s psyche,” he says. “You need to have talked enough with a scriptwriter—or done enough recon with gatekeepers—that you know what to give.” When Oldani found a pharmacist who liked to play the market, he gave him stock options. When he wanted to see a resistant oncologist, he talked to the doctor’s nurse and then gave the oncologist a $100 bottle of his favorite cognac. Reidy put the point nicely when he told me, “You are absolutely buying love.”

Such gifts do not come with an explicit quid pro quo, of course. Whatever obligation doctors feel to write scripts for a rep’s products usually comes from the general sense of reciprocity implied by the ritual of gift-giving. But it is impossible to avoid the hard reality informing these ritualized exchanges: reps would not give doctors free stuff if they did not expect more scripts.

My brother Hal, a psychiatrist currently on the faculty of Wake Forest University, told me about an encounter he had with a drug rep from Eli Lilly some years back, when he was in private practice. This rep was not one of his favorites; she was too aggressive. That day she had insisted on bringing lunch to his office staff, even though Hal asked her not to. As he tried to make polite conversation with her in the hall, she reached over his shoulder into his drug closet and picked up a couple of sample packages of Zoloft and Celexa. Waving them in the air, she asked, “Tell me, Doctor, do the Pfizer and Forest reps bring lunch to your office staff?” A stony silence followed. Hal quietly ordered the rep out of the office and told her to never come back. She left in tears.

It’s not hard to understand why Hal got so angry. The rep had broken the rules. Like an abrasive tourist who has not caught on to the code of manners in a foreign country, she had said outright the one thing that, by custom and common agreement, should never be said: that the lunches she brought were intended as a bribe. What’s more, they were a bribe that Hal had never agreed to accept. He likened the situation to having somebody drop off a bag of money in your garage without your consent and then ask, “So what about our little agreement?”

When an encounter between a doctor and a rep goes well, it is a delicate ritual of pretense and self-deception. Drug reps pretend that they are giving doctors impartial information. Doctors pretend that they take it seriously. Drug reps must try their best to influence doctors, while doctors must tell themselves that they are not being influenced. Drug reps must act as if they are not salespeople, while doctors must act as if they are not customers. And if, by accident, the real purpose of the exchange is revealed, the result is like an elaborate theatrical dance in which the masks and costumes suddenly drop off and the actors come face to face with one another as they really are. Nobody wants to see that happen.

The new drug reps?

Last spring a small group of first-year medical students at the University of Minnesota spoke to me about a lecture on erectile dysfunction that had just been given by a member of the urology department. The doctor’s Power-Point slides had a large, watermarked logo in the corner. At one point during the lecture a student raised his hand and, somewhat disingenuously, asked the urologist to explain the logo. The urologist, caught off guard, stumbled for a moment and then said that it was the logo for Cialis, a drug for erectile dysfunction that is manufactured by Eli Lilly. Another student asked if he had a special relationship with Eli Lilly. The urologist replied that yes, he was on the advisory board for the company, which had supplied the slides. But he quickly added that nobody needed to worry about the objectivity of his lecture, because he was also on the advisory boards of the makers of the competing drugs Viagra and Levitra. The second student told me, “A lot of people agreed that it was a pharm lecture and that we should have gotten a free breakfast.”

This episode is not as unusual as it might appear. Drug company–sponsored consultancies, advisory-board memberships, and speaking engagements have become so common, especially among medical-school faculty, that the urologist probably never imagined that he would be challenged for lecturing to medical students with materials produced by Eli Lilly. According to a recent study in The Journal of the American Medical Association, nine out of ten medical students have been asked or required by an attending physician to go to a lunch sponsored by a drug company. As of 2003, according to the Accreditation Council for Continuing Medical Education, pharmaceutical companies were providing 90 percent of the $1 billion spent annually on continuing medical education events, which doctors must attend in order to maintain their licensure.

Over the past year or two pharmaceutical profits have started to level off, and a backlash against reps has been felt; some companies have actually reduced their sales forces. But the industry as a whole is hiring more and more doctors as speakers. In 2004, it sponsored nearly twice as many educational events led by doctors as by reps. Not long before, the numbers had been roughly equal. This raises the question, Are doctors becoming the new drug reps?

Doctors are often the best people to market a drug to other doctors. Merck discovered this when it was developing a campaign for Vioxx, before the drug was taken off the market because of its association with heart attacks and strokes. According to an internal study by Merck, reported in The Wall Street Journal, doctors who attended a lecture by another doctor subsequently wrote nearly four times more prescriptions for Vioxx than doctors who attended an event led by a rep. The return on investment for doctor-led events was nearly twice that of rep-led events, even after subtracting the generous fees Merck paid to the doctors who spoke.

These speaking invitations work much like gifts. While reps hope, of course, that a doctor who is speaking on behalf of their company will give their drugs good PR, they also know that such a doctor is more likely to write prescriptions for their drugs. “If he didn’t write, he wouldn’t speak,” a rep who has worked for four pharmaceutical companies told me. The semi-official industry term for these speakers and consultants is “thought leaders,” or “key opinion leaders.” Some thought leaders do not stay loyal to one company but rather generate a tidy supplemental income by speaking and consulting for a number of different companies. Reps refer to these doctors as “drug whores.”

The seduction, whether by one company or several, is often quite gradual. My brother Hal explained to me how he wound up on the speakers’ bureau of a major pharmaceutical company. It started when a company rep asked him if he’d be interested in giving a talk about clinical depression to a community group. The honorarium was $1,000. Hal thought, Why not? It seemed almost a public service. The next time, the company asked him to talk not to the public but to practitioners at a community hospital. Soon company reps were making suggestions about content. “Why don’t you mention the side-effect profiles of the different antidepressants?” they asked. Uneasy, Hal tried to ignore these suggestions. Still, the more talks he gave, the more the reps became focused on antidepressants rather than depression. The company began giving him PowerPoint slides to use, which he also ignored. The reps started telling him, “You know, we have you on the local circuit giving these talks, but you’re medical-school faculty; we could get you on the national circuit. That’s where the real money is.” The mention of big money made him even more uneasy. Eventually the reps asked him to lecture about a new version of their antidepressant drug. Soon after that, Hal told them, “I can’t do this anymore.”

Looking back on this trajectory, Hal said, “It’s kind of like you’re a woman at a party, and your boss says to you, ‘Look, do me a favor: be nice to this guy over there.’ And you see the guy is not bad-looking, and you’re unattached, so you say, ‘Why not? I can be nice.’” The problem is that it never ends with that party. “Soon you find yourself on the way to a Bangkok brothel in the cargo hold of an unmarked plane. And you say, ‘Whoa, this is not what I agreed to.’ But then you have to ask yourself, ‘When did the prostitution actually start? Wasn’t it at that party?’”

Thought leaders serve an indispensable function when it comes to a potentially very lucrative marketing niche: off-label promotion, or promoting a drug for uses other than those for which it was approved by the FDA—something reps are strictly forbidden to do. The case of Neurontin is especially instructive. In 1996 a whistle-blower named David Franklin, a medical-science liaison with Parke-Davis (now a division of Pfizer), filed suit against the company over its off-label promotion of this drug. Neurontin was approved for the treatment of epilepsy, but according to the lawsuit, Parke-Davis was promoting it for other conditions—including bipolar disorder, migraines, and restless legs syndrome—for which there was little or no scientific evidence that it worked. To do so the company employed a variety of schemes, most involving a combination of rep ingenuity and payments to doctors. Some doctors signed ghostwritten journal articles. One received more than $300,000 to speak about Neurontin at conferences. Others were paid just to listen. Simply having some of your thought leaders in attendance at a meeting is valuable, Kathleen Slattery-Moschkau explains, because they will often bring up off-label uses of a drug without having to be prompted. “You can’t get a better selling situation than that,” she says. In such circumstances all she had to do was pour the wine and make sure everyone was happy.

The litigation over Neurontin cost Pfizer $430 million in criminal fines and civil damages for the period 1994 to 2002. It was well worth it. The drug’s popularity and profitability soared. In spite of the adverse publicity, Neurontin generated more than $2.7 billion in revenues in 2003, more than 90 percent of which came from off-label prescriptions.

Of course, sometimes speakers discover that the drug they have been paid to lecture about is dangerous. One of the most notorious examples is Fen-Phen, the diet-drug combination that has been linked to primary pulmonary hypertension and valvular heart disease. Wyeth, the manufacturer of Redux, or dexfenfluramine—the “Fen” in Fen-Phen—has put aside $21 billion to cover costs and liabilities from litigation. Similar events played out, on a lesser scale, with Parke-Davis’s diabetes drug Rezulin, and Wyeth’s pain reliever Duract, which were taken off the market after being associated with life-threatening complications.

And what about reps themselves? Do they trust their companies to tell them about potential problems with their drugs? Not exactly. As one veteran rep, voicing a common sentiment, told me, “Reps are the last to know.” Of course, for a rep to be detailing a drug enthusiastically right up to the day it is withdrawn from the market is likely to erode that rep’s credibility with doctors. Yet some reps say they don’t hear about problems until the press gets wind of them and the company launches into damage control. At that point, Slattery-Moschkau explains, “Reps learn verbatim how to handle the concern or objection in a way that spins it back in the drug’s favor.”

Some believe that the marketing landscape changed dramatically for both reps and doctors in 2002, after the Office of the Inspector General in the Department of Health and Human Services announced its intention to crack down on drug companies’ more notorious promotional practices. With the threat of prosecution in the air, the industry began to take the job of self-policing a lot more seriously, and PhRMA issued a set of voluntary marketing guidelines.

Although most reps agree that the PhRMA code has changed things, not all of them agree that it changed things for the better. Some say that as long as reps feel pressure to meet quota, they will find ways to get around the rules. As one former rep pointed out, not all drug companies belong to PhRMA, and those that don’t are, of course, not bound by PhRMA’s guidelines. Jordan Katz says that things actually got worse after 2002. “The companies that tried to follow the guidelines lost a ton of market share, and the ones who didn’t gained it,” he says. “The bottom line is that if you don’t pay off the doctors, you will not succeed in pharmaceuticals. Period.”

A World Without Doctors?

In 1997, John Lantos, a pediatrician and ethicist at the University of Chicago, wrote a book called Do We Still Need Doctors? We will always need health care, of course. But, as Lantos observes, it is not clear that we will always need to get our health care from doctors. Many of us already get it from other providers—nurses, physical therapists, clinical psychologists, nutritionists, respiratory therapists, and so on. The figure of “the doctor” is not cast in stone. It is really just a particular configuration of roles and duties and responsibilities, each of which can be changed.

Many have already been changed. Sometimes I think of my father as one of the last small-town, solo family doctors left in America. His kind of practice has been largely replaced by teams of specialists working in group practices underwritten by insurance companies and for-profit health-care chains. I doubt that any of the doctors my family has ever visited, except for a pediatrician who took care of our children when we lived in Montreal, would recognize us if they passed us in the street. Last year, while driving in Wisconsin, I filled up my car at a combination gas station, pharmacy, and walk-in medical clinic. I don’t mean to complain. As long as our health insurance has been paid up, we have usually gotten good care. We simply live in a country that has decided that the traditional figure of the doctor is not worth preserving in the face of modern economics. Instead, we put our trust in the market.

Perhaps we are right to do so. We can get used to a world without doctors. As Lantos points out, we have gotten used to a world where we have shoes but no cobblers. We can copy documents without scriveners, make tools without blacksmiths, and produce books in the absence of bookbinders. We have left the old world behind, and for the most part, we don’t miss it.

As the figure of the traditional doctor fades away, it is being replaced by a figure akin to the drug rep, one whose responsibilities are to compete as vigorously as possible in the medical marketplace. Patients are being replaced by “health-care consumers,” who shop for the best medical bargains they can find. If it is true that the drug rep does not put my interests first, the same is true of everyone else in the marketplace; and we believe that such problems in the marketplace will be sorted out by the invisible hand. Buyers will stop buying from sellers who provide them with inferior goods. This model of medicine is not unlike that advocated thirty years ago by Robert Sade, a surgeon at my old medical school, the Medical University of South Carolina. Writing in The New England Journal of Medicine, Sade argued, “Medical care is neither a right nor a privilege: it is a service provided by doctors and others to people who wish to purchase it.” He is now the vice chair of the AMA’s Council of Ethical and Judicial Affairs.

Many doctors seem resigned to this shift. They see themselves as a beleaguered group whose lives are made miserable by third-party payers, personal-injury attorneys, and hospital bureaucrats. Whatever idealism they may have had about the practice of medicine is being pushed aside by the concrete realities of hustling in the new medical marketplace. Many academic physicians seem cowed by the power of the drug companies, upon whom some depend for research funding. For some, it’s not so much a question of whether medicine has become a business as what kind of business it has become. When I talked recently to a gastroenterologist at an Ivy League medical school about his work as a thought leader for a variety of drug companies, he shrugged and said, “Better a whore than a concubine.”

Which is not to say that pockets of resistance can’t be found, especially among younger physicians and medical students. The American Medical Student Association may be the only mainstream medical organization with a principled position against taking industry gifts. It stands in striking contrast to the American Academy of Family Practice, which last year refused to grant exhibition space at its annual conference to No Free Lunch, a physician-led advocacy group that advises physicians to “Just say no to drug reps.” The AAFP said that the group’s goals were “not within the character and purpose” of the conference. But it allowed pharmaceutical companies, McDonald’s, and the Distilled Spirits Council of the United States to exhibit. (It reversed its decision about No Free Lunch after protests by a number of AAFP members.)

Whether doctors and reps are all that different from one another is no longer clear. Doctors know a lot more about medicine, and drug reps dress a lot better, but these days both are Organization Men, small cogs in a vast health-care machine. They are just doing their jobs in a market-driven health-care bureaucracy that Americans have designed, and that we defend vigorously to critics elsewhere in the world. Like anyone else, doctors and reps are responding to the pressures and incentives of the system in which they work.

When Michael Oldani and I were having breakfast, he told me a story about a rep he interviewed for his dissertation. The rep had recently spent a day doing a “preceptorship,” a practice in which a drug company pays doctors to let a rep shadow them while they see patients. This rep was shadowing a high-prescribing psychiatrist (she called him “Dr. C”) at a med-check clinic. Med-check clinics are extremely busy sites where psychiatrists see large numbers of patients in quick succession, mainly to make sure that their medications are in proper order. At one point during the day, the rep said, a cheerful man in a wheelchair rolled into the office. Barely looking up from the stack of charts on his desk, Dr. C started quizzing the man about his medications. After a few minutes the man interrupted. “Look at me, Dr. C. Notice anything different?” Dr. C pushed his glasses up on top of his head and looked carefully at the patient for a few seconds before replying, “No, I don’t. What’s up?” The man smiled and said excitedly, “I got my legs cut off!”

After a moment of silence, Dr. C smiled. The man laughed. Neither seemed upset. In a few minutes the session ended, and the next patient came in.