Monday, December 18, 2006

Comment from a senior American anesthesiologist about yesterday's post on the killer NHS

The scenario sounds to me like the sinus infection had spread beyond the eye socket, perhaps downward into the pharynx (behind the tongue), making inserting a breathing tube more difficult, perhaps stirring up bleeding or pus, which would make visualizing the airway more difficult or impossible. If Ms Bromiley was overweight, the large tongue might make intubation difficult. With repeated attempts at intubation, the airway may become swollen. Awakening the patient before this point may have saved her; we have done this on occasion; inconvenient, but life-saving. Careful preoperative examination of the airway may have alerted the anesthesiologist to the precarious conditions present.

Actually, a tracheostomy is NOT the preferred treatment - this takes several minutes. A "cricothyrotomy" - a needle through a membrane, takes seconds, and the patient can be ventilated for a while before a better airway is established. We practice doing cricothyrotomy on dummies.

Of course, if the infection extends all the way to the throat, a tracheostomy or cricothyrotomy may not be possible. For such cases, a flexible fiberoptic device may enable the anesthesiologist to see around corners, and place the breatihing tube. Again, careful preoperative discussion between anesthesiologist and surgeons may make for better planning.

Here in the USA, we have a "difficult airway algorithm". See here

We drill our trainees (and ourselves) many times about these guidelines, on paper, with test questions, and on an electronic simulator (PC verson, and life size rubber dummy connected to a computer). This is standard practice here. This pilot would be stunned if he could see the level of our training on this issue. We have airway workshops where we can practice fiberoptic intubation on dummies, and we do it on patients as well. See here

Having a TV screen is a giant step forward (our institution is too cheap) - it allows the instructor to see what the trainee sees, and speeds up the teaching process.

ASA has close claims data, the best source of complications. I believe there has not been a case (or, more likely, too few to count) of airway disasters where a difficult airway has been diagnosed preoperatively; such cases alert the anesthesiologists to use more care or special methods (like fiberoptic). The most litigation is in emergency C-sections in (usually morbidly obese) where the airway is lost. This is why regional (spinal, epidural) anesthesia is so popular (but there are times and conditions where regional anesthesia is not possible. Hopefully, if intubation is abandoned after multiple attempts, the "cannot intubate cannot ventilate" scenario will never occur; if it does, surgical airway is a no brainer.

Pulse oximeters are a standard of care. When the oxygen in the skin drops, we are alerted that something must be done - NOW. One recently developed device is the Laryngeal Mask airway (LMA). This device allows maintaining an airway in a patient where the larynx cannot be visualized; it has been a lifesaver.

I had a recent emergency C-section in a fat lady where I couldn't intubate her. I could have maintained ventilation, but that would not protect her from vomiting and aspiration. All contraindications are relative; I used a LMA because I believed the small risk of vomiting and aspiration was less than the risk of airway obstruction from further attempts at intubation.

The anesthesiologist is normally in charge of the airway. If we must, WE request the surgeon to establish a surgical airway. The senior anesthesiologist is "in charge". Unfortunately, nervous surgeons may confuse the issue at times. I believe the British pilot would be pleasantly surprised at the level American doctors do such things. There is ACLS (advanced cardiac life support, both for adults and children); ATLS (advanced trauma life support) courses, exams, computer drills, ethc.

I am amused at nurses who claim an exclusive as "patient advocates". I am very proud what anesthesiologists have done to improbe patient safety. We are "patient advocates" as well. It was anesthesiologists who raised hell with hospital administrations to buy equipment to make anesthesia safer. Much of our improvement in safety has been with the initiatives of anesthesiologists, not Government mandates. When the Government demands better safety, then we must begin to worry.

Christmas candles "unsafe" in the Unhinged Kingdom

They've only been doing it for 259 years without mishap but you never know!

Children at one of the biggest Christingle Services in Essex will not be allowed to put lighted candles in their oranges this year in the wake of new safety fears, it has emerged. Instead, youngsters at Chelmsford Cathedral's Christmas Eve celebration will be using non-flamable glowsticks similar to those waved around at rock festivals.

But yesterday, one of the family event's organisers, Richard Spilsbury, said that the move was not in response to political correctness but instead the genuine concerns of some parents at last year's event. "Last year the cathedral was jam packed with people, and it was very difficult to physically move around," he said. "I know it sounds a bit of a kill-joy, but we thought we would give this alternative a try. "What happens at the service is the children process to the altar where they hand over cardboard tubes containing money for the Children's Society. "They then go back to their seats where they are given a Christingle, which is an orange with four spikes on it - with sweets - and a candle in the middle. "The idea is they then form a circle with the candles lit, the lights go down and it really looks very magical. "Last year there were so many you couldn't do this and we had problems getting children back to their seats."

Mr Spilsbury said that last year it was so difficult to move around, supervisors could not light all of the Christingles themselves and instead had to rely on the congregation lighting them from one to the other. "Things were so crammed some parents were very worried about candles and childrens' hair," he said. "We're not talking about 10 or 20 here - there were well-over 300 Christingles given out." Mr Spilsbury said the idea of using glowsticks instead of candles had been proposed by the Childrens' Society itself as an alternative. "We thought we would give it a try. They glow quite brightly," he explained.

He added that the sticks were activated by being shaked or bent. "We haven't quite worked out when to do it - there is a lot of preparation. "But if it doesn't work, we will go back to candles. The thing is, we don't want to spoil things, but we also don't want to put anyone in danger." The Christmas Eve Christingle Service takes place at Chelmsford Cathedral at 3pm.


Do they know it’s Christmas?

By Frank Furedi

Forget 'Peace on Earth' - Christmas has become a battleground in the culture war over the status of religion

Never mind `Peace on Earth, Goodwill to All Men' - Christmas has become a battleground in the confused clash of values over the status of religion in modern society.  It is difficult to know who or what to believe in the perplexing debate about the War on Christmas. On one side, the Archbishop of York, Dr John Sentamu, is convinced that ‘illiberal atheists and aggressive secularists’ have launched a crusade against the Christian symbols of Christmas. On the other side, a Guardian writer claims that ‘The phoney war on Christmas’ is a fantasy dreamt up by religious bigots, while the president of the National Secular Society thinks that those raising the alarm about an attack on Christmas are trying to provoke ‘resentment against a perceived enemy’.

Depending on whom you believe there may or may not be a war on Christmas. And there may or may not be an underhand anti-secular campaign masquerading as a defence of traditional Christmas. The only thing that we can be certain about is that there definitely is a debate between at least two sides that deeply dislike each other. Whether or not there is a war against Christmas, there is certainly a war of words about it. And whatever the facts, Christmas has been turned into a symbolic battlefield in an undeclared culture war throughout the Anglo-American world.

The symbolic significance of Christmas has been recognised in the United States by both sides in the culture war. Liberal author Bill Press’s book, How The Republicans Stole Christmas: Why The Religious Right Is Wrong About Faith and Politics And What Can We Do To Make It Right is more than matched by Fox News anchorman John Gibson’s effort, The War on Christmas: How The Liberal Plot To Ban The Sacred Christian Holiday Is Worse Than You Thought. Both of these books are long on titles, short on ideas and betray a powerful sense of moral illiteracy. 

So what is going on? There may not be a concerted war against Christmas, but this symbolically charged holiday has become a target of critics who would like to marginalise its role in public life. Nibbling away at the status of Christmas is not without consequences. According to a new report, three out of four UK employers have banned Christmas decorations from their offices because they are concerned not to offend other faiths. Of course these headline-seeking surveys should be taken with a large pinch of salt. Christmas celebrations have not quite been abolished in the British workplace. My own quick survey of friends and acquaintances indicates that Christmas is still celebrated, but in a more restrained manner. One human resources director told me that she felt uneasy about the office Christmas party because it ‘raised equality issues’. ‘What if some employees insist on a Diwali Party’ she asked. This kind of attitude explains why in many workplaces the Christmas spirit has become conspicuous by its absence. Some company killjoys are motivated to abolish the Christmas office party to avoid the risk of health and safety and litigation. Others do not want to ‘offend’ non-Christians. They see Christmas becoming a hassle that they can well do without.

That the times are changing is demonstrated by the number of cards I get that self-consciously avoid wishing me ‘Happy Christmas’. The growing tendency towards sending a Christian-free card is definitely not a fantasy invented by religious bigots. Everyone knows that it is happening and that such cards are implicitly making a statement. That is why there has been so much media interest in this year’s seasonal cards sent out by Tony Blair and Gordon Brown. Just this morning I received a surprisingly humorous card from the Commission For Racial Equality. The front of this send-up card states that it is a ‘DRAFT Christmas Card Proposal’, and is covered in scrawled questions about whether the pictured reindeer are sufficiently diverse, whether a risk assessment has been done on the candles etc . Inside, where it states ‘Season’s greetings from the CRE’, the word ‘Season’s’ is circled and linked to a question ‘Christmas?’ The card highlights a world where the words you choose to greet people have symbolic significance. Like all good satire, this card points to something very real going on in society (view the card).

If Christmas is losing its monopoly in the seasonal cards market, its role has also diminished within UK schools. Many schools no longer stage a nativity play, and the Christmas concert is often transformed into a worthy multi-cultural and multi-faith celebration of ‘diversity’ or of nothing in particular. Elsewhere the Red Cross has reportedly banned its staff from putting up Advent calendars associated with Christmas, and there are various reports of the local council language police rebranding Christmas lights as Winterlights or renaming Christmas ‘Winterval’.

The attempt to deprive Christmas of any distinct religious or cultural significance is not confined to Britain. In Australia, the Lord Mayor of Sydney decided to ban the phrase ‘Merry Christmas’ and turn Christmas cards into civic greetings cards. In the USA, too, there are many sad anti-Christmas crusaders who criticise the event for excluding or offending non-Christians. One state government banned employees from saying ‘Merry Christmas’ while at work. Many American schools have renamed the Christmas break as ‘Winter Break’ or ‘Winter Celebration’. These incidents do not quite add up to a war, but they do reflect a cultural mood that seems uncomfortable with the celebration of a traditional Christmas.

Predictably there is now also a counter-campaign to uphold traditional Christmas symbols and practices.  The Sun, Britain’s largest selling daily, has launched a campaign to ‘save’ Christmas from political correctness, denouncing officious bureaucrats for their petty attempts to spoil the Christmas celebrations. Both the Archbishop of Canterbury, Dr Rowan Williams and the Roman Catholic Cardinal Cormac Murphy-O’Connor have attacked the trend for downplaying the traditional image of Christmas; Williams took particular exception to the absence of any Christian themes in Christmas stamps issued by the Royal Mail.  Some Muslim leaders are also worried that those trying to marginalise Christmas could provoke popular hostility, and that Muslims will be blamed. Last month the Christian-Muslim Forum published a letter criticising the attempt to suppress Christmas.

Some supporters of the campaign to save Christmas appear to believe that the problem they confront is that of militant secularism. The missive issued by the Forum, in the name of a leading Islamic cleric and the Anglican Bishop of Bolton, states that ‘there seems to be a secularising agenda which fails to understand the concerns of religious communities’. The leaders of the Church of England and the Roman Catholic Church objected to what they see as an ‘ongoing secularist campaign to drive Christ out of Christmas’ (3). That same theme is expounded upon in a report by a new think-tank, Theos, entitled Doing God: A Future for Faith in the Public Square.  ‘Aggressive secularists’ are also the target of the Archbishop of York.

However, secularism as such should not be held responsible for the behaviour of simpletons who wish to rebrand Christmas into a meaningless exercise in diversity. It is worth noting that the institution of Christmas has coexisted with secularism for a very long time. More importantly, Christmas has been secularised for more than a century. Yes, the festivities have an important religious dimension, but most people experience the rituals associated with Christmas in a very secular manner. Of course, many of us decry the commercialisation, yet shopping represents a far more important dimension of our Christmas experience than going to Church. The amount of energy devoted to the purchase of Christmas presents far outweighs what is channelled into religious reflection.

Whatever church leaders say there is no need for a malevolent atheist campaign to drive Christ out of Christmas. For a very long time now Christ has had only a walk-on part in the proceedings. The gifts, the office party, the family meal, the boozing and all the hectic activity around the Xmas tree are profoundly secular events that nevertheless have major significance for people’s lives. That Christianity provides the story and also gives meaning to this experience points to the relatively harmonious interaction between the religious and the secular, at least at that time of year. That is why, through many decades, the secularisation of Christmas did not diminish the symbolic importance of the event.

By protesting about the alleged aggressive secularisation of Christmas, the Church evades confronting the difficult question: why is it now unable to give Christian meaning to Christmas? This month a vicar in Dorset banned a man from wearing a Santa Claus outfit in his carol service.  Apparently the good vicar wanted to put religion at the heart of the celebration, to counter the influence of secularism and materialism. However, it is more likely to be the Church itself, not the wearing of Santa hats, that is responsible for the feeble sense of religious meaning associated with the celebration of Christmas.

The attempt to restrict the public role of Christmas is encouraged not so much by a hatred of religion, but by a profound sense of moral malaise. It has become commonplace in contemporary Western society to assume that it is not possible for us to have a common language through which we make sense of the world. It is assumed that there are no durable values that can transcend differences in identity, culture and religion. Instead of attempting to uphold values to which all humans can subscribe, we are counselled to respect difference and celebrate diversity. From this perspective, it is offensive to wish ‘Happy Christmas’ to someone who is not a practising Christian. Such sentiments are now fairly widespread – at least among sections of the middle class and in public institutions. Which is why many of us play it safe and send out cards that refrain from wishing the recipient ‘Merry Christmas’.

The bewilderment that surrounds Christmas is symptomatic of the far wider problem of not knowing how to behave in circumstances where we lack a moral language for expressing right and wrong. We feel far more comfortable describing something as safe or risky than in making a value judgement using words like good or bad. That is why critics of Christmas often hide behind the language of health and safety. For example the Sun ripped into the management of a Castleford shopping centre for preventing a 30-strong choir from performing in their usual spot because it was deemed too risky for them to stand in front of the fire exit. In the same way, a major bank warned its employees not to place Christmas decorations near computers as they could be a fire hazard.

The Sun also rightly took exception to the child protection campaign Kidscape’s demand that youngsters should be banned from sitting on Santa’s knee. In this case the prevailing mistrust about the moral status of grown-up men makes it easy to question the role of Santa Claus. Of course although Santa is not a religious figure he serves as a recognised symbol of Christmas. Michelle Elliot, Kidscape’s director argued that ‘you can’t vet all the people dressed as Santa’. Which is why a shopping centre in Llanelli, South Wales has installed a webcam to spy on Santa. And if Santa needs to undergo a police check why not the church leader who is in charge of a choir of children practising their Christmas carols?

Fear of paedophiles masquerading as Santa Claus, an obsession with health and safety, a mood of risk aversion and anxiety about offending others are powerful motifs that influence everyday life and encourage doubts about the familiar. That is why there is so much pressure on Christmas to reform its image. There is also another influence at work. Western society finds it increasingly difficult to affirm its institutions and celebrate its achievements. A powerful mood of cynicism prevails that uncritically dismisses tradition and celebrates the most shallow and philistine reaction against it.

In this vein, Channel 4 television has decided to transmit an ‘Alternative Christmas Message’ by a Muslim woman in a veil, at the same time as the Queen’s traditionally Christian message. Lacking the moral resources to deliver a statement on its own account, Channel 4 has opted for hiding behind a mask. It is not so much a hatred of Christianity but a mood of moral disorientation that encourages the desire to devalue the meaning of Christmas. Nevertheless, it is hardly surprising that some church leaders should interpret this response as symptomatic of a bias against Christianity. ‘This country disbelieves in itself in an amazing way’ observed the Archbishop of York.

Much more here

How green is your organic lettuce?

Even an apparently obvious claim-that organic food is better for the environment than the conventionally farmed kind-turns out to be controversial. There are many different definitions of the term "organic", but it generally involves severe restrictions on the use of synthetic pesticides and fertilisers and a ban on genetically modified organisms. Peter Melchett of the Soil Association, Britain's leading organic lobby group, says that environmental concerns, rather than health benefits, are now cited by British consumers as their main justification for buying organic food. (There is no clear evidence that conventional food is harmful or that organic food is nutritionally superior.)

But not everyone agrees that organic farming is better for the environment. Perhaps the most eminent critic of organic farming is Norman Borlaug, the father of the "green revolution", winner of the Nobel peace prize and an outspoken advocate of the use of synthetic fertilisers to increase crop yields. He claims the idea that organic farming is better for the environment is "ridiculous" because organic farming produces lower yields and therefore requires more land under cultivation to produce the same amount of food. Thanks to synthetic fertilisers, Mr Borlaug points out, global cereal production tripled between 1950 and 2000, but the amount of land used increased by only 10%. Using traditional techniques such as crop rotation, compost and manure to supply the soil with nitrogen and other minerals would have required a tripling of the area under cultivation. The more intensively you farm, Mr Borlaug contends, the more room you have left for rainforest.

What of the claim that organic farming is more energy-efficient? Lord Melchett points out for example that the artificial fertiliser used in conventional farming is made using natural gas, which is "completely unsustainable". But Anthony Trewavas, a biochemist at the University of Edinburgh, counters that organic farming actually requires more energy per tonne of food produced, because yields are lower and weeds are kept at bay by ploughing. And Mr Pollan notes that only one-fifth of the energy associated with food production across the whole food chain is consumed on the farm: the rest goes on transport and processing.

The most environmentally benign form of agriculture appears to be "no till" farming, which involves little or no ploughing and relies on cover crops and carefully applied herbicides to control weeds. This makes it hard to combine with organic methods (though some researchers are trying). Too rigid an insistence on organic farming's somewhat arbitrary rules, then-copper, a heavy metal, can be used as an organic fungicide because it is traditional-can actually hinder the adoption of greener agricultural techniques. Alas, shoppers look in vain for "no till" labels on their food-at least so far.

What about Fairtrade? Its aim is to address "the injustice of low prices" by guaranteeing that producers receive a fair price "however unfair the conventional market is", according to FLO International's website. In essence, it means paying producers an above-market "Fairtrade" price for their produce, provided they meet particular labour and production standards. In the case of coffee, for example, Fairtrade farmers receive a minimum of $1.26 per pound for their coffee, or $0.05 above the market price if it exceeds that floor. This premium is passed back to the producers to spend on development programmes. The market for Fairtrade products is much smaller than that for organic products, but is growing much faster: it increased by 37% to reach _1.1 billion ($1.4 billion) in 2005. Who could object to that?

Economists, for a start. The standard economic argument against Fairtrade goes like this: the low price of commodities such as coffee is due to overproduction, and ought to be a signal to producers to switch to growing other crops. Paying a guaranteed Fairtrade premium-in effect, a subsidy-both prevents this signal from getting through and, by raising the average price paid for coffee, encourages more producers to enter the market. This then drives down the price of non-Fairtrade coffee even further, making non-Fairtrade farmers poorer. Fairtrade does not address the basic problem, argues Tim Harford, author of "The Undercover Economist" (2005), which is that too much coffee is being produced in the first place. Instead, it could even encourage more production.

Mr Bretman of FLO International disagrees. In practice, he says, farmers cannot afford to diversify out of coffee when the price falls. Fairtrade producers can use the premiums they receive to make the necessary investments to diversify into other crops. But surely the price guarantee actually reduces the incentive to diversify?

Another objection to Fairtrade is that certification is predicated on political assumptions about the best way to organise labour. In particular, for some commodities (including coffee) certification is available only to co-operatives of small producers, who are deemed to be most likely to give workers a fair deal when deciding how to spend the Fairtrade premium. Coffee plantations or large family firms cannot be certified. Mr Bretman says the rules vary from commodity to commodity, but are intended to ensure that the Fairtrade system helps those most in need. Yet limiting certification to co-ops means "missing out on helping the vast majority of farm workers, who work on plantations," says Mr Wille of the Rainforest Alliance, which certifies producers of all kinds.

Guaranteeing a minimum price also means there is no incentive to improve quality, grumble coffee-drinkers, who find that the quality of Fairtrade brews varies widely. Again, the Rainforest Alliance does things differently. It does not guarantee a minimum price or offer a premium but provides training, advice and better access to credit. That consumers are often willing to pay more for a product with the RA logo on it is an added bonus, not the result of a formal subsidy scheme; such products must still fend for themselves in the marketplace. "We want farmers to have control of their own destinies, to learn to market their products in these competitive globalised markets, so they are not dependent on some NGO," says Mr Wille.

But perhaps the most cogent objection to Fairtrade is that it is an inefficient way to get money to poor producers. Retailers add their own enormous mark-ups to Fairtrade products and mislead consumers into thinking that all of the premium they are paying is passed on. Mr Harford calculates that only 10% of the premium paid for Fairtrade coffee in a coffee bar trickles down to the producer. Fairtrade coffee, like the organic produce sold in supermarkets, is used by retailers as a means of identifying price-insensitive consumers who will pay more, he says.

As with organic food, the Fairtrade movement is under attack both from outsiders who think it is misguided and from insiders who think it has sold its soul. In particular, the launch by Nestle, a food giant, of Partners' Blend, a Fairtrade coffee, has convinced activists that the Fairtrade movement is caving in to big business. Nestle sells over 8,000 non-Fairtrade products and is accused of exploiting the Fairtrade brand to gain favourable publicity while continuing to do business as usual. Mr Bretman disagrees. "We felt it would not be responsible to turn down an opportunity to do something that would practically help hundreds or thousands of farmers," he says. "You are winning the battle if you get corporate acceptance that these ideas are important." He concedes that the Fairtrade movement's supporters are "a very broad church" which includes anti-globalisation and anti-corporate types. But they can simply avoid Nestle's Fairtrade coffee and buy from smaller Fairtrade producers instead, he suggests.

Besides, this is how change usually comes about, notes Mr Pollan. The mainstream co-opts the fringe and shifts its position in the process; "but then you need people to stake out the fringe again." That is what has happened with organic food in America, and is starting to happen with Fairtrade food too. "People are looking for the next frontier," says Mr Pollan, and it already seems clear what that is: local food.

"Local is the new organic" has become the unofficial slogan of the local-food movement in the past couple of years. The rise of "Big Organic", the large-scale production of organic food to meet growing demand, has produced a backlash and claims that the organic movement has sold its soul. Purists worry that the organic movement's original ideals have been forgotten as large companies that produce and sell organic food on an industrial scale have muscled in.

This partly explains why food bought from local producers either directly or at farmers' markets is growing in popularity, and why local-food advocates are now the keepers of the flame of the food-activism movement. Local food need not be organic, but buying direct from small farmers short-circuits industrial production and distribution systems in the same way that buying organic used to. As a result, local food appears to be immune to being industrialised or corporatised. Organic food used to offer people a way to make a "corporate protest", says Mr Pollan, and now "local offers an alternative to that."

Buying direct means producers get a fair price, with no middlemen adding big margins along the distribution chain. Nor has local food been shipped in from the other side of the country or the other side of the world, so the smaller number of "food miles" makes local food greener, too. Local food thus appeals in different ways to environmentalists, national farm lobbies and anti-corporate activists, as well as consumers who want to know more about where their food comes from.

Obviously it makes sense to choose a product that has been grown locally over an identical product shipped in from afar. But such direct comparisons are rare. And it turns out that the apparently straightforward approach of minimising the "food miles" associated with your weekly groceries does not, in fact, always result in the smallest possible environmental impact.

The term "food mile" is itself misleading, as a report published by DEFRA, Britain's environment and farming ministry, pointed out last year. A mile travelled by a large truck full of groceries is not the same as a mile travelled by a sport-utility vehicle carrying a bag of salad. Instead, says Paul Watkiss, one of the authors of the DEFRA report, it is more helpful to think about food-vehicle miles (ie, the number of miles travelled by vehicles carrying food) and food-tonne miles (which take the tonnage being carried into account).

The DEFRA report, which analysed the supply of food in Britain, contained several counterintuitive findings. It turns out to be better for the environment to truck in tomatoes from Spain during the winter, for example, than to grow them in heated greenhouses in Britain. And it transpires that half the food-vehicle miles associated with British food are travelled by cars driving to and from the shops. Each trip is short, but there are millions of them every day. Another surprising finding was that a shift towards a local food system, and away from a supermarket-based food system, with its central distribution depots, lean supply chains and big, full trucks, might actually increase the number of food-vehicle miles being travelled locally, because things would move around in a larger number of smaller, less efficiently packed vehicles.

Research carried out at Lincoln University in New Zealand found that producing dairy products, lamb, apples and onions in that country and shipping them to Britain used less energy overall than producing them in Britain. (Farming and processing in New Zealand is much less energy intensive.) And even if flying food in from the developing world produces more emissions, that needs to be weighed against the boost to trade and development.

There is a strand of protectionism and anti-globalisation in much local-food advocacy, says Gareth Edwards-Jones of the University of Wales. Local food lets farming lobbies campaign against imports under the guise of environmentalism. A common argument is that local food is fresher, but that is not always true: green beans, for example, are picked and flown to Britain from Kenya overnight, he says. People clearly want to think that they are making environmentally or socially optimal food choices, he says, but "we don't have enough evidence" to do so.

What should a shopper do? All food choices involve trade-offs. Even if organic farming does consume a little less energy and produce a little less pollution, that must be offset against lower yields and greater land use. Fairtrade food may help some poor farmers, but may also harm others; and even if local food reduces transport emissions, it also reduces potential for economic development. Buying all three types of food can be seen as an anti-corporate protest, yet big companies already sell organic and Fairtrade food, and local sourcing coupled with supermarkets' efficient logistics may yet prove to be the greenest way to move food around.

Food is central to the debates on the environment, development, trade and globalisation-but the potential for food choices to change the world should not be overestimated. The idea of saving the world by shopping is appealing; but tackling climate change, boosting development and reforming the global trade system will require difficult political choices. "We have to vote with our votes as well as our food dollars," says Mr Pollan. Conventional political activity may not be as enjoyable as shopping, but it is far more likely to make a difference.


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