Bush faces his Watergate

30 October 2005 |

Sleaze, leaks and an indictment add up to the worst presidential crisis since Nixon. And it will get worse. The White House has lost one key man but the whole chain of command may be engulfed by a scandal slowly revealing the lies that led to war.
By Andrew Buncombe in Washington



Presidential second terms are prone to scandals, from Bill Clinton's embarrassments over Monica Lewinsky to Ronald Reagan's implication in the Iran-Contra imbroglio. But the troubles now circling George Bush's White House could be even worse than Watergate.

It might not appear that way at first. Mr Bush is unlikely to have to join Richard Nixon, the only president in US history forced to resign from office. But the issues raised by "Plamegate" - the leaking of the identity of Valerie Plame, an undercover CIA agent - are far more significant than those involved in the "second-rate burglary" of the Democratic National Committee's offices in Washington's Watergate complex in the 1970s. They go to the heart of why America, and its faithful ally, Britain, went to war in Iraq.

The immediate problems are bad enough. On Friday Vice-President Dick Cheney's chief of staff, Lewis "Scooter" Libby, was indicted for obstruction of justice and making false statements to a grand jury. Patrick Fitzgerald, the special prosecutor appointed to investigate Ms Plame's outing, announced that he was not indicting Karl Rove, President Bush's closest adviser, although he remains under investigation and may have to give evidence against Mr Libby.

The administration and its friends have done their best to portray the Plamegate affair as an obscure, "inside the Beltway" scandal, of interest only to Washington obsessives and conspiracy theorists. On Thursday evening, as the whole of Washington speculated over his position, Mr Rove did his best to reinforce that view.

At his large home in the Palisades district of Washington, Mr Rove stepped from the driver's seat of his blue Jaguar XJ6 and smiled at a waiting cameraman as he headed inside. Moments later, when The Independent on Sunday rapped on his heavy wooden door, his reaction suggested a relaxed family evening rather than someone waiting to be fed to the lions. "Sorry, but we're all having dinner right now," he said.

It is also true that Washington's Democrats, who have suffered years of humiliation at the hands of a Republican Party which holds not only the White House but majorities in both houses of Congress, are rubbing their hands with glee over the scandal at a time when Mr Bush is already reeling from record low approval ratings and problems on many other fronts.

Earlier in the week, the President had already suffered one humiliating setback when he was forced to accept the withdrawal of his nomination for the Supreme Court, Harriet Miers, after a fierce campaign from right-wing members of his own party.

Larry Sabato, professor of politics at the University of Virginia, said: "It's not good news but it could have worse. That's all you can really say. I would emphasise the bad: there is no good way to spin this, though no doubt they will try."

He said that Mr Rove would be able to continue to do his behind-the-scenes work from the White House.

Yet it is possible to view this week's events in much, much starker terms if one steps back from the all but incomprehensible minutiae of the indictments and of who is alleged to have said what to whom and focuses instead on the broader narrative.

If one believes that the government of George Bush - actively assisted by that of Tony Blair - conspired to make a fraudulent case for the invasion of Iraq, then it is possible to see this week's events as nothing less the first fallout for the administration of their attempt to cover-up what they did.

More than 2,100 US and British soldiers and perhaps 100,000 civilians have died since the invasion of Iraq in 2003. If one believes that using false statements and twisted information to mislead a nation and launch that war is a greater crime than orchestrating a dirty tricks campaign against your political rivals, then it is possible to set this week's events in the context of the seminal Washington scandal from which Plamegate - and all the other "gates" - take their inspiration.

Remember, no one knew where it would all lead when, on June 17 1972, five men appeared for a preliminary hearing at a Washington court charged over a break-in at the Democratic party national headquarters at the Watergate complex.

To appreciate the broader potential of Libby's indictment one cannot avoid a little of the labyrinthine background. Mr Fitzgerald's investigation focussed on the leaking of the identity of Ms Plame, wife of former US ambassador Joe Wilson.

In the summer of 2003 Mr Wilson had publicly questioned claims made by Mr Bush that Iraq had been seeking to buy uranium from Niger to re-establish a nuclear weapons programme. The threat of a "mushroom cloud" had been presented to the American public as one of the reasons for a war against Iraq.

Mr Wilson had investigated the claims at the behest of the CIA and found them to be false. Soon after he went public, a conservative columnist, Robert Novak, claimed that Mr Wilson's wife, Valerie, worked for the CIA and that she had suggested sending her husband to Africa. The leak was widely interpreted as an attempt to undermine the former ambassador, who had, ironically, been commended by Mr Bush's father as "a true American hero" for standing up to Saddam Hussein during the 1990 hostage crisis.

It is now clear that a number of officials spoke to reporters about Ms Plame's identity and her alleged role in sending her husband to Africa. The indictments accuse Mr Libby of lying about what he told the reporters about her and where he learned she worked for the CIA. Indeed, as the indictment makes clear, one of the several sources Mr Libby spoke to about Ms Plame's employment was Mr Cheney.

On Friday, the news of Mr Libby's indictment on five felony counts - two of lying to FBI investigators, two of lying to a grand jury and one count of obstructing justice - rapidly reverberated around this incestuous and self-regarding city. Less than half-an-hour after the charges were filed, the 22-page indictment was posted on to the prosecutor's official website for everyone to tear into.

Shortly afterwards, at a press conference, Mr Fitzgerald finally broke his silence and said he believed that Mr Libby, 55, chief of staff to probably the most powerful US vice-president in history, had repeatedly lied and mislead investigators looking into the leaking of a covert CIA operative's name. That was why he had been charged with offences that carried up to 30 years in jail.

"We brought these cases because we realised that the truth is the engine of our judicial system," said Mr Fitzgerald. "We didn't get the straight story and we had to - had to - act. When citizens testify before grand juries they are required to tell the truth. Without truth, our criminal justice cannot serve our nation or its citizens. The requirement to tell the truth applies equally to all citizens, including persons who hold high positions in government."

In the immediate term, Mr Bush and his White House team will busy themselves by focusing on their agenda and perhaps organising some sort of shake-up of administration officials, not least finding a replacement for Mr Libby who immediately stood down.

Shortly after the indictments were released, Mr Bush praised Mr Libby for "working tirelessly on behalf of the American people". He added that while he and his administration were saddened by developments they intended to "remain wholly focused on the many issues and opportunities facing this country".

In the short term this may be possible. Stephen Hess, a former speechwriter for President John F Kennedy, said that most Americans would have no idea who Mr Libby was or what he had done. Of much greater concern to them, he said, was the state of the economy, the war in Iraq and petrol prices. He said that other scandals such as that involving Monica Lewinsky and President Bill Clinton had much greater traction with the public.

"Next week he will be nominating a new justice of the Supreme Court, which is something of infinitely more importance than the [doings] of Scooter Libby. We have a 5-4 balance and this [nominee] will be swing vote," he said. "Everybody will be chasing this story."

But such an assessment might ignore what may develop from Mr Libby's trial and what news may emerge in the remaining 39 months of Mr Bush's presidency. Democrats would like a much broader inquiry, using a Libby trial to examine not just whether or why he lied but the wider effort by the White House to make the case for war against Iraq and to then discredit critics.

And there remains the very real possibility that Mr Rove could yet be charged over the affair, a much more damaging matter for Mr Bush. It is known that Mr Rove spoke to several reporters about Ms Plame. The indictment also reveals that prosecutors know that an unidentified White House official - "official A" - spoke to Mr Novak. It has now emerged that official A is Mr Rove.

Mr Fitzgerald declined to say if Mr Rove will be charged, but given what is already known, this is very possible.

There is also the chance that in Mr Libby's trial prosecutors could seek to call Mr Cheney as a witness, especially since it is known he spoke to him about Ms Plame. He could be asked how he learned of Ms Plame's identity and whether he knew or even suggested that his chief of staff speak to reporters about her. Mr Wilson has always maintained that Mr Cheney must, at the very least, have been aware of what was happening.

That trial could also examine the activities of the so-called White House Iraq group, a small group of senior officials established in August 2002 and chaired by Mr Rove to coordinate the government's activities and "sell" the war in Iraq to the American public. Mr Libby was a member of this group.

And as preparations for Mr Libby's trial are being made, investigators are separately looking into the source of the original forged documents that found their way into the hands of Italian intelligence and which claimed Iraq was seeking to buy uranium yellowcake from Niger. It was those forged documents that resulted in Mr Wilson being dispatched to Africa. To this day it remains unproven who forged these documents.

If, on Thursday night, Mr Rove needed a reminder of the potential perils ahead for him and his boss, he would have needed to do nothing more than look out of the White House windows before he left for home. On the pavement outside were demonstrators holding a vigil and calling for US troops in Iraq to be called home. Among the demonstrators was Cindy Sheehan, the mother whose soldier son was killed in Iraq and who this summer became a focus for the anti-war movement when she demonstrated outside of Mr Bush's Texas ranch.

Mrs Sheehan told the IoS that she would welcome any indictments and that she hoped the American public would see that the war was based in lies. After Mr Libby's five indictments were announced she issued a new statement directed at the man who sits in the Oval Office. She said: "The responsibility for lying to the American people and targeting critics and dissidents needs to go all the way up the chain of command. Scooter Libby was clearly one of the administration's attack dogs unleashed on opponents of this fraudulent war, but he serves higher masters."

Presidential second terms are prone to scandals, from Bill Clinton's embarrassments over Monica Lewinsky to Ronald Reagan's implication in the Iran-Contra imbroglio. But the troubles now circling George Bush's White House could be even worse than Watergate.

It might not appear that way at first. Mr Bush is unlikely to have to join Richard Nixon, the only president in US history forced to resign from office. But the issues raised by "Plamegate" - the leaking of the identity of Valerie Plame, an undercover CIA agent - are far more significant than those involved in the "second-rate burglary" of the Democratic National Committee's offices in Washington's Watergate complex in the 1970s. They go to the heart of why America, and its faithful ally, Britain, went to war in Iraq.

The immediate problems are bad enough. On Friday Vice-President Dick Cheney's chief of staff, Lewis "Scooter" Libby, was indicted for obstruction of justice and making false statements to a grand jury. Patrick Fitzgerald, the special prosecutor appointed to investigate Ms Plame's outing, announced that he was not indicting Karl Rove, President Bush's closest adviser, although he remains under investigation and may have to give evidence against Mr Libby.

The administration and its friends have done their best to portray the Plamegate affair as an obscure, "inside the Beltway" scandal, of interest only to Washington obsessives and conspiracy theorists. On Thursday evening, as the whole of Washington speculated over his position, Mr Rove did his best to reinforce that view.

At his large home in the Palisades district of Washington, Mr Rove stepped from the driver's seat of his blue Jaguar XJ6 and smiled at a waiting cameraman as he headed inside. Moments later, when The Independent on Sunday rapped on his heavy wooden door, his reaction suggested a relaxed family evening rather than someone waiting to be fed to the lions. "Sorry, but we're all having dinner right now," he said.

It is also true that Washington's Democrats, who have suffered years of humiliation at the hands of a Republican Party which holds not only the White House but majorities in both houses of Congress, are rubbing their hands with glee over the scandal at a time when Mr Bush is already reeling from record low approval ratings and problems on many other fronts.

Earlier in the week, the President had already suffered one humiliating setback when he was forced to accept the withdrawal of his nomination for the Supreme Court, Harriet Miers, after a fierce campaign from right-wing members of his own party.

Larry Sabato, professor of politics at the University of Virginia, said: "It's not good news but it could have worse. That's all you can really say. I would emphasise the bad: there is no good way to spin this, though no doubt they will try."

He said that Mr Rove would be able to continue to do his behind-the-scenes work from the White House.

Yet it is possible to view this week's events in much, much starker terms if one steps back from the all but incomprehensible minutiae of the indictments and of who is alleged to have said what to whom and focuses instead on the broader narrative.

If one believes that the government of George Bush - actively assisted by that of Tony Blair - conspired to make a fraudulent case for the invasion of Iraq, then it is possible to see this week's events as nothing less the first fallout for the administration of their attempt to cover-up what they did.

More than 2,100 US and British soldiers and perhaps 100,000 civilians have died since the invasion of Iraq in 2003. If one believes that using false statements and twisted information to mislead a nation and launch that war is a greater crime than orchestrating a dirty tricks campaign against your political rivals, then it is possible to set this week's events in the context of the seminal Washington scandal from which Plamegate - and all the other "gates" - take their inspiration.

Remember, no one knew where it would all lead when, on June 17 1972, five men appeared for a preliminary hearing at a Washington court charged over a break-in at the Democratic party national headquarters at the Watergate complex.

To appreciate the broader potential of Libby's indictment one cannot avoid a little of the labyrinthine background. Mr Fitzgerald's investigation focussed on the leaking of the identity of Ms Plame, wife of former US ambassador Joe Wilson.

In the summer of 2003 Mr Wilson had publicly questioned claims made by Mr Bush that Iraq had been seeking to buy uranium from Niger to re-establish a nuclear weapons programme. The threat of a "mushroom cloud" had been presented to the American public as one of the reasons for a war against Iraq.

Mr Wilson had investigated the claims at the behest of the CIA and found them to be false. Soon after he went public, a conservative columnist, Robert Novak, claimed that Mr Wilson's wife, Valerie, worked for the CIA and that she had suggested sending her husband to Africa. The leak was widely interpreted as an attempt to undermine the former ambassador, who had, ironically, been commended by Mr Bush's father as "a true American hero" for standing up to Saddam Hussein during the 1990 hostage crisis.

It is now clear that a number of officials spoke to reporters about Ms Plame's identity and her alleged role in sending her husband to Africa. The indictments accuse Mr Libby of lying about what he told the reporters about her and where he learned she worked for the CIA. Indeed, as the indictment makes clear, one of the several sources Mr Libby spoke to about Ms Plame's employment was Mr Cheney.

On Friday, the news of Mr Libby's indictment on five felony counts - two of lying to FBI investigators, two of lying to a grand jury and one count of obstructing justice - rapidly reverberated around this incestuous and self-regarding city. Less than half-an-hour after the charges were filed, the 22-page indictment was posted on to the prosecutor's official website for everyone to tear into.

Shortly afterwards, at a press conference, Mr Fitzgerald finally broke his silence and said he believed that Mr Libby, 55, chief of staff to probably the most powerful US vice-president in history, had repeatedly lied and mislead investigators looking into the leaking of a covert CIA operative's name. That was why he had been charged with offences that carried up to 30 years in jail.

"We brought these cases because we realised that the truth is the engine of our judicial system," said Mr Fitzgerald. "We didn't get the straight story and we had to - had to - act. When citizens testify before grand juries they are required to tell the truth. Without truth, our criminal justice cannot serve our nation or its citizens. The requirement to tell the truth applies equally to all citizens, including persons who hold high positions in government."

In the immediate term, Mr Bush and his White House team will busy themselves by focusing on their agenda and perhaps organising some sort of shake-up of administration officials, not least finding a replacement for Mr Libby who immediately stood down.

Shortly after the indictments were released, Mr Bush praised Mr Libby for "working tirelessly on behalf of the American people". He added that while he and his administration were saddened by developments they intended to "remain wholly focused on the many issues and opportunities facing this country".

In the short term this may be possible. Stephen Hess, a former speechwriter for President John F Kennedy, said that most Americans would have no idea who Mr Libby was or what he had done. Of much greater concern to them, he said, was the state of the economy, the war in Iraq and petrol prices. He said that other scandals such as that involving Monica Lewinsky and President Bill Clinton had much greater traction with the public.

"Next week he will be nominating a new justice of the Supreme Court, which is something of infinitely more importance than the [doings] of Scooter Libby. We have a 5-4 balance and this [nominee] will be swing vote," he said. "Everybody will be chasing this story."

But such an assessment might ignore what may develop from Mr Libby's trial and what news may emerge in the remaining 39 months of Mr Bush's presidency. Democrats would like a much broader inquiry, using a Libby trial to examine not just whether or why he lied but the wider effort by the White House to make the case for war against Iraq and to then discredit critics.

And there remains the very real possibility that Mr Rove could yet be charged over the affair, a much more damaging matter for Mr Bush. It is known that Mr Rove spoke to several reporters about Ms Plame. The indictment also reveals that prosecutors know that an unidentified White House official - "official A" - spoke to Mr Novak. It has now emerged that official A is Mr Rove.

Mr Fitzgerald declined to say if Mr Rove will be charged, but given what is already known, this is very possible.

There is also the chance that in Mr Libby's trial prosecutors could seek to call Mr Cheney as a witness, especially since it is known he spoke to him about Ms Plame. He could be asked how he learned of Ms Plame's identity and whether he knew or even suggested that his chief of staff speak to reporters about her. Mr Wilson has always maintained that Mr Cheney must, at the very least, have been aware of what was happening.

That trial could also examine the activities of the so-called White House Iraq group, a small group of senior officials established in August 2002 and chaired by Mr Rove to coordinate the government's activities and "sell" the war in Iraq to the American public. Mr Libby was a member of this group.

And as preparations for Mr Libby's trial are being made, investigators are separately looking into the source of the original forged documents that found their way into the hands of Italian intelligence and which claimed Iraq was seeking to buy uranium yellowcake from Niger. It was those forged documents that resulted in Mr Wilson being dispatched to Africa. To this day it remains unproven who forged these documents.

If, on Thursday night, Mr Rove needed a reminder of the potential perils ahead for him and his boss, he would have needed to do nothing more than look out of the White House windows before he left for home. On the pavement outside were demonstrators holding a vigil and calling for US troops in Iraq to be called home. Among the demonstrators was Cindy Sheehan, the mother whose soldier son was killed in Iraq and who this summer became a focus for the anti-war movement when she demonstrated outside of Mr Bush's Texas ranch.

Mrs Sheehan told the IoS that she would welcome any indictments and that she hoped the American public would see that the war was based in lies. After Mr Libby's five indictments were announced she issued a new statement directed at the man who sits in the Oval Office. She said: "The responsibility for lying to the American people and targeting critics and dissidents needs to go all the way up the chain of command. Scooter Libby was clearly one of the administration's attack dogs unleashed on opponents of this fraudulent war, but he serves higher masters."

America debates evolution: Why now?

24 October 2005 |

Americans are bone-deep into a fight over evolution thanks in large part to a new script that has defined the issue in a way not seen since the "monkey trial" in rural Tennessee 80 years ago, academic and other experts say.

"There are two factors in American society coming to a head right now. One is the long-running opposition to evolution in this culture," said Robert Boston, a spokesman for Americans United for Separation of Church and State.

"The second is a well-coordinated, well-crafted, slick campaign to repackage creationism. They've stripped it of its more outlandish claims ... their new package is significantly more attractive since it doesn't have all this pseudo-scientific baggage," he added.

Religious and societal changes may also be factors, others say.

The question being debated in more than two dozen states is whether schools should be required to teach some sort of creation concept alongside Charles Darwin's 146-year-old theory of natural selection -- or at the least provide lessons saying some doubt his theories.

The Discovery Institute, a Seattle-based think tank, has reframed the issue as "intelligent design," the concept that evolution alone cannot explain nature's complexity, and it must be the work of a "designer" -- a higher being by implication.

Since 1982, Gallup research has indicated about 45 percent of Americans believe God created human beings "pretty much in their present form" within the last 10,000 years while 38 percent think mankind developed "over millions of years from less advanced" life forms "but God guided this process."

Only 15 percent think God had no part in it -- slightly more than the percentage of the populace that doesn't believe in God in the first place.

And a Pew Forum on Public Life and Religion poll earlier this year found that about two-thirds of Americans favored adding creationism to school curriculum.

Debate over evolution has been a constant thread in American society, before and since the 1925 Tennessee trial that found science teacher John Scopes guilty of violating a state law against teaching evolution. A higher court later overturned the verdict on a technicality without ruling on the merits of the law.

The fact that the debate has returned with such force in 2005 may reflect a time of frightening cultural change when people "look for something that is absolute and certain," said Mark Sisk, the Episcopal bishop of New York.

"I believe that a fair amount of this is an attempt to corner God. And when one does that it approaches idolatry," he added. The Biblical account of creation simply means that "God is the source of everything" and nothing in that conflicts with Darwin, he said.

REDEFINING DEBATE

The Discovery Institute is a central player in the current Pennsylvania trial where parents are suing a school board over a requirement that some students be given a brief statement suggesting intelligent design as an alternative to evolution, and then told of a book elaborating on the design theory.

Redefining the debate along intelligent design lines is an attempt by those who want creation taught in schools to find a "silver bullet" that will get them past adverse court rulings, according to Michael Lienesch, a political science professor at the University of North Carolina.

"The courts say if it's in a science class it has to be science," he said. But intelligent design has gained ground because its backers "have a lot of resources and a more sophisticated infrastructure. They have worked very hard to frame the evolution issue in terms of intelligent design."

"What makes it seem convincing is that it splits the difference between certainty and faith in a way that old-style creationism didn't," adds Kirk Wegter-McNelly, a professor of theology at Boston University. "The search for certainty is important among evangelicals and it's important as people live in an increasingly multi-religious society."

John West, a senior fellow at the Discovery Institute, said the debate has ripened because more credentialed scientists are critical of Darwin's theory. The institute has a list of 400 people with a variety of degrees in and out of academia who it said have signed a "dissent."

It states that they are "skeptical of claims for the ability of random mutation and natural selection to account for the complexity of life. Careful examination of the evidence of Darwinian theory should be encouraged."

What the institute would like to see, West, said, is a requirement that schools "teach the controversy" -- to note in lessons on evolution that not everyone accepts the theory.

That approach is equally abhorrent to Michael Zimmerman, dean of the College of Letters and Sciences at the University of Wisconsin, Oshkosh.

He blames the spreading debate in part on "narrow-minded religious leaders repeatedly saying people have to choose between science and religion." What they really want, Zimmerman said, is "to overturn the scientific paradigm that explains the natural world in materialistic terms."

He has gathered nearly 9,000 signatures of U.S. clergy members on a letter posted online urging school boards to keep teaching evolution "as a core component of human knowledge."

Glenn Branch, deputy director of the National Center for Science Education that is opposed to introducing any form of creationism, said the intelligent design approach is but another attempt to skirt the U.S. Constitution's ban on establishing religion.

He also said the 2002 "No Child Left Behind" law requires states to develop standards for science teaching, and that has opened a new forum for the debate.

COKE in hot water

10 October 2005 |

Oct 6th 2005 -From The Economist print edition

The world's biggest drinks firm tries to fend off its green critics




“WATER is to Coca-Cola as clean energy is to BP.” So declares Jeff Seabright, Coca-Cola's manager of environmental affairs, when asked about the firm's new global water strategy. The fizzy-drinks maker unveiled that strategy as part of its annual environmental report, released this week. “We need to manage this issue or it will manage us,” says Mr Seabright.

At first sight, the analogy with oil may seem odd, but it is not so far-fetched. Big Oil has long been the target of activists clamouring for action on global warming. BP stole a march on its oily brethren by accepting that climate change is a real problem, making smallish investments in clean energy, and grandly proclaiming itself “beyond petroleum”.

Coca-Cola has also been targeted by activists, but over the issue of water rather than energy. The firm has been hit hardest in India. First, experts from Delhi's Centre for Science and Environment, a green think-tank, tested various soft drinks and determined that they contained high levels of pesticide. It turned out that Coca-Cola was not the cause of the problem. But its inept handling of the accusations left the firm exposed to a much more damaging allegation: that it is aggravating the growing global problem of fresh-water scarcity. An ongoing controversy in India concerns allegations that some of the firm's bottling plants use too much water in drought-prone areas, thus leaving poor local villagers with too little. Amit Srivastava of the India Resource Centre, a Californian non-governmental group, has been using the Indian controversies to stoke an international grass-roots campaign against Coca-Cola.

The firm brags that it operates in 200 countries—“more than the UN itself”, says Mr Seabright. But Coca-Cola's global reach and iconic status make it an easy target. Mr Srivastava points with glee to recent decisions at a handful of university campuses in America and Britain to suspend or challenge its contracts on ethical grounds.

Worse may be in store, if some have their way. Corporate Accountability International (CAI), an activist group best known for organising a noisy boycott of NestlĂ© (for selling infant milk powder in countries without reliable access to clean water), now has its sights set on the world's largest producer of non-alcoholic drinks. CAI turned up at Coca-Cola's last shareholder meeting to grill the firm's management over the water issue. Kathryn Mulvey, CAI's boss, is concerned not only about its fizzy-drinks divisions but also its newish and booming bottled-water business. Echoing the sentiments of other campaigners, she insists that the “misleading marketing campaign” for the bottled water needlessly undermines confidence in tap water, and amounts to the “commodification of something that should not be bought and sold.”

Company officials argue that they started measuring and improving their use of water long before its troubles in India. The firm improved its water efficiency by 6% between 2003 and 2004. In 2002, it took 3.12 litres of water to produce one litre of final product (as much water is used to clean the assembly lines, flush out glass bottles, and so on). In 2004, that global average came down to 2.72 litres. Mr Srivastava is not impressed: he grouses that it is “ridiculous that a firm that calls itself a ‘hydration company’ should waste so much water; most of it does not even end up in the product.”

To improve that situation, Coca-Cola has just completed a detailed assessment of the “water risks” to its businesses and their local communities. Going plant by plant, the firm's boffins have calculated local water-scarcity ratios, depletion levels for local aquifers, water needs for the local plant, and so on. With this new information, the firm is now setting local targets for improving each plant's efficiency of water and energy use. Mr Seabright explains that before this new study, the firm tried to impose “one-size-fits-all” global targets which local bottlers (who are often not owned by Coca-Cola) refused to accept.

Coca-Cola is also working with non-governmental groups such as the World Wildlife Fund and CARE, as well as UN agencies, in an effort to burnish its image. In India, it is now promising to capture enough water via “rainwater harvesting” (an age-old technique for capturing monsoon run-off) to offset all of its water use by 2006. Even the deeply sceptical Mr Srivastava concedes that “if this company were really not to put any strain on local resources then it would be a different matter. Let us see if this is just greenwash.”

The accusation of “greenwash”—environmental window-dressing as a front for business-as-usual—has also been hurled at BP. But there the similarities between Coca-Cola and BP end, for the question of water is far more important to Coca-Cola than the issue of climate change is to BP. That is because if oil and gas run out, or are deemed too dirty to use one day, BP could still peddle ethanol or hydrogen fuel; it is, in the end, an energy company. Coca-Cola, on the other hand, simply would not exist without water. So while BP may yet see life beyond petroleum, Coca-Cola will never get Beyond Water.

The Compliance Challenge in Treating Helicobacter Pylori

05 October 2005 |

MANAGED CARE April 1996.

It's all well and good to know that H. pylori causes peptic ulcer disease. But putting this knowledge to work curing ulcers–and saving money–means making sure the patient actually takes the pills.


By Linda Wolfe Keister
Contributing Editor

Persuading physicians and patients to change their thinking about ulcers and to comply with new treatment protocols has been a major challenge since 1983, when Australian physicians Barry Marshall and Robin Warren first advanced the notion that the Helicobacter pylori bacterium might be involved in the development of peptic ulcers.

Because the medical community for many years believed ulcers were caused by stress and spicy foods, it disregarded Marshall's findings, especially when he couldn't reproduce the bacteria in his laboratory. Determined to make his point, Marshall swallowed a pure culture of H. pylori, subsequently developed gastritis, and proved that the bacterium was alive and well in his stomach.

Marshall's discovery radically altered recommended ulcer treatment, which now consists of complex, long-term combination therapy–an antisecretory drug plus two or more antibiotic agents–that rapidly and effectively relieves ulcer symptoms and heals ulcers, eradicates H. pylori, and allows only negligible ulcer recurrence for up to six years.

Now the medical community agrees that H. pylori is a culprit in ulcer disease, and many authorities believe curing ulcers by eradicating the bacterium promises dramatic cost savings compared with years of palliative acid-blocker treatment. (See "Say Goodbye to Ulcers, Say Hello to Savings," Managed Care, January 1996.) But another challenge remains: eradicating resistance and reluctance among doctors and patients regarding the new treatment protocols.

Although the National Institutes of Health stated in 1994 that infected ulcer patients "require treatment" with antibiotics, many physicians have resisted deviating from treatment with antisecretory compounds. One of their objections has been a practical one: the difficulty of assuring patient compliance.

Today, the U.S. Food and Drug Administration is considering the approval of combination antibiotic and anti-ulcer drug therapies that will eradicate H. pylori and cure ulcers with a simpler regimen than those previously available.


H. pylori and managed care

"Our goal for treating ulcer disease is to improve the quality of life for patients and decrease long-term expenditures," says Pam Benson, regional pharmacy manager with Healthsource in New Hampshire.

Some plan administrators, however, are reluctant to accept the initial high cost of treating H. pylori infection, even though the treatment leads to reduced costs in the long run, according to Rick Patterson, Pharm.D., clinical pharmacy administrator for HealthPlus of Michigan in Flint.

Thomas Algozzine, a pharmacist at the Medical University of South Carolina, estimates that a 100,000-member HMO can save from $80,000 to $100,000 in one year just by identifying and properly treating 20 percent of the peptic ulcer disease sufferers who have H. pylori in its membership. "That doesn't take into account patients who would have been on chronic H2s," says Algozzine, "and the savings that you would get in subsequent years."

But treating H. pylori ulcer disease with antibiotics isn't easy. Although many different treatment regimens are used, they vary in efficacy, tolerability and cost–and no single choice has yet emerged as superior. Standard 14-day triple therapy involves metronidazole, tetracycline and bismuth subsalicylate, along with an H2-receptor antagonist.

One study on triple therapy, however, has shown that the most important factor in eradication of the bacterium was not the combination of drugs used, but patient compliance with the treatment regimen. The complexity of combination therapies tends to make the compliance rate low, and that can lead to treatment failure and added expense.

What it boils down to is that all the advances the medical community has made in the treatment of H. pylori can be thrown out the window if the physician doesn't comply with the recommended treatment protocol and the patient doesn't comply with the regimen.

What's a physician to do?

Most people consult primary care physicians for ulcers. Although its use is now well established among gastroenterologists, antibiotic therapy aimed at eradicating H. pylori is still embraced by only a minority of the primary care physicians who treat ulcers.

But after the 1994 NIH consensus, doctors "have no excuse if they ignore H. pylori," says Marshall, who is now a clinical associate professor of medicine at the University of Virginia Health Sciences Center and disseminates information through the Internet for the International Foundation for Helicobacter and Intestinal Immunology (http://www.helico.com), which is partially funded by a grant from Glaxo Wellcome. By last year, he adds, the bacterium had gained new renown. "Patients were shopping around for doctors interested in H. pylori."

Some practicing physicians, however, say they are reluctant to jump on the antibiotics bandwagon because they are cautious about overusing antibiotics, uncertain about which regimen to use and concerned about the number of pills their patients must take, as well as about the medications' possible side effects.

Managed care organizations face the challenge of educating their medical staffs about the role of H. pylori in ulcer disease and how it should be eradicated. The situation is complicated by the fact that, with more than a dozen suggested combinations of medicines for treating H. pylori (none of them approved by the FDA), experts have not provided definitive answers about which ones work best. In addition, many of the regimens require patients to juggle three different prescriptions with as many as 17 pills to be taken at different times during the day.

Also, until the FDA clears one or more of those combination therapies, the pharmaceutical companies cannot detail the drugs to physicians. In fact, they can't advertise or even talk to doctors about how to use the drugs in treating H. pylori ulcer disease.

Complicated drug therapies also create problems for primary care physicians who deal with patients from a number of different managed care plans and related formularies. John Zatti, corporate pharmacist with Blue Cross and Blue Shield of North Carolina, says, "If a primary care physician sees 30 or 40 patients a day and belongs to a hundred different plans, he doesn't have time to look up whether the drug is on the formulary. He tends to prescribe what he's most familiar with."

Ultimately, managed care administrators want to provide physicians with information about clinically proven, cost-effective therapies with an easy regimen for the patient to adhere to in terms of duration, complexity and side effects.

Patience with patients

As early as the 4th century B.C., Hippocrates recognized the difficulties of patient compliance when he wrote, "Keep watch also on the faults of the patients, which often make them lie about the taking of things prescribed."

With studies showing that only one-third of patients fully comply with prescribed medication regimens, it's no surprise that a 1991 issue of the American Journal of Hospital Pharmacy called noncompliance "America's other drug problem."

Patient compliance is especially important in H. pylori treatment, says Eugene J. Burbige, a gastroenterologist in Concord, Calif. "Patients who don't complete the course of therapy will have recurrence of Helicobacter pylori." And repeating antibiotic treatment is costly.

To prescribe treatment cost-effectively, physicians need to choose a therapy regimen with a high eradication rate and a low recurrence rate. And for that treatment to be medically effective, physicians need to look at compliance as well as efficacy. The medical community generally agrees that any of the available regimens would be reasonable for treating H. pylori ulcer disease, as long as they have a fairly high eradication rate–and much of that depends on patient compliance, which decreases with each pill that is added to the regimen.

Making ulcers history

To improve patient compliance by simplifying treatment, while offering combination therapies with high eradication rates, Glaxo Wellcome and Abbott Laboratories have submitted drug combinations to the FDA for approval. A combined infectious disease and gastroenterology advisory panel reviewed the applications and recommended that the FDA approve the therapies. FDA approval would allow the companies to market the combination therapies to physicians for the treatment of H. pylori.

Glaxo Wellcome submitted data on a new molecule that includes ranitidine–ranitidine bismuth citrate (RBC)–combined with clarithromycin. Ranitidine, manufactured by Glaxo, suppresses gastric acid and is indicated for the short-term treatment of active duodenal ulcers and for maintenance therapy for duodenal ulcer patients at reduced dosage after the acute ulcers have healed. Though not yet approved in the United States, bismuth citrate has been used in other countries to treat ulcers since 1970. Glaxo says its research shows that bismuth citrate inhibits H. pylori.

RBC is a novel salt of ranitidine complexed with bismuth and citric acid, which promotes better eradication of the bacterium than is achieved by either compound alone or by the two in simple admixture.

The Glaxo combination regimen requires the patient to take five pills a day. It consists of 400 mg. of RBC twice daily for four weeks, plus 500 mg. clarithromycin three times a day for the first two weeks.

Abbott presented data on a combination of clarithromycin, which it manufactures as a treatment for bacterial infections, and omeprazole, an Astra Merck product that suppresses gastric acid, thereby appearing to enhance the effects of many antibiotics. Because of its neutralizing effect on the stomach, omeprazole is indicated for short-term treatment of active duodenal ulcers.

The four-week Abbott course of therapy–500 mg. clarithromycin three times per day plus 40 mg. omeprazole each morning for two weeks, followed by two weeks of 20 mg. omeprazole in the morning–requires the patient to take only four pills a day.

"This year, if the FDA approves the Astra, Abbott and Glaxo therapies," says Marshall, "all doctors will have H. pylori treatment at their fingertips and all symptomatic patients will be treated. Ulcers should be ancient history within five years."

Since half of all U.S. adults are infected with H. pylori and one in 10 Americans will have an ulcer at some time, U.S. health care systems stand to save a considerable amount of money–if physicians and patients comply.

Contributing editor Linda Wolfe Keister is based in Sterling, Va.

I remember watching a programme on BBC - back in 1993, can't remember whether it was in Panorama or what!

It has taken another 12 years for mankind to salute Dr Marshall for his pioneering work on Ulcers.

www.helico.com



Nobel discovery 'bloody obvious'

Robin Warren and Barry Marshall
Robin Warren and Barry Marshall's work on ulcers was pioneering
An Australian scientist who has won the 2005 Nobel prize for medicine has said his discovery was "bloody obvious".

Robin Warren, who shares the prize with his colleague Barry Marshall, said he was "thrilled" to be recognised, but had always believed in their work.

The two scientists have described how they were initially shunned for insisting stomach ulcers were caused by a bacterium, not stress.

Dr Marshall finally swallowed the bacterium himself to prove his point.

The pair, who no longer live in the same part of Australia, were actually having a rare dinner together when they received the call from the Nobel committee telling them they had won.

Professor Warren said he was a "little overcome" by the award.

"It is nice to be officially recognised and it gives some sort of a stamp of approval, but we believed it within a few months because it was so bloody obvious," he told reporters.

Dr Marshall said he was shocked.

"I thought it was a new and exciting discovery but I did not believe it was the type of discovery that one got the Nobel prize for," the researcher at the University of Western Australia in Nedlands, Perth, said.

HELICOBACTER PYLORI
H. pylori is found in the stomach of about 50% of all humans
In developing countries almost everyone is infected
Infection is typically contracted in early childhood, and the bacteria may remain in the stomach for life
In most people there are no symptoms
However, it can trigger ulcers in 10-15% of those infected

The two men made their discovery in the early 1980s, but it took a long time to convince the medical community, who viewed them as eccentric.

"The idea of stress and things like that [as the cause of ulcers] was just so entrenched nobody could really believe that it was a bacteria," Dr Marshall told the Associated Press.

"It had to come from some weird place like Perth, Western Australia, because I think nobody else would have even considered it," he said.

Professor Warren is retired from a pathology position at the Royal Perth Hospital.

Dr Marshall, whom his wife describes as having a "dreadful sense of humour", eventually swallowed Heliobacter pylori, the bacterium they believed responsible for stomach ulcers, and became very ill.

Thanks to the their work, stomach and intestinal ulcers are often no longer a long-term, frequently disabling problem.

They can now be cured with a short-term course of drugs and antibiotics.

It is now firmly established that the bacterium causes more than 90% of duodenal (intestinal) ulcers and up to 80% of gastric (stomach) ulcers.