Tuesday, June 30, 2009

Obama's Health Policy and Prostate Cancer

This is what you could hear if it's passed.....

You’re Too Old!

By J.P. Morgan, D.Min.
Author of: Faith and Proton Therapy vs. Prostate Cancer
ISBN: 978-1-934666-29-6

The U.S. Preventive Services Task Force (USPSTF) says that if you are 75 years or older, you are too old to have prostate cancer screening. In the August 5, 2008 Issue of Annals of Internal Medicine (Vol. 149 – Number 3), they recommend that doctors do not screen such patients or those who have a life expectancy of 10 years or fewer (the time required to experience “a mortality benefit”). Their technical reason has three parts. They start with the conclusion that the psychological impact of false-positive test results could be harmful. Next, the elevated prostate-specific antigen (PSA) screening tests could lead to the discomfort of a prostate biopsy, which in turn could lead to treatments that could cause more harm than good. That’s their position, evidently based on the general health, and life expectancy of those 75 and older, since, according to USPSTF, there are “competing causes of death” for this age group. Not even testing them could amount to a head start for prostate cancer in the competition.

The Task Force, first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), has no enforcement powers. However, some of its recommendations could be used to identify “unnecessary” tests and screenings mentioned in proposed healthcare legislation since they are alleged to cost billions of dollars

As a 76-year-old recent prostate cancer survivor (for now), who continues to receive good reports (PSA reading of 1.6) eighteen months after proton therapy, I can’t agree with them. Although they claim statistical data to overwhelm my anecdotal evidence; in this era of equality, shouldn’t everyone have an equal opportunity to use available medical resources? Or, is this perhaps another, not so subtle example of the allocation of such resources? Has “someone” concluded it is a waste of Medicare money not only to treat those over 75 with prostate cancer, but also to even bother testing them to see if they have it? Are we fast approaching a time when cost and a triage criterion of “likely to benefit from the procedure,” will be used as an excuse to ignore any medical needs of the elderly as our country ushers in an era of euthanasia type mentality? At a press conference on June 24, 2009, President Obama signaled that this is the road his administration wants to travel when commenting on a 100 year old women who had received a pace maker. He indicated that she should have just been given a pain pill.

There have been ongoing discussions in the medical community concerning proton therapy treatments for people of any age, because of the cost. The Blue Cross Blue Shield (BCBS) parent organization (HCSC) for four states, on May 22, 2009, withdrew an earlier announcement that they would no longer cover Proton Therapy because of its cost. (An organized letter writing campaign by those of us who had such treatments helped change their mind.) Medicare was also considering such a move, but they too have pulled back from such a decision –– for now.

Because of my firsthand experience, this article highlights one form of cancer, a particular modality, and its cost. It would seem logical, however, that testing and treatment costs, along with the patient’s age, will be considered during any governmental decision-making process to determine how and who to treat in a national health system. The USPSTF already has recommendations available on many medical procedures which could be used to deny future funding. It is interesting to note that age is one of the factors they consider in evaluating a service. (Task Force reports can be reviewed at: www.ahrq.gov/CLINIC/uspstfix.)

Regarding prostate cancer protocol, I do understand that this type of cancer can be slow moving, and yes, my urologist gave me the option of doing nothing (except “watchful waiting”) after my biopsy revealed two cancerous cells. He asked me “Do you feel you are going to live more than five years?” My affirmative answer triggered my review of treatment alternatives. If I would not have had my yearly PSA test, there would have been no biopsy, and no need to look for treatments. That is what USPSTF is suggesting would have been best for me. Even though I am in an increased risk category, that includes older men, African-American men, and men like me, with a family history of prostate cancer (my father and his father both died from it). Who would be liable for not allowing me the opportunity to monitor the condition of my prostate and take precautionary action? What if the cancer spread and it became too late to do anything about it? Since somewhere between thirty and forty thousand men die from prostate cancer each year, there must be some danger associated with ignoring the possibility completely (which is different from watchful waiting). I guess that is all right statistically speaking, since the USPSTF report tells us that the medium age of death from prostate cancer in the U.S. from 2000 through 2004 was 80 years. For me, living with cancer in my body at any age wasn’t acceptable.

Although it is a mute point in view of my overall challenge to the Task Force’s Class “D” (the strongest) recommendation, I have to take exception to their position on PSA scores and, as a retired university professor, I feel compelled to address some of their research methodology. I also reject the “mortality benefit” argument , but on moral grounds.

The Task Force mentions that the conventional PSA screening cut-point is a “4”. Several medical professionals in the field of prostate cancer have told me that a better predictor of active cancer cells is an increase of .75 between any two tests (PSA Velocity). The velocity issue would seem to call for regular testing. I had hovered above “4” for several years and never had to have a biopsy. When I hit 5.6, I was retested to make sure it wasn’t a false positive. The second time I reached double figures (11.53) which triggered a biopsy, and eventually the search for a treatment. There was a patient receiving his radiation at the same time and location as me who had a PSA of 1.9 (it had jumped from a 1). His biopsy found several very active cancer cells.

When speaking about screening, I would have thought USPSTF would have at least mentioned that Johns Hopkins is developing what is known as EPCA-1 and EPCA-2 as a potential replacement for the current PSA tests. The object is to reduce the number of false-positives which the Task Force feels produces adverse psychological effects.

The report mentions the pain and discomfort associated with a prostate biopsy. That is nothing when compared to the possibility that the random placement of the needles during such a biopsy could miss the cancer. Moreover, when a cancer cell is detected, “needle tracking” has the potential of spreading it. The Diagnostic Center for Disease in Sarasota, Florida, address this subject in a Press Release dated February 19, 2008. They also call for improving pre biopsy diagnostic skills through imaging such as their MRI-S scan as an alternative to a “blind” biopsy.

Since the USPSTF report found “convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death,” I searched the report for what type of treatment they were talking about. It appears that they arrived at their conclusion based on the oldest treatment –– radical prostatectomy. In an e-mail response to my comments on the evidence synthesis, Doctor Lin, the lead author of the report, stated they did look at other treatments, but did not address them because “there{are}no published randomized controlled trials of either.” (Either includes the “PSA velocity” issue I raised.)

So, we are left to wonder if the conclusion of the U.S. Prevention Services Task Force concerning the potential negative outcome of treating prostate cancer would have been the same had the patients received da Vinci prostatectomy? What might have happened had they used radiation therapy via Brachytherapy (radioactive seeds), or external beam radiation such as Intensity Modulation Radiation Therapy (IMRT), some using guidance imagery; or the target specific Proton Therapy? Each of these procedures claims to reduce the harmful side effects associated with surgery. I chose the University of Florida Proton Therapy Institute because its program and people convinced me they had the ability to reduce or eliminate such effects. At least for me, the Institute delivered what I expected.

None of this matters if you are 75 (for now) or older and doctors follow the recommendations of USPSTF. You will never have to make any treatment decisions because you will never be tested for prostate cancer. You will have as much control over prostate cancer’s threat to your life as an unborn child has when he or she is about to be aborted.

Tuesday, June 23, 2009

Obama's Strategy and Health Care

TARP; Stimulus; Auto Bailout; Energy Cap & Trade; Health Care; Financial Regulations......

Since the innauguration, Obama & Co. have been pursuing a Fast Break strategy on the American public and the Republican Party, never stopping their relentless drive to score.  They've never even let the Republicans take the ball out after they've scored, so they've never even had to take the ball away from them since January. That play book has worked fine till now; however, that strategy, and the Democrats, may be running out of steam.

The usual defense against a fast-break offense is a Full Court Press, where the defense is paired up man-to-man with an opposing player. But that takes teamwork, coordination, practice and most of all a coach calling the game strategy.  Unfortunately, the Republicans have no one in the front office, let alone a coach, or even an apparent captain.  It's difficult to get a bunch of 'stars' to agree to play subservient and teamwork roles absent some strong discipline and head banging.

But sometimes teams effective at using a fast break offense can get tired out, or even get over-confident in their own perceived invincibility, and sometimes, stuff just happens.

The Obama Fast-Break offense may be running into the wall, and "stuff" may have just happened to derail them on the path to their most significant objective.  The CBO report on the Democrat's health care plans have been released and they paint a dire cost picture for implementing a plan that would only cover a portion of uninsured people, while a the same time cost over $1Trillion. 

Like the Democrats objective to initiate tremendous economic strangulation under the guise of a highly, and hotly, debated issue of CO2 and the Global Warming that's freezing everybody now, the issue of health care reform has been characterized by the Democrats as a Gordian Knot problem of such proportions that it can only be solved by the Alexander the Great style solution that they've had waiting for over a hundred years - a Public Health Insurance Plan.  In reality, the nation's current problem with health care is not a crisis, and it is solvable without turning our country inside out and destroying our children's future. The problem is really a combination of separate issues that can be, and should be, addressed separately.

There's no denying that Health Care reform is necessary, but not in a way that puts the government in charge of managing it. We've seen how that would work under Medicaid, Medicare, and the V.A., and it’s not acceptable. The Democrats all seem want to address every issue in a “comprehensive” plan, and that usually results in the most inefficient and non-effective approach to solving the real problems. The Health Care problem we have isn’t one simple issue that can be fixed with a new government program. It’s a problem situation that been developing since the mid-60’s that consists of government induced problems via Medicaid and Medicare, outrageous lawsuits, tax issues, insurance regulations, and a corruption of the view of government’s responsibility vs. personal responsibility, and I’m sure a bunch of other issues not named here.

This may be simplistic, but I think that from what I’ve been able to glean from all the articles being written, the following approach would be more effective than what’s generally being proposed by the Democrats (as well as some Republicans):

Address the high costs: Although Obama and the Democrats tend to lump it all together, there are really significantly different issues in play. Medicare and Medicaid cost are running huge expenses and government budget deficits, and because they are underpaying providers, causing higher costs for all other health care system participants who have to pick up the shortfall; Medicaid and Medicare pay providers based on a basis of doing something to a patient – so they do more things; separately, inefficiencies in the way that insurance companies operate on a state by state basis cause higher rates; State mandates cause higher rates; and people who have Medicare or employee health insurance think that their care is “free”, so many tend to abuse their coverage:

-Medical malpractice suits cause a significant amount of doctor "CYA" non-needed tests
-Medicaid and Medicare payments are 20-30% lower than market rates and as a result cause providers to raise the rates for other customers in order to make up that lost differential. Somebody has to pay the freight.
-Medicaid and Medicare expenditures are estimated to be 30% higher than they should be due to claimant fraud that the gov’t doesn’t address
-Providers costs are higher due to Medicaid and Medicare required administrative overhead
-Health Insurance is loaded with a significant number of individual State mandates that drive costs up unnecessarily.
-Health Insurance is set on a state by state basis, preventing real competitive cost savings that could be accomplished by allowing national plans to compete

Address tort reform: Dramatically ratchet down the awards given to plaintiffs and lawyers in both class action and individual malpractice cases. This will directly lower provider's costs, and reduce the addituional costs induced into the system as a result of providers practicing 'CYA' medicine

Restructure the basis of Health Insurance: The concept of insurance should be understood to be about evaluating and paying for offsetting various levels of risk, with the attendant costs associated with the levels of risk you want to insure against, as opposed to paying for all costs associated with Health Care
-Focus on covering against extraordinary procedures, not the basic preventive expenditures that we all should be responsible for paying for ourselves
-Emulate an approach similar to Auto Insurance models in order to get individuals to have more skin in the game and be more judicious about expenditures
-Lifestyle effect risk and should be factored into cost. People who smoke, are obese, use drugs, or demonstrate a risky life styel should pay more based on increased risk factors

Currently, employer provided health care is a tax deductable expense to the corporation and tax free to the individual. It should be kept that way. But in addition, there should be tax deductions for privately paid for health insurance, which should be relatively low cost if the other actions listed above were put into effect. Using a similar basis of risk assessment, Safeway has managed to keep cost of health insurance down, and employee satisfaction up, it’s a good model.

The issue of covering the non-insured now appears to be blown way out of scope, so that instead of being the commonly tossed around figure of 45 million, it’s really only about 15 million, and of that a good number are people who could pay for insurance, but choose not to.

If the Democrats are successful in instituting any form of a Government managed public health plan, it will eventually eliminate any private health insurance options.  And along the way, with it's relentless and mind-numbing drive to lower all costs and standardize all treatments, the Public Plan will manage to eliminate the profit attraction that has been attracting the most talented people, and been the enabling ingredient in creating the worlds best health care.

Let's not accept the Gordian Knot argument.  If we step back and not come at this with the pre-conceived solution of a Government-run Public Health Care Plan, we can unravel the problem and develop a much more effective private approach that will provide us significantly better health care at lower cost 

Quote Of The Day

Governor John Baldacci:

"Without employers, you don't have employees." He adds: "The best social services program is a job.

Said in response to a question about Maine's new tax structure that lowers taxes on the "rich"........

This month the Democratic legislature and Governor John Baldacci broke with Obamanomics and enacted a sweeping tax reform that is almost, but not quite, a flat tax. The new law junks the state's graduated income tax structure with a top rate of 8.5% and replaces it with a simple 6.5% flat rate tax on almost everyone. Those with earnings above $250,000 will pay a surtax rate of 0.35%, for a 6.85% rate. Maine's tax rate will fall to 20th from seventh highest among the states. To offset the lower rates and a larger family deduction, the plan cuts the state budget by some $300 million to $5.8 billion, closes tax loopholes and expands the 5% state sales tax to services that have been exempt, such as ski lift tickets.  WSJ

Monday, June 22, 2009

Obama "Dither's"

The Perfect 'Community Organizer'....

True and principled leaders instinctively understand when events can change the parameters of the game plan, and they act to seize the opportunity to demonstrate their principles.  

If you study Saul Alinsky's prescriptions for Community Organizers, it's all about the tactics of incremental advancement while not exposing your ultimate objective.  President Obama is running true to type.

It's been six day since my last post, and President Obama is still basically voting "Present", as he traditionally did in the the State and Federal Senate.  Never exposing himself, never standing on principle if there was any risk.  

The leader of the Free World is expected to be just that - the Leader.  Asserting the principles of democracy; standing with those people who are attempting to throw off the yoke of oppression, wherever they may be, despite any other particular political agenda that might be in play.

The Clinton team shamelessly scourged themselves for not being on deck for 91, so that they could have had a chance to be able to participate in a truly historical and event instead of Bush.  While people like Neda Soltan are dying attempting to overthrow a truly despotic regime, Obama is standing by, watching to see how the wind blows in Iran, so that he can decide what he should do.

He's the perfect Community Organizer.....unfortunately for us, and the world.

Tuesday, June 16, 2009

Obama Still Voting "Present"

Is that all he can say?

He doesn't want to "meddle" in Iran's politics?  What does he think his actions regarding their nuclear bomb aspirations are?

"What I would say to those people who put so much hope and energy and optimism into the political process, I would say to them that the world is watching and inspired by their participation, regardless of what the ultimate outcome of the election was," Obama said. "And they should know that the world is watching."
This is the great orator; inspiring people?  This is the role model of a great statesman, supporting and exhorting the Iranian people to throw off repression and dictatorship?  Where is the encouragement to the Iranaian people trying to rejoin the world?  Where is the equivalent to "Tear down this wall Mr. Gorbachev" that we expect from an American President?

Does he really think that voting "present" so that he doesn't upset the totalitarian regime that is hell-bent on developing nuclear weaponry will gain him any leverage in negotiating with them if they remain in power?  Apparently, his fall back position is ultimately to "defer" to the Israeli's  taking out Iran's nuclear facilities in their desperation to eliminate the existential threat to their country and the world.

His past actions are clearly defining his ongoing Presidential actions.  He is apparently incapable of stating clear and definable principles and action, unless it's related to his advancement.  With him, everything is a hedge, so that whichever way the situation turns, he  can't be criticized.

( "No Risk" Obama)

Friday, June 12, 2009

Sotomayor, Perfect Afirmative Action Baby, And Justice

Latina 'patina'....?

Like many, I've been interested in learning about Sonya Sotomayor, the person President Obama nominated as the replacement for Justice Souter. Given her relative youth and the longevity evidenced by her mother, she may assume a position enabling her to wield significant impact on the lives of all Americans, and potentially even citizens of other countries as well, for decades to come.

Of all the members of the body politic in the United States, the Justices of the Supreme Court Of The United States are arguably the most significant compared to the President, given their life appointment and the relative finality of their pronouncements regarding the fundamental laws and actions of our society.  In our tricameral governmental structure of Executive-Legislative-Judicial branches, SCOTUS can be seen as trumping all others. As a result, it would appear reasonable that nominees should be subject to comprehensive evaluation, and be expected to meet the highest standards of judicial ethics, jurisprudence and legal scholarship that can be established.

Focused on learning about her, I've now read, watched, and listened to well over a hundred commentaries regarding Judge Sotomayor's nomination.  The Administration initially focused on her "compelling life story", and then, because of her bias-laden comment regarding the superiority of a "wise-Latina woman's" decision capabilities over a white male because of the 'richness of her experience', they have now focused on her varied years of law experience, which should be the main aspect of her qualification.

Having been born and raised in the Bronx, attending parochial schools there, and being only a few years older than Judge Sotomayor, I was intrigued by the comments regarding her 'compelling life story'.  It sounded as if it would be interesting.  However, it wasn't.  In reality, her mother has the "compelling story"; that of a humble  immigrant woman, widowed young, who then manages to successfully raise two children and facilitate their lives as successful professionals in the law and medicine. She is the role model; working two jobs; shepherding her children through Catholic schools and maintaining a strong focus on family, education and accomplishment.  Bravo for Mrs. Sotomayor!

Bronxdale Apartments - Today

As far as compelling life stories, many of the people who I knew while  growing up in the Bronx and Manhattan, had  life stories much more compelling than Sonya Sotomayor's.  Despite the picture that the media has created, the projects in the Bronx during that time period were relatively benign environments, and in some comparisons, better than some other Bronx environments.  There were significantly more mean places to live and grow up in than in the projects, and many of my own classmates in Catholic school had to deal with far worse housing and family situations than she did. Despite that, many also became very successful and prestigious adults and parents - and without any Affirmative Action assistance.

One of the first items that caught my attention in the stories about her was her self description as a "Latina".  In my life experience, that was not phrase that was used.  More to the point, I would guess that she was fully assimilated as just a New Yorker, and didn't even present herself as a minority. If people did mention their cultural background, they usually took significant pride in their specific heritage and culture, identifying themselves as Puerto Rican, Cuban, Dominican, Haitian, Columbian, etc, not "Latina's", or "Latino's".  That was a descriptive that didn't come into play until the early 70's, when people began to understand how to game the Affirmative Action system.  That was right about the time when Sonya Sotomayor was entering Princeton.  She appears to have quickly learned the advantages of being 'disadvantaged', and has used the patina of a disadvantaged "Latina" proudly and effectively to her own advantage, despite it's apparent lack of applicability in her own case.  In an interview on TV the other day, her brother commented that she finally learned to dance Salsa for her 50th birthday party; not exactly the "Latina" she presents herself as.

I've searched for evidence of her scholarship, but unfortunately have only been able to discover comments to the opposite. It's probably fair to discount her decisions that have been overturned by the Supreme Court, as other nominees have also had their decisions overturned. But, her pending case in review regarding the white firemen in Connecticut does have bearing, due to her summary dismissal of their reverse discrimination law suit.  Since she has acknowledged her bias of perceived superiority in decision making against white males, multiple times over a period of years, can her future decisions be seen as un-biased, or will they alway now be suspect?

She may well be a competent and experienced jurist, and she may well be excellent as an Appellate judge, with the possibility of review by the Supreme Court, but is she the model of a Justice of the Supreme Court?  Is she the best person that Obama can nominate  to fill that responsibility, or is she just the best Affirmative Action candidate who provides cover for Obama's election paybacks?

 I found it disturbing to listen to the woman, Angela Langereau(?) who was interviewed on NPR.  She had attended Cardinal Spellman H.S. with Sonya, and had the highest grades in the class.  Normally, she should have been the Class Valedictorian, but the honor was given to Sonia.  One can only assume why that happened, but today, you can still hear the hurt in Angela's voice over the actual discrimination that she experienced.

One of the major aspects of Barack Obama's campaign was that he supposedly represented the possibility of post-racial politics in this country.  Like many of the other turnabouts from his campaign to his Presidency, the post-racial character aspect appears to be absent.  We don't need a Justice who burnishes her patina as a "Latina".  We need an exemplary jurist, and a "Justice" who's blindfold is still covering both of her eyes.

President Obama, you can do better.  Yes, you can.

Reading list....

Sotomayor Related Commentaries
Thomas Sowell: 'Out of Context': Part III
 Sotomayor’s own hiring practices reinforce the concerns of counsel for the plaintiff firefighters in Ricci v. DeStefano 

Thursday, June 4, 2009

G.M. & Chrysler - Déjà Vu

Sound Familiar?

This time the rational is that they'll now be "Green" vehicles....."affordable" and "desirable" now outmoded concepts.

Hitler Among the Cars, 1939
Adolf Hitler tours the 1939 International Auto Exhibition in Berlin. Three years before, at another Berlin auto show, Hitler announced that Porsche would design the "People's Car," or Volkswagen, an affordable, practical vehicle for the working German family

There was a reason that they were named the National Socialists..........

(see full story of German photographer Hugo Jaeger's amazing photographic chronicle of Adolf Hitler)

President Obama's Speech In Cairo

A New Beginning With Muslims

By Barack Obama
I am honored to be in the timeless city of Cairo, and to be hosted by two remarkable institutions. For over a thousand years, Al-Azhar has stood as a beacon of Islamic learning, and for over a century, Cairo University has been a source of Egypt's advancement. Together, you represent the harmony between tradition and progress. I am grateful for your hospitality, and the hospitality of the people of Egypt. I am also proud to carry with me the goodwill of the American people, and a greeting of peace from Muslim communities in my country: assalaamu alaykum.
We meet at a time of tension between the United States and Muslims around the world - tension rooted in historical forces that go beyond any current policy debate. The relationship between Islam and the West includes centuries of co-existence and cooperation, but also conflict and religious wars. More recently, tension has been fed by colonialism that denied rights and opportunities to many Muslims, and a Cold War in which Muslim-majority countries were too often treated as proxies without regard to their own aspirations. Moreover, the sweeping change brought by modernity and globalization led many Muslims to view the West as hostile to the traditions of Islam.
Violent extremists have exploited these tensions in a small but potent minority of Muslims. The attacks of September 11th, 2001 and the continued efforts of these extremists to engage in violence against civilians has led some in my country to view Islam as inevitably hostile not only to America and Western countries, but also to human rights. This has bred more fear and mistrust.
So long as our relationship is defined by our differences, we will empower those who sow hatred rather than peace, and who promote conflict rather than the cooperation that can help all of our people achieve justice and prosperity. This cycle of suspicion and discord must end.
I have come here to seek a new beginning between the United States and Muslims around the world; one based upon mutual interest and mutual respect; and one based upon the truth that America and Islam are not exclusive, and need not be in competition. Instead, they overlap, and share common principles - principles of justice and progress; tolerance and the dignity of all human beings.
I do so recognizing that change cannot happen overnight. No single speech can eradicate years of mistrust, nor can I answer in the time that I have all the complex questions that brought us to this point. But I am convinced that in order to move forward, we must say openly the things we hold in our hearts, and that too often are said only behind closed doors. There must be a sustained effort to listen to each other; to learn from each other; to respect one another; and to seek common ground. As the Holy Koran tells us, "Be conscious of God and speak always the truth." That is what I will try to do - to speak the truth as best I can, humbled by the task before us, and firm in my belief that the interests we share as human beings are far more powerful than the forces that drive us apart.
Part of this conviction is rooted in my own experience. I am a Christian, but my father came from a Kenyan family that includes generations of Muslims. As a boy, I spent several years in Indonesia and heard the call of the azaan at the break of dawn and the fall of dusk. As a young man, I worked in Chicago communities where many found dignity and peace in their Muslim faith.
As a student of history, I also know civilization's debt to Islam. It was Islam - at places like Al-Azhar University - that carried the light of learning through so many centuries, paving the way for Europe's Renaissance and Enlightenment. It was innovation in Muslim communities that developed the order of algebra; our magnetic compass and tools of navigation; our mastery of pens and printing; our understanding of how disease spreads and how it can be healed. Islamic culture has given us majestic arches and soaring spires; timeless poetry and cherished music; elegant calligraphy and places of peaceful contemplation. And throughout history, Islam has demonstrated through words and deeds the possibilities of religious tolerance and racial equality.
I know, too, that Islam has always been a part of America's story. The first nation to recognize my country was Morocco. In signing the Treaty of Tripoli in 1796, our second President John Adams wrote, "The United States has in itself no character of enmity against the laws, religion or tranquility of Muslims." And since our founding, American Muslims have enriched the United States. They have fought in our wars, served in government, stood for civil rights, started businesses, taught at our Universities, excelled in our sports arenas, won Nobel Prizes, built our tallest building, and lit the Olympic Torch. And when the first Muslim-American was recently elected to Congress, he took the oath to defend our Constitution using the same Holy Koran that one of our Founding Fathers - Thomas Jefferson - kept in his personal library.
So I have known Islam on three continents before coming to the region where it was first revealed. That experience guides my conviction that partnership between America and Islam must be based on what Islam is, not what it isn't. And I consider it part of my responsibility as President of the United States to fight against negative stereotypes of Islam wherever they appear.
But that same principle must apply to Muslim perceptions of America. Just as Muslims do not fit a crude stereotype, America is not the crude stereotype of a self-interested empire. The United States has been one of the greatest sources of progress that the world has ever known. We were born out of revolution against an empire. We were founded upon the ideal that all are created equal, and we have shed blood and struggled for centuries to give meaning to those words - within our borders, and around the world. We are shaped by every culture, drawn from every end of the Earth, and dedicated to a simple concept: E pluribus unum: "Out of many, one."
Much has been made of the fact that an African-American with the name Barack Hussein Obama could be elected President. But my personal story is not so unique. The dream of opportunity for all people has not come true for everyone in America, but its promise exists for all who come to our shores - that includes nearly seven million American Muslims in our country today who enjoy incomes and education that are higher than average.
Moreover, freedom in America is indivisible from the freedom to practice one's religion. That is why there is a mosque in every state of our union, and over 1,200 mosques within our borders. That is why the U.S. government has gone to court to protect the right of women and girls to wear the hijab, and to punish those who would deny it.
So let there be no doubt: Islam is a part of America. And I believe that America holds within her the truth that regardless of race, religion, or station in life, all of us share common aspirations - to live in peace and security; to get an education and to work with dignity; to love our families, our communities, and our God. These things we share. This is the hope of all humanity.
Of course, recognizing our common humanity is only the beginning of our task. Words alone cannot meet the needs of our people. These needs will be met only if we act boldly in the years ahead; and if we understand that the challenges we face are shared, and our failure to meet them will hurt us all.
For we have learned from recent experience that when a financial system weakens in one country, prosperity is hurt everywhere. When a new flu infects one human being, all are at risk. When one nation pursues a nuclear weapon, the risk of nuclear attack rises for all nations. When violent extremists operate in one stretch of mountains, people are endangered across an ocean. And when innocents in Bosnia and Darfur are slaughtered, that is a stain on our collective conscience. That is what it means to share this world in the 21st century. That is the responsibility we have to one another as human beings.
This is a difficult responsibility to embrace. For human history has often been a record of nations and tribes subjugating one another to serve their own interests. Yet in this new age, such attitudes are self-defeating. Given our interdependence, any world order that elevates one nation or group of people over another will inevitably fail. So whatever we think of the past, we must not be prisoners of it. Our problems must be dealt with through partnership; progress must be shared.
That does not mean we should ignore sources of tension. Indeed, it suggests the opposite: we must face these tensions squarely. And so in that spirit, let me speak as clearly and plainly as I can about some specific issues that I believe we must finally confront together.
The first issue that we have to confront is violent extremism in all of its forms.
In Ankara, I made clear that America is not - and never will be - at war with Islam. We will, however, relentlessly confront violent extremists who pose a grave threat to our security. Because we reject the same thing that people of all faiths reject: the killing of innocent men, women, and children. And it is my first duty as President to protect the American people.
The situation in Afghanistan demonstrates America's goals, and our need to work together. Over seven years ago, the United States pursued al Qaeda and the Taliban with broad international support. We did not go by choice, we went because of necessity. I am aware that some question or justify the events of 9/11. But let us be clear: al Qaeda killed nearly 3,000 people on that day. The victims were innocent men, women and children from America and many other nations who had done nothing to harm anybody. And yet Al Qaeda chose to ruthlessly murder these people, claimed credit for the attack, and even now states their determination to kill on a massive scale. They have affiliates in many countries and are trying to expand their reach. These are not opinions to be debated; these are facts to be dealt with.
Make no mistake: we do not want to keep our troops in Afghanistan. We seek no military bases there. It is agonizing for America to lose our young men and women. It is costly and politically difficult to continue this conflict. We would gladly bring every single one of our troops home if we could be confident that there were not violent extremists in Afghanistan and Pakistan determined to kill as many Americans as they possibly can. But that is not yet the case.
That's why we're partnering with a coalition of forty-six countries. And despite the costs involved, America's commitment will not weaken. Indeed, none of us should tolerate these extremists. They have killed in many countries. They have killed people of different faiths - more than any other, they have killed Muslims. Their actions are irreconcilable with the rights of human beings, the progress of nations, and with Islam. The Holy Koran teaches that whoever kills an innocent, it is as if he has killed all mankind; and whoever saves a person, it is as if he has saved all mankind. The enduring faith of over a billion people is so much bigger than the narrow hatred of a few. Islam is not part of the problem in combating violent extremism - it is an important part of promoting peace.
We also know that military power alone is not going to solve the problems in Afghanistan and Pakistan. That is why we plan to invest $1.5 billion each year over the next five years to partner with Pakistanis to build schools and hospitals, roads and businesses, and hundreds of millions to help those who have been displaced. And that is why we are providing more than $2.8 billion to help Afghans develop their economy and deliver services that people depend upon.
Let me also address the issue of Iraq. Unlike Afghanistan, Iraq was a war of choice that provoked strong differences in my country and around the world. Although I believe that the Iraqi people are ultimately better off without the tyranny of Saddam Hussein, I also believe that events in Iraq have reminded America of the need to use diplomacy and build international consensus to resolve our problems whenever possible. Indeed, we can recall the words of Thomas Jefferson, who said: "I hope that our wisdom will grow with our power, and teach us that the less we use our power the greater it will be."
Today, America has a dual responsibility: to help Iraq forge a better future - and to leave Iraq to Iraqis. I have made it clear to the Iraqi people that we pursue no bases, and no claim on their territory or resources. Iraq's sovereignty is its own. That is why I ordered the removal of our combat brigades by next August. That is why we will honor our agreement with Iraq's democratically-elected government to remove combat troops from Iraqi cities by July, and to remove all our troops from Iraq by 2012. We will help Iraq train its Security Forces and develop its economy. But we will support a secure and united Iraq as a partner, and never as a patron.
And finally, just as America can never tolerate violence by extremists, we must never alter our principles. 9/11 was an enormous trauma to our country. The fear and anger that it provoked was understandable, but in some cases, it led us to act contrary to our ideals. We are taking concrete actions to change course. I have unequivocally prohibited the use of torture by the United States, and I have ordered the prison at Guantanamo Bay closed by early next year.
So America will defend itself respectful of the sovereignty of nations and the rule of law. And we will do so in partnership with Muslim communities which are also threatened. The sooner the extremists are isolated and unwelcome in Muslim communities, the sooner we will all be safer.
The second major source of tension that we need to discuss is the situation between Israelis, Palestinians and the Arab world.
America's strong bonds with Israel are well known. This bond is unbreakable. It is based upon cultural and historical ties, and the recognition that the aspiration for a Jewish homeland is rooted in a tragic history that cannot be denied.
Around the world, the Jewish people were persecuted for centuries, and anti-Semitism in Europe culminated in an unprecedented Holocaust. Tomorrow, I will visit Buchenwald, which was part of a network of camps where Jews were enslaved, tortured, shot and gassed to death by the Third Reich. Six million Jews were killed - more than the entire Jewish population of Israel today. Denying that fact is baseless, ignorant, and hateful. Threatening Israel with destruction - or repeating vile stereotypes about Jews - is deeply wrong, and only serves to evoke in the minds of Israelis this most painful of memories while preventing the peace that the people of this region deserve.
On the other hand, it is also undeniable that the Palestinian people - Muslims and Christians - have suffered in pursuit of a homeland. For more than sixty years they have endured the pain of dislocation. Many wait in refugee camps in the West Bank, Gaza, and neighboring lands for a life of peace and security that they have never been able to lead. They endure the daily humiliations - large and small - that come with occupation. So let there be no doubt: the situation for the Palestinian people is intolerable. America will not turn our backs on the legitimate Palestinian aspiration for dignity, opportunity, and a state of their own.
For decades, there has been a stalemate: two peoples with legitimate aspirations, each with a painful history that makes compromise elusive. It is easy to point fingers - for Palestinians to point to the displacement brought by Israel's founding, and for Israelis to point to the constant hostility and attacks throughout its history from within its borders as well as beyond. But if we see this conflict only from one side or the other, then we will be blind to the truth: the only resolution is for the aspirations of both sides to be met through two states, where Israelis and Palestinians each live in peace and security.
That is in Israel's interest, Palestine's interest, America's interest, and the world's interest. That is why I intend to personally pursue this outcome with all the patience that the task requires. The obligations that the parties have agreed to under the Road Map are clear. For peace to come, it is time for them - and all of us - to live up to our responsibilities.
Palestinians must abandon violence. Resistance through violence and killing is wrong and does not succeed. For centuries, black people in America suffered the lash of the whip as slaves and the humiliation of segregation. But it was not violence that won full and equal rights. It was a peaceful and determined insistence upon the ideals at the center of America's founding. This same story can be told by people from South Africa to South Asia; from Eastern Europe to Indonesia. It's a story with a simple truth: that violence is a dead end. It is a sign of neither courage nor power to shoot rockets at sleeping children, or to blow up old women on a bus. That is not how moral authority is claimed; that is how it is surrendered.
Now is the time for Palestinians to focus on what they can build. The Palestinian Authority must develop its capacity to govern, with institutions that serve the needs of its people. Hamas does have support among some Palestinians, but they also have responsibilities. To play a role in fulfilling Palestinian aspirations, and to unify the Palestinian people, Hamas must put an end to violence, recognize past agreements, and recognize Israel's right to exist.
At the same time, Israelis must acknowledge that just as Israel's right to exist cannot be denied, neither can Palestine's. The United States does not accept the legitimacy of continued Israeli settlements. This construction violates previous agreements and undermines efforts to achieve peace. It is time for these settlements to stop.
Israel must also live up to its obligations to ensure that Palestinians can live, and work, and develop their society. And just as it devastates Palestinian families, the continuing humanitarian crisis in Gaza does not serve Israel's security; neither does the continuing lack of opportunity in the West Bank. Progress in the daily lives of the Palestinian people must be part of a road to peace, and Israel must take concrete steps to enable such progress.
Finally, the Arab States must recognize that the Arab Peace Initiative was an important beginning, but not the end of their responsibilities. The Arab-Israeli conflict should no longer be used to distract the people of Arab nations from other problems. Instead, it must be a cause for action to help the Palestinian people develop the institutions that will sustain their state; to recognize Israel's legitimacy; and to choose progress over a self-defeating focus on the past.
America will align our policies with those who pursue peace, and say in public what we say in private to Israelis and Palestinians and Arabs. We cannot impose peace. But privately, many Muslims recognize that Israel will not go away. Likewise, many Israelis recognize the need for a Palestinian state. It is time for us to act on what everyone knows to be true.
Too many tears have flowed. Too much blood has been shed. All of us have a responsibility to work for the day when the mothers of Israelis and Palestinians can see their children grow up without fear; when the Holy Land of three great faiths is the place of peace that God intended it to be; when Jerusalem is a secure and lasting home for Jews and Christians and Muslims, and a place for all of the children of Abraham to mingle peacefully together as in the story of Isra, when Moses, Jesus, and Mohammed (peace be upon them) joined in prayer.
The third source of tension is our shared interest in the rights and responsibilities of nations on nuclear weapons.
This issue has been a source of tension between the United States and the Islamic Republic of Iran. For many years, Iran has defined itself in part by its opposition to my country, and there is indeed a tumultuous history between us. In the middle of the Cold War, the United States played a role in the overthrow of a democratically-elected Iranian government. Since the Islamic Revolution, Iran has played a role in acts of hostage-taking and violence against U.S. troops and civilians. This history is well known. Rather than remain trapped in the past, I have made it clear to Iran's leaders and people that my country is prepared to move forward. The question, now, is not what Iran is against, but rather what future it wants to build.
It will be hard to overcome decades of mistrust, but we will proceed with courage, rectitude and resolve. There will be many issues to discuss between our two countries, and we are willing to move forward without preconditions on the basis of mutual respect. But it is clear to all concerned that when it comes to nuclear weapons, we have reached a decisive point. This is not simply about America's interests. It is about preventing a nuclear arms race in the Middle East that could lead this region and the world down a hugely dangerous path.
I understand those who protest that some countries have weapons that others do not. No single nation should pick and choose which nations hold nuclear weapons. That is why I strongly reaffirmed America's commitment to seek a world in which no nations hold nuclear weapons. And any nation - including Iran - should have the right to access peaceful nuclear power if it complies with its responsibilities under the nuclear Non-Proliferation Treaty. That commitment is at the core of the Treaty, and it must be kept for all who fully abide by it. And I am hopeful that all countries in the region can share in this goal.
The fourth issue that I will address is democracy.
I know there has been controversy about the promotion of democracy in recent years, and much of this controversy is connected to the war in Iraq. So let me be clear: no system of government can or should be imposed upon one nation by any other.
That does not lessen my commitment, however, to governments that reflect the will of the people. Each nation gives life to this principle in its own way, grounded in the traditions of its own people. America does not presume to know what is best for everyone, just as we would not presume to pick the outcome of a peaceful election. But I do have an unyielding belief that all people yearn for certain things: the ability to speak your mind and have a say in how you are governed; confidence in the rule of law and the equal administration of justice; government that is transparent and doesn't steal from the people; the freedom to live as you choose. Those are not just American ideas, they are human rights, and that is why we will support them everywhere.
There is no straight line to realize this promise. But this much is clear: governments that protect these rights are ultimately more stable, successful and secure. Suppressing ideas never succeeds in making them go away. America respects the right of all peaceful and law-abiding voices to be heard around the world, even if we disagree with them. And we will welcome all elected, peaceful governments - provided they govern with respect for all their people.
This last point is important because there are some who advocate for democracy only when they are out of power; once in power, they are ruthless in suppressing the rights of others. No matter where it takes hold, government of the people and by the people sets a single standard for all who hold power: you must maintain your power through consent, not coercion; you must respect the rights of minorities, and participate with a spirit of tolerance and compromise; you must place the interests of your people and the legitimate workings of the political process above your party. Without these ingredients, elections alone do not make true democracy.
The fifth issue that we must address together is religious freedom.
Islam has a proud tradition of tolerance. We see it in the history of Andalusia and Cordoba during the Inquisition. I saw it firsthand as a child in Indonesia, where devout Christians worshiped freely in an overwhelmingly Muslim country. That is the spirit we need today. People in every country should be free to choose and live their faith based upon the persuasion of the mind, heart, and soul. This tolerance is essential for religion to thrive, but it is being challenged in many different ways.
Among some Muslims, there is a disturbing tendency to measure one's own faith by the rejection of another's. The richness of religious diversity must be upheld - whether it is for Maronites in Lebanon or the Copts in Egypt. And fault lines must be closed among Muslims as well, as the divisions between Sunni and Shia have led to tragic violence, particularly in Iraq.
Freedom of religion is central to the ability of peoples to live together. We must always examine the ways in which we protect it. For instance, in the United States, rules on charitable giving have made it harder for Muslims to fulfill their religious obligation. That is why I am committed to working with American Muslims to ensure that they can fulfill zakat.
Likewise, it is important for Western countries to avoid impeding Muslim citizens from practicing religion as they see fit - for instance, by dictating what clothes a Muslim woman should wear. We cannot disguise hostility towards any religion behind the pretence of liberalism.
Indeed, faith should bring us together. That is why we are forging service projects in America that bring together Christians, Muslims, and Jews. That is why we welcome efforts like Saudi Arabian King Abdullah's Interfaith dialogue and Turkey's leadership in the Alliance of Civilizations. Around the world, we can turn dialogue into Interfaith service, so bridges between peoples lead to action - whether it is combating malaria in Africa, or providing relief after a natural disaster.
The sixth issue that I want to address is women's rights.
I know there is debate about this issue. I reject the view of some in the West that a woman who chooses to cover her hair is somehow less equal, but I do believe that a woman who is denied an education is denied equality. And it is no coincidence that countries where women are well-educated are far more likely to be prosperous.
Now let me be clear: issues of women's equality are by no means simply an issue for Islam. In Turkey, Pakistan, Bangladesh and Indonesia, we have seen Muslim-majority countries elect a woman to lead. Meanwhile, the struggle for women's equality continues in many aspects of American life, and in countries around the world.
Our daughters can contribute just as much to society as our sons, and our common prosperity will be advanced by allowing all humanity - men and women - to reach their full potential. I do not believe that women must make the same choices as men in order to be equal, and I respect those women who choose to live their lives in traditional roles. But it should be their choice. That is why the United States will partner with any Muslim-majority country to support expanded literacy for girls, and to help young women pursue employment through micro-financing that helps people live their dreams.
Finally, I want to discuss economic development and opportunity.
I know that for many, the face of globalization is contradictory. The Internet and television can bring knowledge and information, but also offensive sexuality and mindless violence. Trade can bring new wealth and opportunities, but also huge disruptions and changing communities. In all nations - including my own - this change can bring fear. Fear that because of modernity we will lose of control over our economic choices, our politics, and most importantly our identities - those things we most cherish about our communities, our families, our traditions, and our faith.
But I also know that human progress cannot be denied. There need not be contradiction between development and tradition. Countries like Japan and South Korea grew their economies while maintaining distinct cultures. The same is true for the astonishing progress within Muslim-majority countries from Kuala Lumpur to Dubai. In ancient times and in our times, Muslim communities have been at the forefront of innovation and education.
This is important because no development strategy can be based only upon what comes out of the ground, nor can it be sustained while young people are out of work. Many Gulf States have enjoyed great wealth as a consequence of oil, and some are beginning to focus it on broader development. But all of us must recognize that education and innovation will be the currency of the 21st century, and in too many Muslim communities there remains underinvestment in these areas. I am emphasizing such investments within my country. And while America in the past has focused on oil and gas in this part of the world, we now seek a broader engagement.
On education, we will expand exchange programs, and increase scholarships, like the one that brought my father to America, while encouraging more Americans to study in Muslim communities. And we will match promising Muslim students with internships in America; invest in on-line learning for teachers and children around the world; and create a new online network, so a teenager in Kansas can communicate instantly with a teenager in Cairo.
On economic development, we will create a new corps of business volunteers to partner with counterparts in Muslim-majority countries. And I will host a Summit on Entrepreneurship this year to identify how we can deepen ties between business leaders, foundations and social entrepreneurs in the United States and Muslim communities around the world.
On science and technology, we will launch a new fund to support technological development in Muslim-majority countries, and to help transfer ideas to the marketplace so they can create jobs. We will open centers of scientific excellence in Africa, the Middle East and Southeast Asia, and appoint new Science Envoys to collaborate on programs that develop new sources of energy, create green jobs, digitize records, clean water, and grow new crops. And today I am announcing a new global effort with the Organization of the Islamic Conference to eradicate polio. And we will also expand partnerships with Muslim communities to promote child and maternal health.
All these things must be done in partnership. Americans are ready to join with citizens and governments; community organizations, religious leaders, and businesses in Muslim communities around the world to help our people pursue a better life.
The issues that I have described will not be easy to address. But we have a responsibility to join together on behalf of the world we seek - a world where extremists no longer threaten our people, and American troops have come home; a world where Israelis and Palestinians are each secure in a state of their own, and nuclear energy is used for peaceful purposes; a world where governments serve their citizens, and the rights of all God's children are respected. Those are mutual interests. That is the world we seek. But we can only achieve it together.
I know there are many - Muslim and non-Muslim - who question whether we can forge this new beginning. Some are eager to stoke the flames of division, and to stand in the way of progress. Some suggest that it isn't worth the effort - that we are fated to disagree, and civilizations are doomed to clash. Many more are simply skeptical that real change can occur. There is so much fear, so much mistrust. But if we choose to be bound by the past, we will never move forward. And I want to particularly say this to young people of every faith, in every country - you, more than anyone, have the ability to remake this world.
All of us share this world for but a brief moment in time. The question is whether we spend that time focused on what pushes us apart, or whether we commit ourselves to an effort - a sustained effort - to find common ground, to focus on the future we seek for our children, and to respect the dignity of all human beings.
It is easier to start wars than to end them. It is easier to blame others than to look inward; to see what is different about someone than to find the things we share. But we should choose the right path, not just the easy path. There is also one rule that lies at the heart of every religion - that we do unto others as we would have them do unto us. This truth transcends nations and peoples - a belief that isn't new; that isn't black or white or brown; that isn't Christian, or Muslim or Jew. It's a belief that pulsed in the cradle of civilization, and that still beats in the heart of billions. It's a faith in other people, and it's what brought me here today.
We have the power to make the world we seek, but only if we have the courage to make a new beginning, keeping in mind what has been written.
The Holy Koran tells us, "O mankind! We have created you male and a female; and we have made you into nations and tribes so that you may know one another."
The Talmud tells us: "The whole of the Torah is for the purpose of promoting peace."
The Holy Bible tells us, "Blessed are the peacemakers, for they shall be called sons of God."
The people of the world can live together in peace. We know that is God's vision. Now, that must be our work here on Earth. Thank you. And may God's peace be upon you.

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