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Are Mammograms Useless in Screening for Breast Cancer?

This morning the New York Times trumpeted the  news that “mammograms fail to cut risk of death and causes overdiagnosis”, apparently the result of a major Canadian study involving 90,000 women over 25 years (to read the article, click here). For women like me who’ve been undergoing mammograms ever since we turned 40, this is nothing short of astonishing. Now we find we’ve been taken for a ride all these years, really?Not quite. It is a little more complicated than that.

First, let me be honest about this and tell you on which side I fall. I’ve had my doubts about the usefulness of mammograms for a long time, ever since I had a surgical intervention back in the 1980s, with the removal of an 8cm tumor from a breast – a tumor that resulted benign and the whole operation could easily have been skipped with a simple biopsy (but in those days in Italy, and with the conservative MD I had, a biopsy was not considered as reliable as total removal). What really annoyed me at the time was the obvious fact that the mammogram hadn’t revealed anything more than what was already known via a simple palpation.

So why do it at all? Anyone who’s gone through a mammography knows how unpleasant it is, a machine that squeezes you flat in order to supposedly “photograph” better what’s under the skin. Machines have improved since early days and are no longer so invasively painful, but it is still a deeply unpleasant experience.

Now my doubts are confirmed. It is an unnecessary experience. What the Canadian study shows without a shadow of a doubt are two things:

1. early detection of “lumps” do not change ultimate results in terms of number of lives saved because many of those super tiny lumps that only a mammogram shows actually disappear of themselves or never evolve to a cancerous stage; hence the overdiagnosis and “false positives”.

2. what has changed are recent improvements in medical cures (e.g. drugs like tamoxifen) that have improved the survival rate for women (and men) with breast cancer.

So should we abandon mammograms? As I said earlier, not quite. They are still a useful adjunct after a normal palpation exam by your doctor has shown a problematic lump. But don’t expect wonders from it. Just a confirmation of your doctor’s exam. 

I honestly believe that mammography, once touted as a fantastic means to “catch” cancer at an early stage, thus improving chances of survival, has done its time and is ready to be shelved in historic medical libraries. Even if it never really did anything more than a simple palpation could do, it still served a historic role in drawing women’s attention to the problem of breast cancer. 

Your views?

English: Mammography in process: Shown is a dr...Mammography in process: Shown is a drawing of a female having a mammogram. A mammogram is a picture of the breast that is made by using low-dose x-rays. (Photo credit: Wikipedia)

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MIGRANTS FROM AFRICA: THE BATTLE FOR FRANCE!

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You can check out this post on my original site: click HERE
Of the 20,000 illegal immigrants that have invaded Italy since January, most are Tunisians and most want to go to France: they speak French, they have family there and they are (mostly) young men who want to work. In Italy, for them there’s no work (the recession is still on-going). And of course they don’t feel at home, they don’t speak Italian.

But France won’t have it. Unbelievable! What has happened to the country of “freedom” and “equality”? Where has the French cultural heritage and revolutionary motto of “liberté, égalité, fraternité” gone to? Not to mention the deep-seated cultural linkage with Tunisia, a one-time colony of France that has had its values shaped by France’s liberal heritage…

True, the French were slow to respond to Tunisia’s “Jasmine Revolution“. Does anyone still call it that? Since popular uprisings, starting from Tunisia and spreading to Egypt, have eventually overwhelmed the whole of the Middle East, the tendency now is to talk of the “Arab Spring”.

Well, the calendar says it’s springtime but the French will have none of it. They are determined to stay in winter and they’ve tightly shut their doors against what Italian Prime Minister Berlusconi likes to call the “immigrant tsunami”. They’ve already sent back to Italy some 1700 illegal immigrants that had managed to cross into France since the beginning of the year, presumably from the Ventimiglia bordertown. At this point, I’m pretty sure that if the immigrants are smart,  they’re flooding into France from other places because French border police patrols have turned the whole area between Nice and Ventimiglia into a well-guarded military zone.

And now other European countries are following France in this bunker mentality: Germany and Belgium! Expect more countries soon as everyone takes the stance that the illegal immigrant emergency is Italy’s problem, and Italy’s alone…Actually not quite. Today Germany declared that they are more willing than the Italians – “ten times more willing!” – to receive immigrants and they have taken in…100 Africans who had taken refuge in Malta. One hundred as compared to the 20,000 (more likely 22,000) now milling about in Italy? And they pretend they are “more willing”? I can’t believe this: what is Europe and the European spirit of cooperation coming to? Actually, it is clear that there never was any, and Ms. Merkel who is one tough lady couldn’t care less about Europe (as she’s amply shown when Greece got into deficit). All she thinks of is Germany first – without realizing that by weakening Europe she is in the end weakening Germany too. But I’m getting carried away: that would be the subject matter of another post…

As of now, the fact is that Fortress Europe has been breached on its southern border. 20,000 immigrants in 3 months is clearly more than any single European country can handle, even a big one like Italy.  But it seems that the rest of Europe prefers to jettison Italy rather than try to help it solve the problem. Do you think I’m exaggerating? I’m not. The Italians have justifiably complained now for months that they are alone in bearing the brunt of the invasion. And so they are. Europe won’t hear about it and in Brussels the European Commission has gone mum on the subject. The Commission has yet to develop a common policy to address the issue of immigration, and that’s a policy that should have been developed BEFORE we ever got into the mess we are now in.

What can Italy do? Not much. So far, it’s done everything it can to wiggle out of this uncomfortable situation. First it has had to solve its own internal problems (I’ve blogged about this before, see here). Nobody in Italy wanted refugee holding camps near their own hometown, and some still don’t. Such as Alemanno, the Mayor of Rome who claims Rome has had its “fill of problems” and can’t take anymore – not a very Christian position, and certainly not in line with the Catholic Church.

Second, Italy turned to Tunisia, the major source of the problem, to see what could be done.The first politicians to go there were the Foreign Affairs Minister Frattini and the Interior Minister Maroni. Remarkably, the latter belongs to the anti-immigrant Lega Nord or Northern League but he is a very practical individual – not someone given to wearing ideological goggles. While most of the work was likely done by Maroni, Prime Minister Berlusconi took a last trip early this week to try and gather the laurels for himself. Regardless of who managed it, some positive results were in fact achieved.

In exchange for Italian investment support to Tunisia (the exact terms of the agreement are not available as I write, but possibly some €150 million were offered) and an agreement not to expel the first 20,000 immigrants that have landed, Maroni obtained from Tunisia that all additional immigrants that might be coming in Italy would be returned home and that new migrant sailings would be stopped. In return, Maroni issued temporary travel permits (up to 3 months) that in principle allow the immigrants to travel within the visa-free Shengen Area that covers 25 countries in continental Europe – including France and Switzerland, thus opening a wide swath of frontier between the three countries. As of today and keeping to its side of the agreement, Tunisia has started again to patrol its borders and is said to have stopped a boat from sailing off to Italy.

Problem solved? Not at all. Paris is furious and sent yesterday its Interior Minister Claude Guéant to Rome. Germany and Belgium are equally furious and several officials have said so publicly. The day before coming to Italy, Guéant issued an order to his prefects that no one was allowed in France without a proper passport (something illegal immigrants don’t have) and demonstrated income for self-support (at least €62/day – something immigrants dream of having !). On top of that, they can be expelled if they “disturb the public peace” – something very easy to provoke and a perfect basis for expulsion. To make matters even more complicated, there is a 1997 Italo-French treaty, the so-called “Chambéry agreement” signed a few weeks before Schengen and thus effectively putting a lid on Schengen. This agreement enables France to return to Italy any and all immigrants as it sees fit provided it can prove they came from Italy – thereby negating the very spirit of the Schengen treaty which was supposed to provide European citizens with the kind of freedom across state borders that Americans enjoy without even noticing it.

Indeed, the Italian Interior Minister Maroni was quick to point out that France’s move is equivalent to a suspension of Schengen. To his accusation, the Belgians and Germans were equally quick to point out that it is Italy who has “broken” Schengen – because it wasn’t able to “defend” its frontiers and “manage” the wave of illegal immigration (remember: 22,000 in 3 months – that’s 7,000/month. Who can “manage” such numbers when these are people without papers or money?) I really believe that France has turned anti-European, and with it, so has Germany and Belgium.

Everybody would like to see the Italians resolve the immigration problem for them. And if they don’t, that’s because the Italians are hopeless, and Berlusconi is a buffoon, right? Wrong! I’m really angry because what’s behind all this anti-European stance is nothing but self-interest and parochial politics. President Sarkozy is worrying about getting re-elected in 2012: he is playing to the extreme right, trying to win back votes from Marine Le Pen‘s party (she went to Lampedusa a few weeks ago and has created a storm over the immigrant issue). Ditto for Ms. Merkel who’s just lost regional elections and is in a very precarious position. If they can get votes at the expense of Europe, what do they care?

Oh my Europe, where have you gone?

Okay, today France and Italy have supposedly resolved their “diplomatic disagreement”. Maroni and Guéant have agreed to jointly patrol the waters to stop migrants from Africa. But how France will deal with the temporary permits issued by Italy to immigrants is a bit befuddled in the news. Both countries said they would “deal” with this problem. But how?

I have a suspicion – and I only hope I’m wrong. Would you believe that what is facing illegal immigrants, rather than liberté, égalité and fraternité,  is  “la mort” – death? If you don’t believe me, look at the French Revolution motto I put up at the top of my post. It very clearly says: “la mort“! All right, I’m kidding: it’s not actual death. But it is the social equivalent: people won’t be allowed to stay on, full stop. And that’s what Sarkozy’s France means – regardless of the stance he has taken on Lybia and the kudos gained for being the first to protect civilian lives in Benghazi with air strikes and the first to recognize the Lybian opposition’s government. In other words, the doors are shut!

And of course, Germany is not far behind. Just watch their anger against Italy unfold and expand!

Of the 20,000 illegal immigrants that have invaded Italy since January, most are Tunisians and most want to go to France: they speak French, they have family there and they are (mostly) young men who want to work. In Italy, for them there’s no work (the recession is still on-going). And of course they don’t feel at home, they don’t speak Italian.

But France won’t have it. Unbelievable! What has happened to the country of “freedom” and “equality”? Where has the French cultural heritage and revolutionary motto of “liberté, égalité, fraternité” gone to? Not to mention the deep-seated cultural linkage with Tunisia, a one-time colony of France that has had its values shaped by France’s liberal heritage…

True, the French were slow to respond to Tunisia’s “Jasmine Revolution“. Does anyone still call it that? Since popular uprisings, starting from Tunisia and spreading to Egypt, have eventually overwhelmed the whole of the Middle East, the tendency now is to talk of the “Arab Spring”.

Well, the calendar says it’s springtime but the French will have none of it. They are determined to stay in winter and they’ve tightly shut their doors against what Italian Prime Minister Berlusconi likes to call the “immigrant tsunami”. They’ve already sent back to Italy some 1700 illegal immigrants that had managed to cross into France since the beginning of the year, presumably from the Ventimiglia bordertown. At this point, I’m pretty sure that if the immigrants are smart,  they’re flooding into France from other places because French border police patrols have turned the whole area between Nice and Ventimiglia into a well-guarded military zone.

And now other European countries are following France in this bunker mentality: Germany and Belgium! Expect more countries soon as everyone takes the stance that the illegal immigrant emergency is Italy’s problem, and Italy’s alone…Actually not quite. Today Germany declared that they are more willing than the Italians – “ten times more willing!” – to receive immigrants and they have taken in…100 Africans who had taken refuge in Malta. One hundred as compared to the 20,000 (more likely 22,000) now milling about in Italy? And they pretend they are “more willing”? I can’t believe this: what is Europe and the European spirit of cooperation coming to? Actually, it is clear that there never was any, and Ms. Merkel who is one tough lady couldn’t care less about Europe (as she’s amply shown when Greece got into deficit). All she thinks of is Germany first – without realizing that by weakening Europe she is in the end weakening Germany too. But I’m getting carried away: that would be the subject matter of another post…

As of now, the fact is that Fortress Europe has been breached on its southern border. 20,000 immigrants in 3 months is clearly more than any single European country can handle, even a big one like Italy.  But it seems that the rest of Europe prefers to jettison Italy rather than try to help it solve the problem. Do you think I’m exaggerating? I’m not. The Italians have justifiably complained now for months that they are alone in bearing the brunt of the invasion. And so they are. Europe won’t hear about it and in Brussels the European Commission has gone mum on the subject. The Commission has yet to develop a common policy to address the issue of immigration, and that’s a policy that should have been developed BEFORE we ever got into the mess we are now in.

What can Italy do? Not much. So far, it’s done everything it can to wiggle out of this uncomfortable situation. First it has had to solve its own internal problems (I’ve blogged about this before, see here). Nobody in Italy wanted refugee holding camps near their own hometown, and some still don’t. Such as Alemanno, the Mayor of Rome who claims Rome has had its “fill of problems” and can’t take anymore – not a very Christian position, and certainly not in line with the Catholic Church.

Second, Italy turned to Tunisia, the major source of the problem, to see what could be done.The first politicians to go there were the Foreign Affairs Minister Frattini and the Interior Minister Maroni. Remarkably, the latter belongs to the anti-immigrant Lega Nord or Northern League but he is a very practical individual – not someone given to wearing ideological goggles. While most of the work was likely done by Maroni, Prime Minister Berlusconi took a last trip early this week to try and gather the laurels for himself. Regardless of who managed it, some positive results were in fact achieved.

In exchange for Italian investment support to Tunisia (the exact terms of the agreement are not available as I write, but possibly some €150 million were offered) and an agreement not to expel the first 20,000 immigrants that have landed, Maroni obtained from Tunisia that all additional immigrants that might be coming in Italy would be returned home and that new migrant sailings would be stopped. In return, Maroni issued temporary travel permits (up to 3 months) that in principle allow the immigrants to travel within the visa-free Shengen Area that covers 25 countries in continental Europe – including France and Switzerland, thus opening a wide swath of frontier between the three countries. As of today and keeping to its side of the agreement, Tunisia has started again to patrol its borders and is said to have stopped a boat from sailing off to Italy.

Problem solved? Not at all. Paris is furious and sent yesterday its Interior Minister Claude Guéant to Rome. Germany and Belgium are equally furious and several officials have said so publicly. The day before coming to Italy, Guéant issued an order to his prefects that no one was allowed in France without a proper passport (something illegal immigrants don’t have) and demonstrated income for self-support (at least €62/day – something immigrants dream of having !). On top of that, they can be expelled if they “disturb the public peace” – something very easy to provoke and a perfect basis for expulsion. To make matters even more complicated, there is a 1997 Italo-French treaty, the so-called “Chambéry agreement” signed a few weeks before Schengen and thus effectively putting a lid on Schengen. This agreement enables France to return to Italy any and all immigrants as it sees fit provided it can prove they came from Italy – thereby negating the very spirit of the Schengen treaty which was supposed to provide European citizens with the kind of freedom across state borders that Americans enjoy without even noticing it.

Indeed, the Italian Interior Minister Maroni was quick to point out that France’s move is equivalent to a suspension of Schengen. To his accusation, the Belgians and Germans were equally quick to point out that it is Italy who has “broken” Schengen – because it wasn’t able to “defend” its frontiers and “manage” the wave of illegal immigration (remember: 22,000 in 3 months – that’s 7,000/month. Who can “manage” such numbers when these are people without papers or money?) I really believe that France has turned anti-European, and with it, so has Germany and Belgium.

Everybody would like to see the Italians resolve the immigration problem for them. And if they don’t, that’s because the Italians are hopeless, and Berlusconi is a buffoon, right? Wrong! I’m really angry because what’s behind all this anti-European stance is nothing but self-interest and parochial politics. President Sarkozy is worrying about getting re-elected in 2012: he is playing to the extreme right, trying to win back votes from Marine Le Pen‘s party (she went to Lampedusa a few weeks ago and has created a storm over the immigrant issue). Ditto for Ms. Merkel who’s just lost regional elections and is in a very precarious position. If they can get votes at the expense of Europe, what do they care?

Oh my Europe, where have you gone?

Okay, today France and Italy have supposedly resolved their “diplomatic disagreement”. Maroni and Guéant have agreed to jointly patrol the waters to stop migrants from Africa. But how France will deal with the temporary permits issued by Italy to immigrants is a bit befuddled in the news. Both countries said they would “deal” with this problem. But how?

I have a suspicion – and I only hope I’m wrong. Would you believe that what is facing illegal immigrants, rather than liberté, égalité and fraternité,  is  “la mort” – death? If you don’t believe me, look at the French Revolution motto I put up at the top of my post. It very clearly says: “la mort“! All right, I’m kidding: it’s not actual death. But it is the social equivalent: people won’t be allowed to stay on, full stop. And that’s what Sarkozy’s France means – regardless of the stance he has taken on Lybia and the kudos gained for being the first to protect civilian lives in Benghazi with air strikes and the first to recognize the Lybian opposition’s government. In other words, the doors are shut!

And of course, Germany is not far behind. Just watch their anger against Italy unfold and expand!

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Is Traditional Publishing Headed for a Smash-up?

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Dear Readers,

Some of you may know me from my site on blogspot.com and I’ll try to keep you posted on both sites, with comments on politics, books, art (everything I like) and economics (everything I dislike!) – in short, our world as I see it. But since this is just a bunch of personal opinions, you’re most welcome to shoot them down!

I love a rousing discussion!

Here is my take on what is happening to the publishing world as it has to face (and survive) the tsunami of the digital revolution…If you disagree, please make comments!

The sales of e-books have outpaced printed books for the first time this year at Amazon, the number one on line bookseller in the world. People are talking about the digital revolution being something as big, nay, BIGGER than Gutenberg’s invention of the printing press around 1440.  We’re into a new age, the possibilities are infinite, everything will change!

Does that mean that the printed book is dead and that traditional publishers are on their way out?

No, I don’t believe so. I am convinced the future of publishing is anything but bleak! By the way, I’m looking at it as an economist and political analyst – not as an aspiring fiction writer (which I also happen to be, but that’s incidental – for that matter, I’m also a painter – which has nothing to do with the argument at hand…).  I just wanted to point out that I’m trying to evaluate the situation in a detached, scientific way (hum, gasp, cough).

The first thing to realize is that e-books are NOT going to eat into the current market. The pie, with the advent of digital titles, will expand. E-books will add to the book market in general, bringing in lots of new readers – people who after a first jolly experience on their i-pad or kindle will go on to buy paper books for the first time in their lives! And remember, digital editions are forever. They’re not like printed books, sitting on your local bookstores shelves for a few weeks and then gone. E-books are FOREVER! Which means they are accessible, ready to be downloaded on your e-reader anytime. You don’t have to go to the book store to order and then wait for the book to be sent by mail. No, e-books are just a click away!

Second, as with any BIG change in an industry’s parameters, expect a wave of bankruptcies and consolidations. The biggest bookstore in the US, Borders, has gone into receivership which means, inter alia, that traditional publishers have lost miles of physical shelf space for their books. Talk of a tsunami! You can expect that over the next few years, even the Big 6 (the main American publishers) will have to reconsider their marketing strategies, their costs and do everything they can to ensure their survival – perhaps even move out (gasp!) of Manhattan! And expect some to go under. That may not be fun for those involved, but it’s physiological. When structural change comes to an industry, only the fittest survive.

Bookstores, however, are at this moment taking the brunt of the storm (as shown by Borders). They need to react ASAP and become more imaginative to turn themselves into welcoming places, like Starbucks and provide coffee to attract clients or organize conferences and local contests to engage the community. There are a number of bookstores of that sort in Europe, places that straddle the Internet and offer a haven to the local community, and they seem to prosper.  Advisory services could also be provided to their clients, things like advice on e-readers, the best apps, and help them locate interesting stuff to read on Internet – that is, turn themselves into “gatekeepers” of sorts, to guide people in the jungle of e-books.

Because it’s fast becoming a jungle: there are lots and lots of titles out there. If you look at the top 100 best-selling titles on Kindle, you’ll be amazed at the BIG proportion of self-published books – I didn’t count, but at a glance, it’s much more than half! To find “good” authors (in the sense of “good read”) is becoming a well-nigh impossible enterprise. I know because I do that repeatedly for my mother who’s 97 and an avid reader (she loves her Kindle). You get the feeling that the famous “slush pile”, all those manuscripts rejected by publishers and literary agents as “unfit to print”, all of them are suddenly on sale. And, perhaps more surprisingly, they are finding customers! Yes, people do buy these books! Sure, they’re priced at $O.99 so that’s probably why people buy them. But the more successful e-authors who started at that price, have found they could jack up their price to $2.99 and more (but always well under the $9.90 borderline established by traditional publishers) and still make money…in spite of the lack of editing, poor plot structure and typos… Which goes to show that a good yarn sells more easily than “literature”.

That may be a depressing thought for some but it’s definitely a golden opportunity for others: with the expansion of the book market, a lot of “unsophisticated” first-time readers have been drawn in, and they’re the sort of people who enjoy a good story and don’t care too much about how it’s told.

This means that one of the traditional roles of publishers of printed books, i.e. being “gatekeepers” to ensure a “minimum” level of “quality”, has been seriously weakened and others could jump in the void. Magazines and papers and blogs with a big following that review books are doing that job now, but why not bookstores? And the big bookstore chains could consider providing print-on-demand services for all things digital. Indeed, that’s where the real competition for printed books might yet come from…

To sum up: with the digital revolution, everybody’s role is changing, and it’s not just bookstores that have to rethink themselves. Publishers also need to reconsider their role. They often give the impression of being on the defensive as they progressively tighten their contracts with writers and lower advances. Six-digit figures are a rarity nowadays. Publishers even cut advances up in 4 parts, meant to follow the different stages in the publishing process, and that means you  get only 1/4th of your “advance” upon signing the contract.  Sure, this is a tough business, they try to get the most out of every deal. But writers are publishers’ natural allies: writing is the source of their business. So publishers need to realize that if they stop scraping authors naked, and instead treat them right, they will make of them faithful allies. I am willing to bet that the first publishers who realize this will see their prospects turn for the better real fast. And the first thing they should consider doing is giving authors a better deal on e-book royalties and making a better job of providing supportive book marketing. Because in this Internet age, the buzz word is king, and authors, through such important blogs as Writer Beware learn real soon who are the publishers to avoid…

Because e-rights are forever and more and more writers are realizing this. And more and more are unwilling to give up returns on their books forever  when all the publishers have done is a one-time investment in them. After all, the money you have to put up front to get yourself e-published is relatively small – just about anyone can afford to do it. Of course, not everyone has the necessary on line presence and the desire to spend all that time into marketing one’s book.

Most writers would still prefer to spend most of their time writing…

So there’s a glimmer of hope for traditional or “legacy publishers”. There will be more Amanda Hockings who after establishing themselves as self-published wonders (she made one million dollars in her first year of digital self-publishing), will be coming back into their fold. And there will be probably fewer Barry Eisler walking away from them. Remember him? He is that feisty writer who refused a $ 500,000 advance from St.Martin’s Press for two books. But then, on closer examination, it wasn’t really such a good deal: $250,000 per book minus the 15% going to his agent, plus the fact that he’d get next to nothing for his e-rights. And, remember, e-rights are forever!

The real challenge for legacy publishers will be the midlist authors who can make a big buck turning their back list into e-books. Joe Konrath‘s success is an example for all midlist writers. Publishers will just have to figure out a way to get into that juicy market – and they won’t get into it unless they bend their position on e-rights. They want too much for far too long. They really should consider another model, for example putting a time frame on e-rights and allow authors to regain them after, say, 5 years, but – and that’s an important “but” – with a renewal clause for another 5 years on condition that the publisher agrees to engage in some additional marketing. That would encourage writers to sign up with them rather than go the self-publishing e-route.

AND they need to provide a service of value to the authors, in particular marketing support (that’s something writers normally don’t like to do: if you’re a writer, let’s face it, you’re an introvert, you really don’t have a salesman personality…) Publishers could easily make sure their authors get reviews, and not any kind of reviews, but good ones from respected reviewers with a known and proven following.

And they could consider doing something else too, something no one talks about much because it’s scary: I’m referring to piracy. Yes, publishers could try and provide more effective means to fight off piracy. Individual authors are not well-placed to defend themselves and few are internet-savvy. To fight off piracy requires experts. Pirates – I mean hackers – are getting better all the time and a lot of people out there, a writer’s regular readers, don’t even think that downloading a book for free is a form of criminal offense. The author has sweated over writing his book and deserves a fair $ return for his pains. Let’s face it, pirate are pirates and should be jailed. Now, in the digital world, that’s hard to do and it requires huge means to properly police the Internet. And it means publishers and e-book sellers will have to work together.

Because, let’s face it, the biggest danger the digital revolution brings to the publishing industry is PIRACY! It might yet bring together everybody: Amazon.com, traditional bookstores, e-book platforms and publishers, both those into “legacy” publishing and e-books, for the greater good of authors and their readers…But then I’m an incorrigible optimist!


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