History > 2007 > USA > Health (IV)

Scientists

Note Brain's Reaction to Fear

October 30, 2007
Filed at 9:52 p.m. ET
By THE ASSOCIATED PRESS
The New York Times

WASHINGTON (AP) -- Science is getting a grip on people's fears. As Americans revel in all things scary on Halloween, scientists say they now know better what's going on inside our brains when a spook jumps out and scares us. Knowing how fear rules the brain should lead to treatments for a major medical problem: When irrational fears go haywire.

''We're making a lot of progress,'' said University of Michigan psychology professor Stephen Maren. ''We're taking all of what we learned from the basic studies of animals and bringing that into the clinical practices that help people. Things are starting to come together in a very important way.''

About 40 million Americans suffer from anxiety disorders, according to the National Institute of Mental Health. A Harvard Medical School study estimated the annual cost to the U.S. economy in 1999 at roughly $42 billion.

Fear is a basic primal emotion that is key to evolutionary survival. It's one we share with animals. Genetics plays a big role in the development of overwhelming -- and needless -- fear, psychologists say. But so do traumatic events.

''Fear is a funny thing,'' said Ted Abel, a fear researcher at the University of Pennsylvania. ''One needs enough of it, but not too much of it.''

Armi Rowe, a Connecticut freelance writer and mother, said she used to be ''one of those rational types who are usually calm under pressure.'' She was someone who would downhill ski the treacherous black diamond trails of snowy mountains. Then one day, in the midst of coping with a couple of serious illnesses in her family, she felt fear closing in on her while driving alone. The crushing pain on her chest felt like a heart attack. She called 911.

''I was literally frozen with fear,'' she said. It was an anxiety attack. The first of many.

The first sign she would get would be sweaty palms and then a numbness in the pit of the stomach and queasiness. Eventually it escalated until she felt as if she was being attacked by a wild animal.

''There's a trick to panic attack,'' said David Carbonell, a Chicago psychologist specializing in treating anxiety disorders. ''You're experiencing this powerful discomfort but you're getting tricked into treating it like danger.''

These days, thanks to counseling, self-study, calming exercises and introspection, Rowe knows how to stop or at least minimize those attacks early on.

Scientists figure they can improve that fear-dampening process by learning how fear runs through the brain and body.

The fear hot spot is the amygdala, an almond-shaped part of the deep brain.

The amygdala isn't responsible for all of people's fear response, but it's like the burglar alarm that connects to everything else, said New York University psychology and neural science professor Elizabeth Phelps.

Emory University psychiatry and psychology professor Michael Davis found that a certain chemical reaction in the amygdala is crucial in the way mice and people learn to overcome fear. When that reaction is deactivated in mice, they never learn to counter their fears.

Scientists found D-cycloserine, a drug already used to fight hard-to-treat tuberculosis, strengthens that good chemical reaction in mice. Working in combination with therapy, it seems to do the same in people. It was first shown effective with people who have a fear of heights. It also worked in tests with other types of fear, and it's now being studied in survivors of the World Trade Center attacks and the Iraq war.

The work is promising, but Michigan's Maren cautions that therapy will still be needed: ''You're not going to be able to take a pill and make these things go away.''

When it comes to ruling the brain, fear often is king, scientists say.

''Fear is the most powerful emotion,'' said University of California Los Angeles psychology professor Michael Fanselow.

People recognize fear in other humans faster than other emotions, according to a new study being published next month. Research appearing in the journal Emotion involved volunteers who were bombarded with pictures of faces showing fear, happiness and no expression. They quickly recognized and reacted to the faces of fear -- even when it was turned upside down.

''We think we have some built-in shortcuts of the brain that serve the role that helps us detect anything that could be threatening,'' said study author Vanderbilt University psychology professor David Zald.

Other studies have shown that just by being very afraid, other bodily functions change. One study found that very frightened people can withstand more pain than those not experiencing fear. Another found that experiencing fear or merely perceiving it in others improved people's attention and brain skills.

To help overcome overwhelming fear, psychologist Carbonell, author of the ''Panic Attacks Workbook,'' has his patients distinguish between a real threat and merely a perceived one. They practice fear attacks and their response to them. He even has them fill out questionnaires in the middle of a fear attack, which changes their thinking and causes reduces their anxiety.

That's important because the normal response for dealing with a real threat is either flee or fight, Carbonell said. But if the threat is not real, the best way to deal with fear is just the opposite: ''Wait it out and chill.''

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On the Net:

David Carbonell's tips on how deal with anxiety problems:

http://www.anxietycoach.com/steps.htm

Scientists Note Brain's Reaction to Fear, NYT, 31.10.2007, http://www.nytimes.com/aponline/us/AP-Facing-Our-Fears.html

More Young Adults

on Cholesterol Drugs

October 30, 2007
Filed at 7:40 a.m. ET
By THE ASSOCIATED PRESS
The New York Times

TRENTON, N.J. (AP) -- Use of cholesterol and blood pressure medicines by young adults appears to be rising rapidly -- at a faster pace than among senior citizens, according to an industry report being released Tuesday.

Experts point to higher rates of obesity, high blood pressure and high cholesterol problems among young people. Also, doctors are getting more aggressive with preventive treatments.

''This is good news, that more people in this age range are taking these medicines,'' said Dr. Daniel W. Jones, president of the American Heart Association.

Still, he said many more people should be on the drugs that lower cholesterol or blood pressure and which have been shown to reduce risks for heart attack and stroke.

The new data, from prescription benefit manager Medco Health Solutions Inc., indicate use of cholesterol-lowering drugs among people aged 20 to 44, while still low, jumped 68 percent over a six-year period.

The rate rose from 2.5 percent in 2001 to just over 4 percent in 2006 among Medco customers. That means roughly 4.2 million Americans in that age group are now taking cholesterol medicines.

Meanwhile, use of blood pressure medicines increased 21 percent, from about 7 percent of 20- to 44-year-olds in 2001 to over 8 percent in 2006. That translates into about 8.5 million Americans in that age group taking drugs to lower their blood pressure.

''It was a surprise to us,'' said Dr. Robert Epstein, chief medical officer at Franklin Lakes, N.J.-based Medco. ''Maybe the fact that we're seeing more young people with high cholesterol and blood pressure is indicative of the epidemic of obesity and overweight that we're seeing in this country.''

Among people 65 and older, use of blood pressure drugs increased only 9.5 percent and use of cholesterol drugs by 52 percent. That's because half the seniors were already taking blood pressure drugs and more than one in four were taking cholesterol drugs in 2001.

Jones, dean of the University of Mississippi School of Medicine, said he has seen some increase in young adults with blood pressure or cholesterol problems, but not of the magnitude suggested by Medco's data.

Dr. Howard Weintraub, the heart disease prevention expert at the American College of Cardiology, said he's ''thrilled'' by the dramatic increase, which he says is tied to requests from patients with ''a brand new sense of urgency'' and referrals from other doctors to his private practice.

''If you wait until a heart attack or stroke, it's a little bit late,'' Weintraub said.

He and Epstein both said patients with problems should first work with their doctors on lifestyle changes -- more exercise, a better diet and weight loss. But Weintraub said many people need medication to achieve and maintain the ever-lower levels of blood pressure and cholesterol that experts now recommend.

However, Dr. John LaRosa, president of SUNY Downstate Medical Center, said, ''particularly for young people, lifestyle change is worth a try.''

Once patients start taking these medicines, they usually stay with them and there are some side effects, LaRosa said.

''It's amazing what (losing) five or 10 pounds will do'' to reduce blood pressure and cholesterol levels, he said.

Federal health statistics show that while the percentage of people with high cholesterol has dropped overall in recent years, it has risen among younger people, especially those 20 to 34 years old.

Meanwhile, the prevalence of high blood pressure was flat or up slightly among those age groups; among women in the 35 to 44 age group, the rate of high blood pressure rose significantly.

Medco processes prescription claims for about 60 million insured Americans. The report's findings are based on a representative sample of data from 2.5 million members.

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On the Net: www.medco.com

    More Young Adults on Cholesterol Drugs, NYT, 30.10.2007, http://www.nytimes.com/aponline/us/AP-Young-Hearts.html

Seeking Savings,

Employers Help Smokers Quit

October 26, 2007
The New York Times
By MILT FREUDENHEIM

Corporate America has made big strides toward the smoke-free workplace. Its next goal: the smoke-free worker.

Many businesses are seeking to reduce their medical bills by paying for programs to help employees stop smoking. A decade ago, such programs were rare. But recent surveys indicate that one-third of companies with at least 200 workers now offer smoking cessation as part of their employee benefits package. Among the nation’s biggest companies, the number may be nearly two-thirds of employers.

“Tobacco cessation has been the hot topic for the last year,” said Helen Darling, president of the National Business Group on Health, which includes more than 200 large employers.

The programs are yet another example, along with various other corporate wellness efforts like weight management and diabetes control, of how private employers are taking health care reform into their own hands, even as politicians continue to debate proposals and tactics in Washington and on the campaign trail.

For businesses, it is a bottom-line calculus. Spending as much as $900 or so to give a participant free nicotine patches and drugs to ease withdrawal, as well as phone sessions with smoking addiction counselors, can more than offset the estimated $16,000 or more in additional lifetime medical bills that a typical smoker generates, according to federal health data.

That federal figure does not count the costs of absenteeism or the drain on productivity when smokers periodically duck outside for a cigarette.

Smoking’s toll goes well beyond the financial, of course. Even though the percentage of adult smokers has dropped to just above 20 percent, compared with more than 40 percent in 1965, there are more than 44 million smokers in the United States.

The habit is blamed for 435,000 premature deaths in this country each year, and it adds more than $75 billion to annual spending on health care, according to the federal Centers for Disease Control and Prevention.

With business employers accounting for about $650 billion of the nation’s $2 trillion annual medical bill, companies have a big monetary incentive to get workers to kick the tobacco habit.

Research has shown that smoking cessation programs, when they include counseling, have long-term success rates of 15 to 35 percent, said Dr. Michael Fiore, a University of Wisconsin professor of medicine who is also chairman of the federal Public Health Service’s guidelines panel on smoking cessation.

“For a number of smokers, it takes multiple tries before they can achieve long-term remission,” he said.

United Parcel Service, which has a work force of nearly 428,000 and spent $2.6 billion on employee health care last year, began offering a smoking cessation program in February to the estimated 13 percent of its employees who use tobacco.

“We decided this was the time to do this,” said Judy Pirnie Smith, a registered nurse who is a health and productivity manager at U.P.S.

Another employer, the Union Pacific railroad, which has 50,000 workers, credits a smoking cessation program it adopted two years with helping cut the smoking rate to about 17 percent of its work force, compared with 40 percent as recently as the 1990s.

Participants often say they need the help an employer program can provide.

“The day my dad passed away, I started praying for a solution, a way to quit smoking,” said Monte Hall, a 43-year-old cargo handler with U.P.S. in Louisville, Ky. His father, who smoked a pack and a half a day, died from lung disease a few years ago.

The solution came in the form of the company’s program. Mr. Hall got advice and encouragement from counselors, read articles they suggested and used nicotine patches. He says he has not had a cigarette since Feb. 24.

U.P.S. belongs to the National Business Group on Health, which surveyed 58 of its biggest members and found that nearly two-thirds offered stop-smoking programs as part of their health plans. That was a sharp contrast with the mid-1990s, when companies rarely covered smoking cessation, according to Ms. Darling.

A survey by the nonprofit Kaiser Family Foundation found that smoking programs are offered by one in three companies with more than 200 workers. Among smaller firms, that was one in 12.

The number of employers sponsoring the programs “is going up even while firms are cutting back on medical benefits” in general to limit costs, said Dr. Steven A. Schroeder, director of the Smoking Cessation Leadership Center at the University of California, San Francisco, which promotes stop-smoking programs nationally.

The number of people who enroll in the programs and then slip back into smoking in the first three months is high, said Bruce C. Kelley, a senior executive with the Watson Wyatt Worldwide benefits consulting firm in Minneapolis. But “for people who quit for 12 months,” he said, “the recidivism rate is very low.”

Reaching that milestone is the challenge. “I could start again, any time,” a 47-year-old warehouse worker worried aloud during a recent phone counseling session, his third, after 10 days without a cigarette. “I really need some time to feel comfortable with doing it,” he said.

His coach, Ryan Crawford, replied soothingly: “I completely agree, it does take time. It’s a process.” A reporter listened to a recording of the conversation on condition that neither the worker nor the employer be identified.

Mr. Crawford is a counselor for a Seattle firm, Free and Clear, whose services include operating phone lines 18 hours a day to help workers stop smoking. The firm’s clients include 104 employers, including Boeing, Caterpillar and nearly 30 other companies among the nation’s 500 largest.

Free and Clear, the leader in its field, also runs smoking cessation programs for 16 states, financed in part by the sweeping 1999 settlement of lawsuits against tobacco companies. In the last 12 months, Free and Clear has enrolled 165,000 participants. That is nearly 60 percent more than a year earlier, and it translates to about 700 new participants a day, said Sean Bell, a Free and Clear executive vice president.

Typically, Mr. Bell said, employers do not know who the smokers are. Often his firm sends information to all of a client’s employees, inviting them to join the program. In other cases, invitations go only to employees who identify themselves as smokers on health questionnaires.

Under federal health care privacy law, a few officials in an employer’s human resources and accounts payable departments may be authorized to know who is participating. But it is illegal for them to share that information with others in the company.

Some employers go beyond invitations to apply financial pressure to motivate people to stop smoking. This month, for example, the Tribune Company, the big media business, asked employees to indicate if they or family members were smokers when they sign up for the 2008 health plan. Smokers will be penalized a $100 a month unless they join a company-paid cessation program run by Free and Clear.

“It’s an honor system,” said Gary Weitman, a Tribune spokesman. “We believe employees will volunteer.”

Other smoking cessation specialists include Healthways, a disease management company based in Nashville, whose services include an online program called QuitNet.

I.B.M. is a customer, providing the QuitNet program and access to online counselors to any of its 350,000 employees who feel the need. Seven states and two Canadian provinces are also customers of QuitNet, which has a free Web version — without the counseling service — that draws 1,500 to 2,000 visitors each day, said Jim Purvis, a QuitNet executive.

Small employers often do not have the time or money for wellness programs. But Buffalo Supply, a hospital equipment wholesaler based in Lafayette, Colo., offers $2,500, along with payment for nicotine patches or gum, to employees who quit smoking for 30 days and promise to stick with it. Two have collected.

Harold L. Jackson, the company president, said none of the nonsmokers had suggested that rewarding smokers for quitting might be unfair. “We have a very family atmosphere,” he said. “We try to look out for each other and everyone’s welfare.” Buffalo Supply has 25 employees, including 5 who still smoke, Mr. Jackson said. “I would like it to be zero.”

    Seeking Savings, Employers Help Smokers Quit, NYT, 26.10.2007, http://www.nytimes.com/2007/10/26/business/26smoking.html?hp

More Women Getting Double Mastectomies

October 22, 2007
Filed at 10:39 p.m. ET
By THE ASSOCIATED PRESS
The New York Times

WASHINGTON (AP) -- More women who have cancer in only one breast are getting both breasts removed, says research that found the trend more than doubled in just six years. It's still a rare option: Most breast cancer in this country is treated by lumpectomy, removing just the tumor while saving the breast.

But the new study suggests 4.5 percent of breast cancer surgery in 2003 involved women getting cancerous and healthy breasts simultaneously removed, a 150 percent increase from 1998 -- with no sign that the trend was slowing.

Young women are most likely to choose the aggressive operation, researchers report Monday in the Journal of Clinical Oncology.

The concern is whether they're choosing in the heat of the moment -- breast cancer surgery often is within two weeks of diagnosis -- or with good understanding of its pros and cons.

''Are these realistic decisions or not?'' asks Dr. Todd Tuttle, cancer surgery chief at the University of Minnesota, who led the study after more women sought the option in his own hospital.

''I'm afraid that women believe having their opposite breast removed is somehow going to improve their breast cancer survival. In fact, it probably will not affect their survival,'' he said.

The initial tumor already may have sent out seeds of spread to key organs, Tuttle explained.

But removing the remaining healthy breast does greatly lower, although not eliminate, chances of a new cancer developing on the opposite side.

Don't underestimate the peace of mind that brings, said Trisha Stotler Meyer of Vienna, Va., who had her breasts removed three weeks ago.

''Doctors are not up at night crying'' in fear of their next mammogram, said Meyer, 37, who went back for a double mastectomy after her initial cancer surgery. ''I don't want to have to deal with the stress.''

Meyer is far from alone.

In a single day last week, Dr. Shawna Willey of Georgetown University's Lombardi Cancer Center had two patients seek the operation.

One needed her entire cancerous breast removed, and immediately asked to have the healthy one removed, too. Another woman had recently undergone a lumpectomy and was sick from chemotherapy -- and returned to ask that both breasts be fully removed.

''Her perception is, 'If I have my breasts taken off, I never have to do this again,''' said Willey, who asked the woman to see a counselor and finish chemo before deciding.

''I can understand that point of view,'' she added. ''But I always tell them, it's not a guarantee.''

The American Cancer Society estimates 178,480 U.S. women will be diagnosed with breast cancer this year. About 40,460 will die of it.

Some women at high risk, because of notorious breast cancer genes or family history, choose preventive mastectomies before cancer ever strikes.

Tuttle's study is the first national look at how many women choose to remove both a diseased and healthy breast together.

He used a government cancer registry that covers 16 regions, a representative sample of the U.S. population, to track more than 150,000 breast cancer surgeries between 1998 and 2003.

Tuttle calculated that lumpectomies accounted for almost 60 percent of those surgeries in 2003. Lumpectomies have gradually increased since they were proven just as effective as breast removal for early cancer in 1991.

The surprise: Single mastectomies remain the No. 2 option but are dropping -- while double mastectomies, although uncommon, were on the rise for every stage of cancer. Even women who qualify for anti-hormone drugs that greatly protect the remaining breast were as likely to choose removal as women with harder-to-treat tumors.

Why? Tuttle is planning a new study to tell, and to see if candidates are warned about such risks as infection that increase with the bigger surgery.

Meyer, the Virginia woman, had time to fully consider the option. She was diagnosed with cancer in January 2005, shortly after her son's birth. At first, she was content with a lumpectomy, followed by chemotherapy and radiation. But she didn't qualify for protective anti-hormone drugs. And then in March, Meyer found a lump in her healthy breast. It wasn't cancer but a cyst that would wax and wane, making for tense checkups.

''It really freaked me out,'' Meyer said. ''It was at that moment that my breasts became like tonsils. I don't need them anymore. They're gone.''

Georgetown's Willey says better reconstructive surgery is partly spurring the trend. Still, she often encourages women to wait to remove the second breast, as lining up reconstruction sometimes dangerously delays treating the cancer.

''When I was younger ... I really tried to argue with patients and talk them out of it,'' Willey said. Now, if they've weighed the options, she doesn't.

''I can't recall a single patient who tells me they regret that decision.''

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On the Net:

American Society of Clinical Oncology consumer info: http://www.plwc.org/CancerAdvances

    More Women Getting Double Mastectomies, NYT, 22.10.2007, http://www.nytimes.com/aponline/us/AP-Double-Mastectomies.html

A Two-Cigarette Society

October 22, 2007
By DAVID G. ADAMS
Op-Ed Contributor
The New York Times

Washington

WHEN it comes to the health of our children, two cigarettes may be better than one. Young smokers who begin their habit with nicotine-laden cigarettes need a cigarette that will not leave them to later fight the ravages of addiction.

Experts tell us that teenagers often begin smoking to copy their peers and others whom they see smoking. As adults, however, they continue smoking largely because of the addictive qualities of nicotine. (Ninety percent of smokers regret having begun smoking and most make efforts to stop.) This means that in the absence of addictive levels of nicotine in their cigarettes, most young smokers would ultimately quit.

A two-cigarette strategy would prohibit young smokers from buying addictive cigarettes. The tobacco industry is capable of producing cigarettes that are virtually free of nicotine, and regulators could develop clear standards for non-addictive cigarettes. (Disclosure: My law firm represents tobacco companies, but I have recused myself from that work.)

The age to purchase addictive cigarettes might be set at 21. Better yet, sales of addictive cigarettes could be restricted to individuals born 19 or more years before the two-cigarette strategy was put into effect. Under this approach, 18-year-olds who start smoking non-addictive cigarettes would be prohibited from switching to addictive cigarettes even after they turned 21. In addition, a higher federal excise tax on addictive cigarettes than on non-addictive cigarettes would create a financial incentive for smokers of all ages, including scofflaw adolescents, to select non-addictive cigarettes.

Granted, a two-cigarette policy would not be a panacea. It would not end smoking, it would not give us safer cigarettes, and it would not undo the addiction that grips the current generation of smokers.

The Institute of Medicine, a unit of the National Academy of Sciences, has called for a gradual reduction of the nicotine content in all cigarettes to non-addictive levels (an approach I proposed 13 years ago when I worked at the Food and Drug Administration). But it would take decades to eliminate addictive cigarettes from the market. While a worthy strategy for eliminating addiction many years from now, a gradual approach would still permit the addiction of the next generation of smokers.

Decades of addiction will mean disease and death for millions of our children. If we can prevent addiction at the outset, we shouldn’t waste another day.

David G. Adams, a lawyer, was the director of the policy staff at the Food and Drug Administration from 1992 to 1994.

    A Two-Cigarette Society, NYT, 22.10.2007, http://www.nytimes.com/2007/10/22/opinion/22adams.html

Baltimore Journal

The Smoking Scourge Among Urban Blacks

October 20, 2007
The New York Times
By ERIK ECKHOLM

BALTIMORE, Oct. 15 — Outside subways stops and bars in parts of this blighted city, slouching hustlers mutter “loosies, loosies” to passers-by, offering quick transactions, 50 cents a stick or three for a dollar.

Their illegal, if rarely prosecuted vocation: selling loose Newport cigarettes to those who do not have $4.50 to buy a pack.

In small corner markets, customers sometimes use code words like “bubble gum” or “napkins” to receive individual cigarettes wrapped in a napkin. Or they buy a flavored Black and Mild, the latest smoking craze here, from an opened five-pack.

Out-of-package sales are common in the poor areas of many cities, an adaptation to meager, erratic incomes and rising cigarette taxes. But researchers say they are just one facet of a high smoking rate among low-income urban blacks.

Even as antismoking campaigns have sharply reduced tobacco use in society at large, smoking has remained far more common among the poor of all races.

Still, officials here said they were surprised when a recent study suggested that more than half of poor, black young adults smoke cigarettes — almost always menthol, almost always Newports.

In the latest twist, the study also found that nearly one in four of them also smoke candy-flavored cigarillos, often inhaling despite the danger posed by higher tar and nicotine levels.

Alarmed by the findings, the city’s health commissioner, Dr. Joshua Sharfstein, on Monday convened health experts, community leaders and high school students to discuss the spreading use of Black and Milds, plastic-tipped cigarillos that come in flavors like wine, cream and apple and are often seen in hip-hop videos and the HBO series “The Wire,” which is set in Baltimore.

Jamila Wilson, 17, said at the meeting that she had started smoking Black and Milds at 15 and now smoked several a day, inhaling.

“If you smoke the wine flavor, it gives you a buzz, ” Jamila said, adding that if she goes too long without, “I get light-headed.”

Amid violence and drug problems, smoking may seem a comparatively harmless vice. “But if you take a step back,” Dr. Sharfstein said, “it’s the smoking that will end up killing a lot of these kids, maybe not next week but well ahead of their time.”

In a stepped-up antismoking campaign, Baltimore officials are offering free nicotine patches or gum and are considering stronger measures to control sales of loosies, which are easily available to youngsters.

“The whole issue here is that the social norms haven’t changed the way they have in most of society,” said Frances Stillman of the Johns Hopkins School of Public Health, co-author of the study of smoking habits among Baltimore’s poor, which was published in August in the American Journal of Public Health. “Everybody smokes, and everybody thinks it’s O.K.”

In this latest study, researchers interviewed 160 blacks ages 18 to 24 who were enrolled in job training. In the group, 60 percent smoked cigarettes and 24 percent had recently smoked cigarillos.

A survey of 1,021 low-income blacks in Detroit, published in 2005 in the American Journal of Preventive Medicine, found that 59 percent of men and 41 percent of women smoked, a finding that “shocked everybody,” said the chief author, Jorge Delva of the University of Michigan School of Social Work.

It has long been known that smoking rates are higher among the poor and least educated of all races, but Mr. Delva and other experts said the rates recently found among inner city blacks were surprisingly high, possibly indicating that they were undercounted in broad standard surveys.

For a mix of cultural reasons as well as targeted marketing, menthol cigarettes are particularly favored by blacks: 75 percent of blacks nationwide smoke them, compared with less than 30 percent of whites.

In the 1960s, Kools dominated the market. But Newports, with a lower menthol level that many say feels smoother, and backed by marketing including the green “Newport Pleasure!” posters in nearly every deli and gas station here, have taken a strong lead in many cities.

“All my friends smoke, and they all smoke Newports,” said Collin Mazick, 24, a resident of northeast Baltimore who is studying to become a geriatric nursing assistant.

In recent years, the promotion budgets of major cigarette companies have been disproportionately devoted to menthols, said Gregory N. Connolly, director of tobacco control research at the Harvard School of Public Health. “It appears the industry is targeting the most vulnerable groups through advertising and manipulation of menthol levels,” Mr. Connolly said.

In an e-mailed response to questions, the Lorillard Tobacco Company, maker of Newports, said its marketing was directed at “all adult smokers,” although 51 percent of Newport buyers are blacks.

In Montebello, a tough section of northeast Baltimore, Newports are shared, sometimes for cash by people trying to recoup the cost of a pack.

“Everybody here smokes who can afford it,” said Eddie Johnson, 54, who broke a heroin addiction during a recent jail stay and is now training to be a drug counselor. Mr. Johnson said he smoked 10 to 20 cigarettes a day.

Scientists have not found that menthol cigarettes per se are more dangerous, but they say that menthol may make it easier to start smoking and harder to quit, and that it intensifies the effect of nicotine.

A resident of the Montebello alleys, Antonio Stokes, 39, who was vague about how he made money, agreed. Of the Newport he bummed off a friend the other evening, he said: “It’s worse than crack. They should have a detox center for these things, too.”

    The Smoking Scourge Among Urban Blacks, NYT, 20.10.2007, http://www.nytimes.com/2007/10/20/health/20tobacco.html

Staph Fatalities May Exceed AIDS Deaths

October 17, 2007
Filed at 7:50 a.m. ET
By THE ASSOCIATED PRESS
The New York Times

CHICAGO (AP) -- More than 90,000 Americans get potentially deadly infections each year from a drug-resistant staph ''superbug,'' the government reported in its first overall estimate of invasive disease caused by the germ.

Deaths tied to these infections may exceed those caused by AIDS, said one public health expert commenting on the new study. Tuesdays report shows just how far one form of the staph germ has spread beyond its traditional hospital setting.

The overall incidence rate was about 32 invasive infections per 100,000 people. That's an ''astounding'' figure, said an editorial in Wednesday's Journal of the American Medical Association, which published the study.

Most drug-resistant staph cases are mild skin infections. But this study focused on invasive infections -- those that enter the bloodstream or destroy flesh and can turn deadly.

Researchers found that only about one-quarter involved hospitalized patients. However, more than half were in the health care system -- people who had recently had surgery or were on kidney dialysis, for example. Open wounds and exposure to medical equipment are major ways the bug spreads.

In recent years, the resistant germ has become more common in hospitals and it has been spreading through prisons, gyms and locker rooms, and in poor urban neighborhoods.

The new study offers the broadest look yet at the pervasiveness of the most severe infections caused by the bug, called methicillin-resistant Staphylococcus aureus, or MRSA. These bacteria can be carried by healthy people, living on their skin or in their noses.

An invasive form of the disease is being blamed for the death Monday of a 17-year-old Virginia high school senior. Doctors said the germ had spread to his kidneys, liver, lungs and muscles around his heart.

The researchers' estimates are extrapolated from 2005 surveillance data from nine mostly urban regions considered representative of the country. There were 5,287 invasive infections reported that year in people living in those regions, which would translate to an estimated 94,360 cases nationally, the researchers said.

Most cases were life-threatening bloodstream infections. However, about 10 percent involved so-called flesh-eating disease, according to the study led by researchers at the federal Centers for Disease Control and Prevention.

There were 988 reported deaths among infected people in the study, for a rate of 6.3 per 100,000. That would translate to 18,650 deaths annually, although the researchers don't know if MRSA was the cause in all cases.

If these deaths all were related to staph infections, the total would exceed other better-known causes of death including AIDS -- which killed an estimated 17,011 Americans in 2005 -- said Dr. Elizabeth Bancroft of the Los Angeles County Health Department, the editorial author.

The results underscore the need for better prevention measures. That includes curbing the overuse of antibiotics and improving hand-washing and other hygiene procedures among hospital workers, said the CDC's Dr. Scott Fridkin, a study co-author.

Some hospitals have drastically cut infections by first isolating new patients until they are screened for MRSA.

The bacteria don't respond to penicillin-related antibiotics once commonly used to treat them, partly because of overuse. They can be treated with other drugs but health officials worry that their overuse could cause the germ to become resistant to those, too.

A survey earlier this year suggested that MRSA infections, including noninvasive mild forms, affect 46 out of every 1,000 U.S. hospital and nursing home patients -- or as many as 5 percent. These patients are vulnerable because of open wounds and invasive medical equipment that can help the germ spread.

Dr. Buddy Creech, an infectious disease specialist at Vanderbilt University, said the JAMA study emphasizes the broad scope of the drug-resistant staph ''epidemic,'' and highlights the need for a vaccine, which he called ''the holy grail of staphylococcal research.''

The regions studied were: the Atlanta metropolitan area; Baltimore, Connecticut; Davidson County, Tenn.; the Denver metropolitan area; Monroe County, NY; the Portland, Ore. metropolitan area; Ramsey County, Minn.; and the San Francisco metropolitan area.

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On the Net:

JAMA: http://jama.ama-assn.org

CDC: http://www.cdc.gov

    Staph Fatalities May Exceed AIDS Deaths, NYT, 17.10.2007, http://www.nytimes.com/aponline/us/AP-Staph-Infections.html

U.S. Cancer Death Rates Are Found to Be Falling

October 15, 2007
The New York Times
By DENISE GRADY

Death rates from cancer have been dropping by an average of 2.1 percent a year recently in the United States, a near doubling of decreases that began in 1993, researchers are reporting.

“Every 1 percent is 5,000 people who aren’t dying,” said Dr. Richard L. Schilsky, a professor of medicine at the University of Chicago and president-elect of the American Society of Clinical Oncology. “That’s a huge sense of progress at this point.”

Much of the progress comes not from miracle cures, but from more mundane improvements in prevention, early detection and treatment of some of the leading causes of cancer death — lung, colorectal, breast and prostate tumors. Years of nagging and pleading by health officials are finally beginning to pay off, experts say, in smoking cessation and increased use of mammograms, colonoscopies and other screening tests for colorectal and prostate cancer.

But the new statistics also contain bad news: American Indians and Alaska Natives in some regions are not benefiting from the same improvements as the rest of the population and have higher rates of preventable cancers and late-stage tumors that would have had a better prognosis had they been detected sooner. Some groups within those populations have high rates of smoking. Researchers attribute the problems to poverty, lower education levels and lack of insurance and access to medical care.

About 1.8 million of the 3.3 million American Indians and Alaska Natives receive their medical care through the Indian Health Service, but its facilities generally do not treat cancer. Outside contractors provide cancer treatment; to get it patients may have to navigate complicated rules and restrictions.

“The concern we have,” said Elizabeth Ward, director of cancer surveillance for the American Cancer Society, “is that much of the progress we’ve attained in reducing death rates comes from tobacco control, screening and access to timely and high-quality treatment, and those positive effects are not being seen in all populations in the U.S.”

The new information, in an annual report from the cancer society, the National Cancer Institute and others, is being published online today (www.interscience.wiley.com/cancer/report2007) and in the Nov. 15 issue of the journal Cancer.

In the United States, cancer remains the second leading cause of death after heart disease, with 559,650 deaths expected this year.

But over all, death rates from cancer have been dropping by an average of 1.1 percent a year since 1993.

The report, using a statistical technique to analyze death rates, finds that the rate of decline deepened recently, averaging 2.1 percent a year from 2002 to 2004, the latest dates for which statistics are available. For men, the average decline during that period was 2.6 percent, and for women 1.8 percent.

“I’m hopeful that these improvements will serve to at least partially satisfy the cynics who have questioned whether the investment in cancer treatment has borne fruit,” said Dr. Neal J. Meropol, director of the gastrointestinal cancer program at Fox Chase Cancer Center in Philadelphia. “In my view these numbers are starting to highlight the advances that have been made.”

But Dr. Meropol added that the figures “also highlight how we are failing large segments of our population in not providing health insurance.”

In men, death rates decreased for most cancers, but went up for esophageal and liver cancer.

In women, death rates also dropped for most common cancers, but increased for liver and lung cancer. Lung cancer rates are still increasing for women because they started smoking, and quit, later than men did. But the death rate in women is increasing more slowly than in the past.

“What we think the statistics show now,” said Dr. Ward of the American Cancer Society, “is that the epidemic of lung cancer in women has peaked, and we hope we’ll start seeing a downturn.”

The report found that the incidence of both breast and ovarian cancer had decreased in the past few years. Researchers think the decline may be due in part to a sharp drop in hormone use after menopause, a response to a landmark study in 2002 that found the drugs increased the risk of breast cancer.

Dr. Ward said the report was the first to analyze American Indians and Alaska Natives region by region, and it found striking differences among the groups.

For instance, lung cancer rates were highest in Alaska and the northern and southern plains, lower on the Pacific Coast and in the East, and lowest in the Southwest. Colorectal cancer incidence was three or more times higher in Alaska and the northern plains than in the Southwest. Alaska also had the highest rates of breast cancer. Smoking explains the lung cancer variations, but the other differences are not fully understood.

The American Cancer Society has said that lack of access to medical care is a major obstacle to reducing death rates. It recently began an advertising campaign to publicize the problem.

“Access to care truly is the message,” said Dr. Patricia Ganz, director of cancer prevention and control research at the Jonsson Comprehensive Cancer Center at the University of California, Los Angeles. “When people have equal access to care, they have equal outcomes.”

Dr. Meropol of the Fox Chase Cancer Center said: “What jumps out is that we really still have a long way to go.

“In spite of improvements, it’s still a minority of individuals in our country that undergo screening for colon cancer,” he said. “If everyone were screened appropriately, these incidence numbers would fall even more dramatically annually.”

    U.S. Cancer Death Rates Are Found to Be Falling, NYT, 15.10.2007, http://www.nytimes.com/2007/10/15/us/15cancer.html?hp

Progress Cited in Developing Alzheimer’s Diagnosis

October 14, 2007
The New York Times
By ANDREW POLLACK

Scientists reported progress today toward one of medicine’s long-sought goals: the development of a blood test that can accurately diagnose Alzheimer’s disease, and even do so years before truly debilitating memory loss.

A team of scientists, based mainly at Stanford University, developed a test that was about 90 percent accurate in distinguishing the blood of people with Alzheimer’s from the blood of those without the disease. The test was about 80 percent accurate in predicting which patients with mild memory loss would go on to develop Alzheimer’s disease two to six years later.

Outside experts called the results, published online today by Nature Medicine promising but very preliminary. They cautioned that the work must be validated by others and in much larger studies, because there have been many disappointments in the past.

“Looking for biomarkers for Alzheimer’s disease is a very hot area,” said Dr. William Jagust, professor of public health and neuroscience at the University of California, Berkeley. “Things tend to get a lot of attention and they are not always borne out.”

Right now, Alzheimer’s disease is diagnosed by a battery of mental and other tests, and even that diagnosis rests on the judgment of the physician. Doctors say it would be very useful to have something like a pregnancy test for Alzheimer’s — one that is simple and definitive and can pick up the disease very early, maybe even before symptoms appear.

At present, treatments for Alzheimer’s disease are not very effective, so some people might not want early notification that they have an incurable ailment. But other people might want it.

“There are people who want to know what their future holds so they can plan their estates and lives,” said Dr. Sam Gandy, a professor at Mount Sinai School of Medicine who is chairman of the medical and scientific advisory council of the Alzheimer’s Association.

But the real usefulness of an early diagnostic test would come when drugs are developed that slow or halt the progression of Alzheimer’s disease. Several therapies that might be able to do that are now being tested. The drugs would be most valuable if they could be used before cognitive ability has declined too much.

Numerous efforts have been made to find an early marker in blood, urine, spinal fluid, eye movements, as well as through brain imaging using PET scans and M.R.I. A Norwegian company, DiaGenic, has presented some early results of a blood test that analyzes gene activity. Researchers at Cornell published early results last December using a pattern of 23 proteins in the spinal fluid. But no test has gained universal acceptance. The closest is a test of two proteins in the spinal fluid, which is used in some European countries, said Dr. Dennis Selkoe, a professor of neurology in Boston at Brigham and Women’s Hospital and Harvard.

A blood test would be easier for patients than a spinal tap, he said. But a blood test is possible only if Alzheimer’s disease leads to changes outside the brain that can be detected in the blood.

Dr. Tony Wyss-Coray, an associate professor of neurology at Stanford and the senior author of the new paper, said there was evidence from animal studies that brains affected by Alzheimer’s send out signals to the body’s immune system. So his team decided that rather than looking at all proteins in the blood, it would focus on those involved in communication between cells, hoping to eavesdrop, as it were, on dialogue related to Alzheimer’s.

The researchers gathered more than 200 blood samples from people with Alzheimer’s and those without. Using 83 of the samples, they measured the abundance of 120 proteins involved in cell signaling and found they could distinguish the Alzheimer’s samples from the controls using 18 of the proteins.

They then tested their 18-protein signature on another 92 samples. The tests agreed with the clinical diagnosis about 90 percent of the time.

Perhaps most intriguing were the results of the test on 47 blood samples taken from people with mild cognitive impairment, a minor loss of memory that can be a precursor of Alzheimer’s. The test was able to predict with about 80 percent accuracy whether a patient went on to develop Alzheimer’s two to six years after the blood sample had been collected.

Dr. Wyss-Coray, who is also at the Veterans Affairs Palo Alto Health System, said that monitoring communications between cells might be a way to develop diagnostic tests for other diseases. And understanding why the levels of the 18 proteins are different in Alzheimer’s patients might provide a better understanding of the disease.

The study was paid for by the National Institute on Aging, the John Douglas French Alzheimer’s Foundation, the Alzheimer’s Association and Satoris, a company co-founded by Dr. Wyss-Coray to commercialize the test.

The company said in a news release that it hopes to have a test available for research purposes next year. But even if the preliminary results are validated, it is likely to be a few years before an test is approved and ready for use by doctors.

    Progress Cited in Developing Alzheimer’s Diagnosis, NYT, 14.10.2007, http://www.nytimes.com/2007/10/14/health/14cnd-blood.html?hp

3 Win Nobel in Medicine for Gene Manipulation

October 8, 2007
Filed at 11:50 a.m. ET
By THE ASSOCIATED PRESS
The New York Times

STOCKHOLM, Sweden (AP) -- Two American scientists and a Briton won the 2007 Nobel Prize in medicine on Monday for groundbreaking discoveries that led to a powerful technique for manipulating mouse genes.

The widely used process has helped scientists use mice to study heart disease, diabetes, cancer, cystic fibrosis and other diseases.

The prize is shared by Mario R. Capecchi, 70, of the University of Utah in Salt Lake City; Oliver Smithies, 82, a native of Britain now at University of North Carolina in Chapel Hill, and Sir Martin J. Evans, 66, of Cardiff University in Wales.

The Nobel is a particularly striking achievement for Capecchi, (pronounced kuh-PEK'-ee). A native of Italy, he was separated from his mother at age 4 when she was taken to the Dachau concentration camp as a political prisoner during World War II.

For four years, Capecchi lived on the street or in orphanages, ''and most of the time hungry,'' he recalled in a University of Utah publication in 1997. Malnutrition sent him to a hospital where his mother found him on his ninth birthday. Within two weeks they left for the United States, where he went to school for the first time, starting in third grade despite not knowing English.

The three scientists were honored for a technique called gene targeting, which lets scientists deactivate or modify particular genes in mice. That in turn lets them study how those genes affect health and disease.

To use this technique, researchers introduce a genetic change into mouse embryonic stem cells. These cells are then injected into mouse embryos. The mice born from these embryos are bred with others, to produce offspring with altered genes.

The first mice with genes manipulated in this way were announced in 1989. More than 10,000 different genes in mice have been studied with the technique, the Nobel committee said. That's about half the genes the rodents have.

''Gene targeting has pervaded all fields of biomedicine. Its impact on the understanding of gene function and its benefits to mankind will continue to increase over many years to come,'' said the citation for the $1.54 million prize.

Steve Brown, director of the mammalian genetics unit at the Medical Research Council in London, said the three researchers have ''given us the toolkit to understand how genes function'' in mice and so, by extension, in humans. As a result, of their work, he said, ''we're on the cusp of having a much better understanding of the relationship between genes and disease.''

In a telephone interview from Salt Lake City, Capecchi called the award ''a fantastic surprise.''

He said he was deep asleep when he got the phone call from the Nobel committee at 3 a.m. local time. ''He sounded very serious,'' Capecchi said, ''so the first reaction was, `This must be real.'''

Evans, reached while visiting his daughter in Cambridge, England, said ''I haven't come to terms with it yet. In many ways it is the boyhood aspiration of science, isn't it? And here I am unexpectedly with it. It's amazing.''

After working on the research for more than 20 years, Smithies told The Associated Press, it's ''rather enjoyable being recognized at this level.''

Smithies said he hopes winning the prize will make it easier to secure funding for other work.

The three scientists mostly worked separately, although they exchanged information about their research. Evans identified embryonic stem cells in mice, while the gene-targeting technique used on those cells came from work by Capecchi and Smithies.

Scientists are also attempting to do this genetic manipulation in human embryonic cells to create a basic research tool, said John Gearhart, a stem cell expert at the Johns Hopkins School of Medicine.

The idea is to make cells with disease-related gene mutations so they can be studied in the laboratory. That could give clues about how the disease develops, and serve as a screening tool for potential therapies, he said.

Capecchi's work has uncovered the roles of genes involved in organ development in mammals, the committee said. Evans has developed strains of gene-altered mice to study cystic fibrosis, and Smithies has created strains to study such conditions as high blood pressure and heart disease.

The medicine prize was the first of the six prestigious awards to be announced this year. The others are chemistry, physics, literature, peace and economics.

The prizes are handed out every year on Dec. 10, the anniversary of award founder Alfred Nobel's death in 1896.

Last year, the Nobel Prize in medicine went to Americans Andrew Z. Fire and Craig C. Mello for discovering RNA interference, a process that can silence specific genes.

Since the medicine prize was first awarded in 1901, 90 Americans and 29 Britons have received it.

------

On the Net:

http://nobelprize.org

------

Associated Press writer Bernard Mcghee in Atlanta contributed to this report.

    3 Win Nobel in Medicine for Gene Manipulation, NYT, 8.10.2007, http://www.nytimes.com/aponline/health/AP-Nobel-Medicine.html?hp

Small Scanners Find Hidden Heart Disease

October 7, 2007
Filed at 12:46 p.m. ET
By THE ASSOCIATED PRESS
The New York Times

MADISON, Wis. (AP) -- What if your doctor could swipe a wand over your neck and reveal whether you have hidden heart disease?

That is now possible in places other than the sickbay of the starship Enterprise.

Miniature ultrasound machines are starting to make their way into ordinary doctors' offices, where they may someday be as common as stethoscopes and EKGs. A pocket-sized one weighing less than 2 pounds hit the market last week.

Some of these devices can make images of neck arteries, which offer a ''window'' to heart arteries that cannot easily be seen. If the neck vessels are clogged, doctors know that those around the heart probably are, too, and that treatment or more testing is needed.

The new ultrasound machines offer a relatively cheap, painless way to screen people with no symptoms of heart problems for signs of hidden trouble.

Is that a good thing?

Many doctors say yes, because for one-third of heart disease sufferers, the first symptom is dropping dead of a heart attack. Finding these people early and treating them could save lives. The test may be especially good for women, who often have few traditional signs.

Lisa Rosenstock of Madison, Wis., is an example. At age 41, this trim, athletic mom had normal cholesterol and blood pressure but a troubling family history of heart attacks. Ultrasound revealed a big clog in the main artery from her heart to her head.

Her cardiologist, Dr. James Stein of the University of Wisconsin-Madison, put her on medicines to lower her risk of a heart attack or stroke. He also is leading a study aimed at making ultrasound testing more common.

''There's a great need for a noninvasive and safe way to identify people who don't have signs but have risk'' of heart disease, he said.

But there are potential downsides to more people doing this testing without extensive training. Suddenly, small-town family doctors could see scary-looking artery buildups and rush to treat some that might never be life-threatening.

And while patients who see the pictures may be motivated to quit smoking, lose weight or go on cholesterol drugs, some might suffer side effects from unnecessary treatment.

Ultrasounds also are being advertised directly to consumers -- the latest ''peace of mind'' test like whole-body CT scans and MRIs. Some drugmakers are promoting wider testing because it could boost cholesterol pill sales.

The American Heart Association says testing with traditional ultrasound machines can help certain patients, but does not endorse widespread screening with the small devices because proof of benefit is lacking.

Guidelines from several groups suggesting who should use the small ultrasound devices, and on which patients, are expected next spring, said Stein, who heads a panel writing the advice.

On balance, many doctors see more promise than peril.

''It's equivalent to a mammogram of the heart,'' said Dr. Christopher Rembold, a cardiologist at the University of Virginia. If doctors see something suspicious, they can refer patients to specialists for more extensive tests before deciding whether or how to treat it, he said.

Screening involves checking for buildups called plaque and measuring the thickness of the wall of the main neck artery. Normal thickness varies by age, race and sex, and charts give doctors detailed guidance. Too-thick arteries are a sign of higher risk for heart attack.

Until recently, only ultrasound specialists did these tests, which were analyzed by a radiologist. That often meant patients needed another appointment at a hospital or ultrasound center, and a return trip to their primary doctor for results.

The portable ultrasound devices are changing that. SonoSite Inc. of Bothell, Wash., came out with one in 1999. It was followed by GE Healthcare, a suburban Milwaukee unit of General Electric. They mostly are used in emergency rooms to check for problems with the heart's valves or pumping capacity, or bulging abdominal arteries threatening to rupture.

But scanning neck arteries became more common after SonoSite's MicroMaxx came out in 2005. The 8-pound device is a small laptop and costs $25,000, or about $40,000 with related software.

The pocket-sized device that went on sale last week -- the $10,000 Acuson P10 -- might eventually expand artery scanning even more. Siemens Medical Solutions, the Malvern, Pa.-based unit of the German company Siemens AG, initially will sell the device for traditional heart imaging and emergency use, but plans to offer artery imaging in the near future. The quality of the images will have to be proved for the device to gain wide acceptance, several experts said.

At UW-Madison, doctors have done neck scans with portable ultrasounds on about 900 patients. They charge $295, and three local HMOs agreed to pay. Most insurers do not, because of limited proof of the value of such tests.

Others are selling neck scanning directly to consumers.

Dr. Robert Bonow, cardiology chief at Northwestern University and a past heart association president, recently got an ad in the mail for screening at a shopping center near his Glencoe, Ill., home. He worries about the accuracy of such testing.

Suppose the scanning is 90 percent accurate, and the normal rate of heart disease is 10 percent, he said. That would mean 20 out of 200 people would have heart disease and 180 would not. But the scan would tell 18 people they had it when they didn't, and would miss heart disease in 18 who did.

Because of the false alarms, ''you may be treating twice as many people as you have to,'' he said. ''If you're dealing with 2 million people, that's a lot of people who don't need treatment.''

Robert Rosner, an ultrasound technician in Fort Myers, Fla., sells screening to police, fire and other municipal workers and through doctor offices and health clubs. He charges $180 and offers a personal testimonial. At age 42, he scanned his own arteries and was surprised to see a 30 percent narrowing in one. A doctor put him on medications, and a couple of years later, the plaque was gone.

''Without needles or radiation or pain ... there's disease in the body that can be reversed,'' he said. ''I'm living proof.''

UW's Stein is leading a study to see whether family practice doctors can be trained in a weekend to accurately do the tests. SonoSite donated equipment, and a university-administered grant is paying for the study, which will test 350 patients.

''The danger of overtreating is low, especially in an environment where we dangerously undertreat risk factors,'' Stein said. Screening itself can be good, he pointed out. A previous study found that even those whose arteries were found to be normal were motivated to exercise more.

It should do even more good for people who do have heart disease, said Dr. Sanford Carimi, a Janesville, Wis., physician participating in Stein's study.

''If I tell you your cholesterol is 130, that won't bother you,'' he said. ''If I show you you have a plaque in the blood vessel leading to your brain, you're more likely to make some changes.''

------

On the Net:

Siemens ultrasound: www.pocketultrasound.com

SonoSite: www.sonosite.com

GE Healthcare: http://www.gehealthcare.com

    Small Scanners Find Hidden Heart Disease, NYT, 7.10.2007, http://www.nytimes.com/aponline/us/AP-Artery-Scanners.html

News Analysis

A Battle Foreshadowing a Larger Health Care War

October 6, 2007
The New York Times
By ROBERT PEAR

WASHINGTON, Oct. 5 — The debate now raging here over the children’s health insurance program offers a cautionary lesson to Democrats running for president. It shows how hard it will be to persuade many Republicans to sign on to their vision of universal coverage.

If Democrats and Republicans had so much difficulty agreeing on a plan to cover 10 million children, most of them from low-income families, how can they ever agree on legislation to guarantee insurance for 250 million or 300 million people?

Many of the questions that provoked fierce argument in the battle over the child health bill would be even more divisive in a debate over universal coverage: Should the government subsidize insurance for middle-income people? How much government involvement is too much? How much should the government spend, and who should foot the bill?

In vetoing a $35 billion expansion of the State Children’s Health Insurance Program on Wednesday, President Bush said the bill would improperly allow higher-income families to benefit from assistance meant to help poor children.

Democrats said the president was out of step with the nation. They see a consensus forming around the goal of universal coverage, meaning access to health insurance for all, with payment coming from public and private sources. Given presidential leadership, they said, the goal can be achieved.

But it will not be easy. This year’s debate over the child health bill prefigures a battle over health policy that is likely to run through the presidential campaign and occupy center stage in Congress in 2009, regardless of who wins the election.

Representative Jeb Hensarling, Republican of Texas, said the debate over coverage of children was “a proxy fight” between advocates for two competing visions.

“This is only the first battle in this Congress over who will control health care in America,” Mr. Hensarling said. “Will it be parents, families and doctors? Or will it be Washington bureaucrats? That’s what this debate is all about.”

The child health bill was overwhelmingly approved in the Senate, 67 to 29, with support from 18 Republicans. In the House, 45 Republicans, more than one-fifth of the party caucus, supported the bill, which passed there by 265 to 159. (Currently lacking a veto-proof majority for the legislation, House Democratic leaders have decided to delay an override attempt until Oct. 18.)

The substantial margin of passage in both houses obscured visceral disagreements over philosophy and ideology. Those differences could create formidable obstacles for a president of either party, in the absence of a landslide like those that preceded creation of Social Security in 1935 and Medicare in 1965.

Democrats insisted that the proposed expansion of the child health program would not mean a new entitlement or lead to government-run health care. They repeatedly pointed out that while the federal government and the states pay for the program, most children on the rolls receive care from private doctors and hospitals, and most states have contracts with private insurers to manage the care.

One co-author of the bill, Senator Charles E. Grassley, Republican of Iowa, said critics in his own party who referred to the expansion as “socialized medicine” were making “outlandish accusations.”

But that is exactly the accusation many Republicans are making.

Representative Pete Sessions of Texas said the child health bill was an “attempt to make millions of Americans completely reliant upon the government for their health care needs.”

Senator Mel Martinez of Florida, a Cuban refugee who is general chairman of the Republican Party, said the bill would move the nation toward “socialized health care, a Cuban-style health care system, with rationing of care, long waiting lines and, worse yet, no choice.”

The criticism reflects the concerns of many Republicans. Mr. Grassley himself said, “Many in the Democratic Party, including several of the Democratic presidential candidates, want a government-run single-payer health care system.”

While the Democratic candidates for president deny wanting a single-payer system, they do say the government should play a larger role. Defining that role is perhaps the biggest domestic policy challenge facing the next president.

Under Senator Hillary Rodham Clinton’s proposal, people could keep their existing coverage, choose a private plan offered by the Federal Employees Health Benefits Program or sign up for a new “public plan option similar to Medicare.”

Former Senator John Edwards would give everyone “a choice between private insurers and a public insurance plan modeled after Medicare.”

Senator Barack Obama says he would “establish a new public insurance program” for people who do not have access to group coverage.

Amid the partisan uproar, some lawmakers see the nucleus of a possible bipartisan coalition.

Senator Ron Wyden, an Oregon Democrat who has worked on health care for three decades, said: “What’s emerging is a sense, in both parties, that each side has been right on a key point. Democrats have been right about coverage; if you don’t cover everybody, the cost of caring for the uninsured is shifted to people with insurance. Republicans are right about the need for choices and private alternatives.”

Mr. Wyden said he saw a potential for bipartisan agreement “if we link the idea of universal coverage to the idea of a private health care delivery system.”

Stuart M. Butler, a vice president of the conservative Heritage Foundation, said the debate over the child health program carried an important lesson for Republicans.

“Many Republicans have yet to recognize that it’s important to cover children, and that you have to offer a different vision as an alternative to simply expanding government programs,” Mr. Butler said.

Mr. Butler would offer financial help, through the tax system, to families with incomes two to three times the poverty level ($41,300 to $61,950 for a family of four) to help them pay for private insurance covering their children.

Many Republicans like that approach, of course, but Mr. Butler suggests that they failed to push it sufficiently in the tug of war on child health care.

“It’s hard to fight something with nothing,” he said.

    A Battle Foreshadowing a Larger Health Care War, NYT, 6.10.2007, http://www.nytimes.com/2007/10/06/washington/06health.html?hp

Medicare Premium Rise Less Than Usual

October 1, 2007
Filed at 12:46 p.m. ET
By THE ASSOCIATED PRESS
The New York Times

WASHINGTON (AP) -- Elderly and disabled people will see their monthly Medicare premiums rise 3.1 percent next year to $96.40 -- the lowest increase in six years.

The good news is temporary, though.

That's because the formula used to calculate the premium assumes that physicians will take a 10 percent cut in their reimbursement rates next year, an unlikely occurrence.

The increase was lower than expected because officials fixed an accounting error that otherwise would have added $2.50 to beneficiaries' monthly premiums in 2008.

The Medicare program pays for most of the health care received by about 43 million elderly and disabled people. The program's expenses have soared in recent years as health care costs go up and as more people join the program.

Beneficiaries will be most concerned about two key expenses for next year:

First, there is Medicare Part A, which covers inpatient hospital and hospice care as well as short stays in nursing homes. For this program, participants don't pay a monthly premium. However, they do pay a deductible when they have to go to the hospital. That deductible will increase from $992 to $1024 next year.

Second, there is Medicare Part B, which covers services received at the doctor's office and in outpatient settings. The program also pays for medical equipment such as wheelchairs and oxygen tanks. About a quarter of the revenue for this program comes from beneficiaries' monthly premiums. About 95 percent of participants will pay the $96.40 premium next year, though wealthier participants will pay more.

    Medicare Premium Rise Less Than Usual, NYT, 1.10.2007, http://www.nytimes.com/aponline/us/AP-Medicare-Premiums.html

Helped by Generics, Inflation of Drug Costs Slows

September 21, 2007
The New York Times
By STEPHANIE SAUL

As overall health care costs continue to rise sharply, prescription drugs have emerged as a surprising exception.

Annual inflation in drug costs is at the lowest rate in the three decades since the Labor Department began using its current method of tracking prescription prices. The rate over the last 12 months is 1 percent, according to the government’s latest data, released Wednesday.

“The way the index is going, it looks like drug price increases are not going to be very painful this year,” said Daniel H. Ginsburg, a supervisory economist at the Bureau of Labor Statistics, where he is involved in compiling the Consumer Price Index.

As recently as 2005, inflation in drug prices was running at an annual rate of 4.4 percent.

Economists say the slowdown has come about because more people are turning to generics and because generic versions of some of the most common drugs have recently come on the market.

In the past year and a half alone, generic equivalents have become available for the cholesterol treatment Zocor, the sleeping pill Ambien and the blood pressure drug Norvasc.

Another factor could be the so-called Wal-Mart effect. Last fall, Wal-Mart began offering many generic prescriptions at $4 a month. Target quickly announced a similar plan, and Kmart expanded its program, which offers a 90-day supply of generic drugs for $15. Other retailers have followed with their variations. Publix, a grocery store chain with 684 pharmacies in five states in the Southeast, announced last month that it would not charge for prescriptions for seven commonly used antibiotics.

To be sure, the government still expects spending on medications to rise, to nearly $500 billion a year within a decade, up from an estimated $275 billion this year. That will happen as more people take more drugs and as new drugs are introduced. Also, costs are likely to soar in some specialized categories like cancer treatments and biotechnology drugs.

And yet for the average household, the drug index is perhaps a better reflection of the actual day-to-day impact of prices for their most commonly used drugs, like antibiotics, blood pressure pills and cholesterol medicines. According to the nonprofit Kaiser Family Foundation, in 2006 the average brand-name prescription cost more than three times the average generic: $111, compared with $32.

But now, tamer drug inflation could add credibility to the platforms of presidential candidates who have embraced generics as part of a solution to rising health care costs, according to Dr. Robert Berenson, an M.D. who is a senior fellow at the Brookings Institution. Three Democratic candidates — Hillary Rodham Clinton, John Edwards and Barack Obama — have included generics in their health care proposals.

Generics made up 63 percent of prescriptions dispensed in the United States in 2006, up 13 percent from 2005. And these days, the country’s biggest supplier of prescription drugs, as measured by prescriptions filled, is not a high-profile American company like Pfizer or Merck. It is Teva Pharmaceutical, a generic manufacturer based in Israel, according to data from IMS Health, a firm that tracks the market.

A Labor Department economist, Francisco Velez, said his office noted a drop in generic drug prices shortly after the large stores’ promotions began, particularly in the South, where Wal-Mart started its program. His colleague, Mr. Ginsburg, called the drop in prices for generic drugs “dramatic.” Wal-Mart and other large chain stores make up 15 to 20 percent of the pharmacies that the government surveys for the index.

The fourth quarter of 2006 was the first time in several decades that the index registered three consecutive months in which prices declined. Mr. Ginsburg said that the effect of the promotions by large retailers could be a one-time phenomenon, unless the companies decide to expand the number of drugs they discount.

Wal-Mart’s list of discounted generics includes fewer than 350 drugs. On Tuesday, Wal-Mart announced that, beginning next year, 2,400 generics would be available to its employees at $4 a month. The company has also indicated that later this month it may make an announcement regarding its generic drug program for consumers.

The use of generics has been promoted by Medicare, private employers and the pharmacy benefit managers that administer employee drug plans. Len Nichols, director of health policy for the New America Foundation, a Washington policy group, noted that many pharmacy benefit managers have encouraged the trend with tiered co-payments, allowing consumers to pay less if they choose the cheapest generic drugs and more for the most expensive name brands.

“My guess is that the increasing market share of generics, driven largely by firms using two- and three-tier pricing — that’s what’s slowing us down over time,” Mr. Nichols said.

Although the Consumer Price Index is only one measure of prescription drug inflation, Medicare has also reported slower increases in spending on prescriptions, beginning in 2003 and continuing through 2005. The 2006 numbers are not yet available.

Despite the slowed inflation recorded by the index, overall spending for pharmaceuticals is still on the rise, up 8.3 percent in 2006, according to IMS. And that is unlikely to diminish anytime soon, as an aging population faces increasing health problems. According to Medicare, there have been great increases in the use of drugs for the cardiovascular and central nervous systems and for Type 2 diabetes.

High prices for new cancer drugs are also driving up spending, and pharmaceutical companies are collecting healthy profits. But John C. Rother, the policy director for AARP, said there were signs that even as brand-name manufacturers have posted higher prices for their top drugs, they have offered bigger rebates to major customers like pharmacy benefit managers. Because those rebates are negotiated individually and privately, they are difficult to measure.

“For specific drugs that are near the end of their patent life, the manufacturers are trying to think about how to hang on to sales,” Mr. Rother said. “The only way they can do that is to offer deeper rebates so there isn’t as much interest in generics.”

Though the role of the so-called Wal-Mart effect in the slowing of drug cost inflation is debated, a similar phenomenon has been documented on retail prices for other items. In a recent paper, two economists, Emek Basker of the University of Missouri and Michael D. Noel of the University of California, San Diego, described how the arrival of a Wal-Mart Supercenter results in a drop in grocery prices of 1 to 1.2 percent throughout the community.

Wal-Mart constitutes 5 to 6 percent of annual retail spending on pharmaceuticals, according to Adam J. Fein, president of Pembroke Consulting, which focuses on the drug supply chain.

Mr. Fein said Wal-Mart’s promotion had been beneficial not only to people without insurance but also to Wal-Mart itself, increasing traffic in the retailer’s pharmacies, which he said had been underused. “In the first two months of this program, the average Wal-Mart pharmacy’s daily volume increased by about 22 percent,” he said. “That translated to about 30 prescriptions a day.”

One customer who was drawn to Wal-Mart by the generic promotion is Bernadine Peterson, a nurse who lives in Westbury, N.Y. Ms. Peterson said she started using the Wal-Mart pharmacy four or five months ago because of the $4 generics. As a result, she said, she was saving $100 a month, reducing her monthly prescription bill to $200.

But the number of factors limiting inflation for prescriptions makes it unclear what effect Wal-Mart’s prices have. Several health care economists and financial analysts said they doubted the direct influence of drug plans at stores like Wal-Mart in slowing the inflationary trend. They noted that because the generics offered under the plans were typically the most established, and cheapest, ones, a price of $4 a month did not represent a large discount.

But Wal-Mart’s initiative could be having a less direct effect, according to Sharon Treat, the executive director of the National Legislative Association on Prescription Drug Prices, a coalition of state and local policy makers. Ms. Treat said that publicity about Wal-Mart’s plan had raised awareness of generics.

“I think it may be having a spillover effect psychologically,” Ms. Treat said. “Folks are seeing generics as more acceptable than they had.”

    Helped by Generics, Inflation of Drug Costs Slows, NYT, 21.9.2007, http://www.nytimes.com/2007/09/21/business/21generic.html?hp

Health Plan Overhauled at Wal-Mart

September 19, 2007
The New York Times
By MICHAEL BARBARO

Wal-Mart, long criticized for its health care coverage, unveiled a broad plan yesterday that is intended to cut employee costs, expand coverage and offer workers thousands of cheap prescription drugs.

Starting Jan. 1, Wal-Mart’s insurance will look a lot like that offered by many other American companies, but with some twists that even longtime critics described as innovative. Independent experts praised several features of the plan and said it could represent a turning point for the retailer, the nation’s largest private employer.

“On face value, this looks like a very significant change and improvement,” said Ron Pollack, president of Families USA, a health care advocacy group in Washington that has been critical of Wal-Mart.

Wal-Mart said it would give each employee or family that signs up for coverage a grant of $100 to $500 to defray health expenses while charging premiums as low as $5 a month. It will eliminate expensive hospital deductibles and make 2,400 generic drugs available to employees for $4 a prescription — about 1,000 more than it sells to customers at that price.

The plans with the lowest premiums would still charge annual deductibles as high as $2,000 — typical for American corporate health plans, but perhaps steep for Wal-Mart employees, many of whom work part time and earn less than $20,000 a year. And the company’s plans have other limitations, including waiting periods as long as a year for new employees.

Wal-Mart Watch, a group long critical of the company, said yesterday that “these plans are still unaffordable due to low wages or inaccessible due to waiting periods.”

It is unclear how many of the 125,000 Wal-Mart workers without health coverage would sign up. But industry analysts said the program represented an upgrade for the 636,000 employees who already receive health insurance through Wal-Mart. They said it could force the company’s discount-retailing competitors to offer more generous plans for their own workers.

Helen Darling, president of the National Business Group on Health and a former benefits consultant, called it “a very good plan,” saying that “parts of it, like the $4 generics, are game-changing for the industry.”

Mr. Pollack and others noted, though, that they had yet to see the fine print of the new program.

Wal-Mart has long been held up to ridicule for its health care programs.

Two years ago, the Maryland legislature took the unusual step of requiring Wal-Mart — and only Wal-Mart — to increase spending on health insurance. The law was later overturned.

Even before yesterday’s announcement, Wal-Mart had taken some steps to answer critics. It allowed part-time employees to enroll their children in the company’s insurance program, reduced the waiting period before a new part-time employee was eligible for benefits to one year from two, and created plans with premiums as low as $11 a month.

But critics contended that the company had not done enough, pointing to the still high deductibles and lengthy waiting periods.

The new program, for which workers can sign up starting this month, offers 50 ways to customize coverage, with varying trade-offs like higher premiums and lower deductibles.

In one plan, for example, an employee would pay premiums up to $79 a month, receive a health care credit of $100 and pay a deductible of $500. In another, the employee would pay premiums of $8 a month, receive a $100 health care credit, but pay a deductible of $2,000. Though many generic drugs will be available for $4, brand-name drugs will cost $30 to $50.

In an interview, Wal-Mart’s executive vice president for benefits, Linda M. Dillman, said the company hoped to persuade those workers without health coverage to sign up for it. About half of Wal-Mart workers have coverage from the company, while 40 percent more get their coverage elsewhere — through a spouse, a parent, a second job or a state program like Medicaid. About 10 percent have no health coverage.

“We are removing any barriers of entry” to the company’s health care plan, Ms. Dillman said. “When you are talking about $8 a month and a $100 health care credit, why would you not sign up?”

She said the program emphasized preventive care, paid for by the company before a deductible kicked in. Health care credits, for example, would make it possible for employees to see doctors and buy prescription drugs without paying anything out of pocket.

“If they need to seek care, they will do it, not forgo it,” Ms. Dillman said.

Milt Freudenheim contributed reporting.

    Health Plan Overhauled at Wal-Mart, NYT, 19.9.2007, http://www.nytimes.com/2007/09/19/business/19health.html?hp

Clinton Unveils Health Care Plan

September 17, 2007
By THE ASSOCIATED PRESS
Filed at 12:49 p.m. ET
The New York Times

DES MOINES, Iowa (AP) -- Democratic presidential candidate Hillary Rodham Clinton on Monday offered a sweeping health care reform plan to ensure coverage for all Americans with federal assistance to help defray the cost.

Thirteen years after her first effort was abandoned -- but saying she still bore the scars from that failure, Clinton described her new plan as necessary to address the crisis of some 47 million uninsured.

''I believe everyone -- every man, woman and child -- should have quality, affordable health care in America,'' the New York senator told an audience in Iowa. She vowed to accomplish the goal in her first term.

Her original plan was an unprecedented initiative for a first lady. This time, she is offering a $110 billion a year program as a candidate for the presidency, in the leadoff state that is her toughest battleground. The health care plan came late in her primary campaign, after several rivals had already described their visions.

''Perhaps more than anybody else I know just how hard this fight will be,'' Clinton said.

Dismissing the inevitable Republican criticism, Clinton admonished the crowd. ''I know my Republican opponents will try to equate health care for all Americans with government-run health care. Don't let them fool us again. This is not government-run.''

Clinton says she has learned from the 1990s experience, which almost derailed Bill Clinton's presidency and helped put Republicans in control of Congress for years to come. Aides say she has jettisoned the complexity and uncertainty of the last effort in favor of a plan that stresses simplicity, cost control and consumer choice.

The centerpiece of Clinton's ''American Health Choices Plan'' is the so-called ''individual mandate,'' requiring everyone to have health insurance -- just as most states require drivers to purchase auto insurance. Rival John Edwards has also offered a plan that includes an individual mandate, while the proposal outlined by Barack Obama does not.

The Democratic presidential contenders have been united in advocating universal coverage. They have parted ways on certain specifics, including the individual mandate, which has detractors from both ends of the political spectrum.

Republican skeptics say it would be too invasive and would restrict personal freedom and choice. Liberal Democrats have expressed concern that such a mandate would be too financially burdensome for lower-income individuals and families -- a concern shared by Obama, who has said individuals cannot be forced to purchase insurance until the cost of coverage is substantially reduced.

Aides said Clinton believes that an individual mandate is the only way to achieve health care for all. A key component of her plan would be a federal tax subsidy to help individuals pay for coverage.

Clinton's plan builds on the existing employer-based system of coverage. People who receive insurance through the workplace could continue to do so; businesses, in turn, would be required to offer insurance to employees, or contribute to a government-run pool that would help pay for those not covered. Clinton would also offer a tax subsidy to small businesses to help them afford the cost of providing coverage to their workers.

For individuals and families who are not covered by employers or whose employer-based coverage is inadequate, Clinton would offer expanded versions of two existing government programs: Medicare, and the health insurance plan currently offered to federal employees. Consumers could choose between either government-run program, but aides stress that no new federal bureaucracy would be created under the Clinton plan.

Clinton proposed several specific measures to pay for her plan, including an end to some of the Bush-era tax cuts for people making more than $250,000 per year. Edwards has vowed to completely repeal the tax cuts for high earners to pay for the cost of his plan, estimated at $90 billion-$120 billion per year, while Obama would pay for his plan in part by letting the tax cuts expire in 2010.

In response, Obama said Clinton's plan is similar to one he proposed in the spring, ''though my universal health care plan would go further in reducing the punishing cost of health care than any other proposal that's been offered in this campaign.''

He took another swipe at the Clinton administration's closed-door sessions on health care in the 1990s, saying ''the real key to passing any health care reform is the ability to bring people together in an open, transparent process that builds a broad consensus for change.''

Other Democratic rivals were swift in their criticism.

Delaware Sen. Joe Biden said, ''If universal health-care plans could have gotten us health care, we would have gotten it a long time ago,'' while Connecticut Sen. Chris Dodd said, ''To ensure all Americans have affordable health care will take more than leadership that simply knows how to fight.''

Added John Edwards: ''If you're going to negotiate universal health care with the same powerful interests that defeated it before, your proposal isn't a plan, it's a starting point.''

Republican Mitt Romney, in New York City for a fundraising stop, criticized Clinton's proposal, saying, '''Hillary care' continues to be bad medicine ... in her plan, we have Washington-managed health care. Fundamentally, she takes her inspiration from European bureaucracies.''

The plan that Romney helped institute while governor of Massachusetts requires the same individual insurance mandate as Clinton's and uses state subsidies to help reduce the cost of private coverage. Since then, Romney has said he would leave it up to the states to decide whether they supported such a mandate.

Said Republican Rudy Giuliani's campaign: ''Senator Clinton's latest health scheme includes more government mandates, expensive federal subsidies and more big bureaucracy -- in short, prescription for an increase in wait times, a decrease in patient care and tax hikes to pay for it all.''

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Associated Press Writer Ashley M. Heher in Chicago contributed to this report.

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http://www.hillaryclinton.com

    Clinton Unveils Health Care Plan, NYT, 17.9.2007, http://www.nytimes.com/aponline/us/AP-Clinton-Health-Care.html?hp

Prestigious Lasker Awards Announced

September 16, 2007
By THE ASSOCIATED PRESS
Filed at 2:44 a.m. ET
The New York Times

NEW YORK (AP) -- Two researchers who opened up the field of heart-valve replacement and a scientist who discovered a type of cell that plays a key role in the immune system have won prestigious medical prizes.

The $150,000 Albert Lasker Medical Research Awards will be presented Sept. 28 in New York by the Albert & Mary Lasker Foundation.

Dr. Albert Starr of the Providence Health System in Portland, Ore., and Dr. Alain Carpentier of the Georges Pompidou European Hospital in Paris will share the clinical research prize for developing replacement heart valves. More than 300,000 people a year worldwide get heart valves replaced, and it's the second most common heart surgery in the United States, the foundation said.

In the 1950s, Starr and the late engineer Lowell Edwards defied conventional wisdom by developing an artificial heart valve that looked nothing like a natural one. Their design, a free-floating ball inside a cage, had been used in bottle stoppers for a century.

In September 1960, Starr performed the first successful valve replacement in a human, a man who survived for a decade before dying in an accident.

But people who get artificial heart valves must take blood thinners for the rest of their lives to cut their risk of blood clots. To get around that, Carpentier adapted valves from pigs. In 1965, he and a colleague did the first successful replacement of a human valve with an animal valve. In 1968, he implanted an improved version in a patient who survived for 18 years.

Carpentier also developed a valve repair surgery that ''ushered in the modern era of valve reconstruction,'' the foundation said.

The prize for basic research goes to Dr. Ralph Steinman of The Rockefeller University in New York for discovering dendritic cells, which trigger defenses against germs.

''He revolutionized our understanding of the events that instigate an immune response,'' the foundation said.

Steinman began his work in 1970, trying to discover what made immune system cells react to invaders. Working with material recovered from mouse spleens, he spotted the irregularly shaped dendritic cells under a microscope. He went on to show that dendritic cells goaded other cells called T cells into action against invaders.

Dendritic cells are now being studied for turning the immune system against cancers and germs such as HIV.

In addition to the research prizes, the $150,000 Lasker award for public service will be presented to Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, for spearheading government efforts against AIDS and bioterrorism.

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On the Net:

http://www.laskerfoundation.org

    Prestigious Lasker Awards Announced, NYT, 16.9.2007, http://www.nytimes.com/aponline/us/AP-Lasker-Awards.html

Clinton to Propose Universal Health Care

September 16, 2007
The New York Times
By ROBERT PEAR

WASHINGTON, Sept. 15 — Senator Hillary Rodham Clinton on Monday will lay out a plan to secure health insurance for all Americans while severely limiting the ability of insurers to deny coverage or charge higher premiums to people with chronic illnesses and other medical problems, her aides and advisers say.

Mrs. Clinton’s purpose, they said, is not only to cover the 47 million people who are uninsured but to improve the quality of health care and make insurance more affordable for those who already have it.

The goal of Mrs. Clinton’s plan, to be outlined in a speech in Des Moines, is similar to that of the ill-fated plan that she and President Bill Clinton pushed in 1993 and 1994.

But advisers to Mrs. Clinton, a Democrat from New York, said Saturday that she would try to avoid the perception that she was advocating a bureaucratic, big-government solution. That perception, promoted by conservative Republicans and the insurance industry, sank the Clinton plan in 1994.

In her campaign for the Democratic presidential nomination, Mrs. Clinton routinely receives applause when she admits having made mistakes as first lady. “I’ve tangled with this issue before, and I’ve got the scars to show for it,” she said recently.

Previewing her speech, Clinton aides said she would assert on Monday that there was a moral imperative to ensure that “every single American has quality affordable health coverage,” just as she contends there is an economic imperative to rein in costs.

Phil Singer, a spokesman for the Clinton campaign, said Saturday that he could not provide details. But aides and advisers who spoke on condition on anonymity said that Mrs. Clinton would propose expanding the Children’s Health Insurance Program as a step toward universal coverage. She has denounced President Bush’s efforts to restrict eligibility and limit spending on the program.

Clinton aides said her plan would preserve a large role for private insurance companies; would promote the use of health information technology and low-cost generic drugs; and would create a public-private institute to evaluate and compare drugs, devices and medical treatments.

Mrs. Clinton will not try to impose an overall limit on national health spending, the aides said. But she is prepared once again to do battle with insurance companies, which she has said “spend tens of billions of dollars a year figuring out how not to cover people” and “how to cherry-pick the healthiest persons, and leave everyone else out in the cold.”

Aides to Mrs. Clinton said her proposal would elaborate several ideas that she has floated this year.

They said, for example, that Mrs. Clinton would amplify a comment in March when she declared, “We could require that every insurance company had to insure everybody, with no exclusion for pre-existing conditions.”

On another occasion, she vowed, “As president, I will end the practice of insurance company cherry-picking once and for all by allowing anyone who wants to join a plan to do so, and by prohibiting insurance companies from carving out benefits or charging higher rates to people with health problems.”

Karen M. Ignagni, president of America’s Health Insurance Plans, the chief lobby for insurers, said they endorsed the goal of universal coverage. But Ms. Ignagni said that insurers denied only 3 percent of claims, and that many of those were for experimental procedures that employers did not cover.

Mary Nell Lehnhard, senior vice president of the Blue Cross and Blue Shield Association, said, “Some of Mrs. Clinton’s proposals, while trying to make insurance more affordable for older, sicker people, could unintentionally drive up costs for young, healthy people and ultimately for everyone.”

Mrs. Clinton’s role as architect and champion of the plan to remake the nation’s health care system in 1993 and 1994 is still hotly debated.

In an essay posted Friday on the Web site of The American Prospect, Paul Starr, who was a senior adviser at the White House in 1993, said that Bill Clinton had “settled on the basic model for reform” before he took office. Mrs. Clinton’s role was “not to choose a policy, but to develop the one that the president had already adopted,” said Mr. Starr, a Princeton professor and co-founder of The American Prospect, a liberal journal.

But aides to Senator Barack Obama of Illinois, one of Mrs. Clinton’s rivals for the Democratic presidential nomination, said she bore a large measure of responsibility for the fiasco.

She insisted on developing the 1993-94 plan under a veil of secrecy, refused to compromise on her vision of “health care reform” and threatened to demonize anyone who tried to block it, the Obama aides said.

    Clinton to Propose Universal Health Care, NYT, 16.9.2007, http://www.nytimes.com/2007/09/16/us/politics/16clinton.html?hp

Cancer Free at Age 33, but Weighing a Mastectomy

September 16, 2007
The New York Times
By AMY HARMON

CHICAGO — Her latest mammogram was clean. But Deborah Lindner, 33, was tired of constantly looking for the lump.

Ever since a DNA test had revealed her unusually high chance of developing breast cancer, Ms. Lindner had agonized over whether to have a mastectomy, a procedure that would reduce her risk by 90 percent.

She had stared at herself in the mirror, imagining the loss of her familiar shape. She had wondered, unable to ask, how the man she had just started dating would feel about breasts that were surgically reconstructed, incapable of feeling his touch or nursing his children.

But she was sure that her own mother, who had had chemotherapy and a mastectomy after a bout with the cancer that had ravaged generations of her family, would agree it was necessary.

“It could be growing inside of me right now,” she told her mother on the phone in February, pacing in her living room here. “We could find it any time.”

Waiting for an endorsement, she added, “I could schedule the surgery before the summer.”

But no approval came.

“Oh, sweetheart,” her mother said. “Let’s not rush into this.”

Joan Lindner, 63, is a cancer survivor. Her daughter, by contrast, is one of a growing number of young women who call themselves previvors because they have learned early that they are genetically prone to breast cancer, and have the chance to act before it strikes.

As they seek to avoid the potentially lethal consequences of a mutant gene, many of them turn to relatives who share its burden. But at a moment when a genetic test has made family ties even more tangible, they are often at their most strained.

Parents who have fought cancer typically have no experience with the choices that confront their children, and guilt over being the biological source of the problem can color their advice. Siblings and cousins who carry the risk gene evangelize their own approach to managing it, while those who dodged its inheritance seem unqualified to judge.

Even as she searched for her own answer in the year after her DNA test, Deborah Lindner, medical resident, found herself navigating her family’s strong and divergent opinions on the imperfect options that lay before her.

Her father, who once feared he would lose his wife to cancer, encouraged the surgery. Her sister reminded her that cancer might be cured in a few years if she could wait.

Her aunt said she hated to see her niece embrace a course of action akin to “leechings of the Dark Ages.” A cousin declined even to take the DNA test.

But it was her mother’s blessing that Deborah most eagerly sought.

Mrs. Lindner, who had passed her defective gene to her daughter, wanted to will her more time. When she had her own breasts removed she had been married for 27 years and had raised two daughters. Now Mrs. Lindner couldn’t shake the fear that her daughter might trade too much in her quest for a cancer-free future. What if taking such a radical step made it harder for Deborah to find someone special and become a mother herself?

“I have this amazing gift of knowing my risk,” her daughter told her over the phone that winter night, gazing out over the frozen city from her apartment on the 38th floor. “How can I not do anything about that?”

The Lindners share a defective copy of a gene known as BRCA1 (for breast cancer gene 1) that raises their risk of developing breast cancer sometime in their lives to between 60 and 90 percent. Only 30,000 of more than 250,000 American women estimated to carry a mutation in BRCA1 or a related gene, BRCA2, have so far been tested. But their numbers have doubled in the last two years, and with a sharp increase in genetic testing, are expected to double again in the coming one.

About a third opt for preventive mastectomies that remove the tissue where the breast cancer develops. A majority have their ovaries removed, halving their breast cancer odds while decreasing the risk of highly lethal ovarian cancer, to which they are also prone. Some take drugs that ward off breast cancer. Others hope that frequent checkups will catch the cancer early, or that they will beat the odds.

Their decisions, which require weighing an inborn risk against other life priorities, are highly individual. But with DNA forecasts of many other conditions on their way, BRCA carriers offer the first clues for how to reckon with a serious disease that may never arise — and with the family turmoil that nearly always does.

A 50-50 Chance

Deborah Lindner’s sister, Lori French, got her results first.

Long ago, before she knew about the DNA test, Ms. French, 37, had resolved to have her breasts and ovaries removed by age 40 to avoid the family cancer. Nor did she want reconstructive surgery, having seen her mother struggle with the pain and cosmetic disappointment of hers.

“Plan on it,” she had told her husband before they got married a decade earlier. “I’m going to get old and have big hips and no breasts.”

The envelope with the test results that Ms. French opened with shaking hands in the summer of 2005 offered a reprieve. She and her husband sobbed, hugging each other in the knowledge that she was free of the genetic defect. While she still had the 12 percent chance any woman has of developing breast cancer, she could not have passed on the steep BRCA risk to either her daughter or son.

“It’s done!” Ms. French told her family. “In our line, it’s ended.”

For years, the sisters had united in a common dread. Now it was Deborah’s alone.

“I’m so sorry you have to be the one,” Ms. French said when her sister called a week later with the news that she had tested positive for the mutation.

“I’m so glad it’s not you,” Deborah replied.

It could have been either, neither or both of them — each sister, she knew, had had a 50 percent chance of inheriting the defective gene from their mother, dictated solely by a roll of the genetic dice. But if it was going to be one of them, Deborah thought she was in a better position to handle it. Her sister taught at a missionary school in the Philippines, where she lived with her family, while Deborah was single and in the second year of her medical residency program at Northwestern University, with ready access to quality health care.

Yet in the weeks that followed, Deborah fought off pangs of jealousy and the fantasy that fate could somehow be rearranged.

“She already has a husband, she already has kids,” Deborah thought on morning runs along Lake Michigan.

She enrolled in a stepped-up surveillance program that required alternating mammograms and sonograms with M.R.I.’s every six months. But on the mornings of her appointments, and at unpredictable moments in between, she was overwhelmed with fear. Often, she would examine her breasts every other day.

“It’s taking over my mind,” she told Erin King, a close friend and fellow resident in the obstetrics and gynecology program.

Ms. King, 33, who had had breast implants for cosmetic reasons, and another resident friend were proponents of pre-emptive surgery.

“Get them off and get new ones,” they told her. “They’ll be awesome and perky and cute.”

But they sympathized with her distress at the appearance of traditional reconstruction, with skin grafts molded into a fake nipple that can never quite match the texture of a real one and the areola simulated by a tattoo.

“They just don’t look normal,” Deborah sighed as they debated the question over the barbecue grill at Ms. King’s apartment one night.

Accustomed to seeking her mother’s counsel, Deborah kept her distance in those months, not wanting to worry her. Instead, she pestered breast specialists. How many cancers do you actually catch? How many in an early stage? The answers were vague. Still, they discouraged her from surgery. Most women who had a preventive mastectomy, a breast surgeon told her, already had a family.

A Frightening Pattern

In the fall of 2006, Deborah turned her residency research requirement into a personal quest for better information, analyzing the records of BRCA mutation carriers who had been counseled at Northwestern.

One file told of a woman who had developed cancer and chosen a lumpectomy, a procedure that leaves the breast mostly intact. The cancer came back — while she was pregnant. When she had an early Caesarean section so she could get chemotherapy without harming the baby, doctors discovered an ovarian tumor that had already spread to her abdomen.

The pattern was not uncommon. BRCA-related breast cancer usually strikes early, before age 50, and is more likely to recur in the other breast. Ovarian cancer, which strikes about 50 percent of BRCA1 carriers, compared with 2 percent of the general population, is rarely detected early and is fatal three-quarters of the time.

“It’s like I’m reading this book and I know what’s coming,” Deborah told her fellow residents. “I see the note, ‘Patient opts for surveillance,’ and I’m like, ‘No, don’t do it, don’t do it!’ ”

Several times during her oncology rotation that term, she slipped out of an ovarian cancer patient’s room to cry in the stairwell. To eliminate her risk of ovarian cancer, doctors had recommended that she have her own ovaries removed by age 40, or as soon as she had children. Removing her ovaries would halve her breast cancer risk as well, but the hormones that are generally used to treat the harsh menopausal symptoms brought on by the procedure, Deborah learned, would then raise the risk again — unless she had her breasts removed first.

Unspoken Questions

Over Thanksgiving at her parents’ winter home in Florida, Deborah ran through her risk analysis. Her father, Philip Lindner, listened and nodded. Mammograms and ultrasounds, she noted, may miss more than half of cancers in younger women with denser breasts. Magnetic resonance imaging tests are more reliable but produce more false positives, which can lead to unnecessary biopsies and worry. And it is not yet clear that early detection improves survival rates in women with BRCA mutations.

“You can’t argue with statistics,” said Mr. Lindner, a financial executive. “You don’t want to get cancer and then say, ‘I wish I would have done thus and so.’ ”

Deborah’s mother agreed it was important to know the risks. But not knowing them could be a luxury, too. Had she had the same options as her daughter, would she have found a man and had a family? It might have altered her whole life.

“I know the joy that my girls have brought to me,” she confided to a friend. “If Deb misses it, she won’t know what she missed. But having experienced it, I would never have wanted to miss it.”

Tentatively, she broached the subject of breast-feeding with her daughter. “That was something very special to me,” Mrs. Lindner said.

“Wouldn’t it be more special,” Deborah shot back with uncharacteristic edge, “if I was around to have children in the first place?”

But if her mother worried that surgery would make her less attractive to men, Deborah shared those concerns.

“Do fake boobs freak you out?” she often imagined asking Jeff Zehr, the man she had begun dating a few months before.

Mr. Zehr, a fellow marathon runner who attended her church, had told her she was special to him, and she felt similarly. But she didn’t want to scare him away or, worse, put pressure on the relationship to proceed faster than it otherwise would.

As Deborah felt increasingly torn between life events that couldn’t be rushed, and surgeries that shouldn’t wait, there was one more piece of information she thought would sway her mother.

“Will you do something for me?” she asked. “Look through the family tree and find out how old everyone was when they got their cancer.”

The answers were chilling. One of her first cousins, Mrs. Lindner learned, had breast cancer at age 33. Now the cancer had returned, and she was losing the fight.

Another first cousin got her breast cancer diagnosis at 34; she died. Her daughter, at 33, had recently learned she had the disease.

Mrs. Lindner called her daughter. “Have the surgery as soon as possible,” she said.

But a few days later, Mrs. Lindner called back. Her mother’s ovarian cancer, she remembered, had not surfaced until she was in her 70s — and she had survived. Joan Lindner had been 48 when the doctors detected her breast cancer, and she had survived too.

“We were really on the far side of the bell curve,” she said.

Memories of Chemotherapy

Deborah remembered her mother’s cancer diagnosis, which came just before her graduation from high school. Her school choir had been selected to sing at Carnegie Hall, and her parents had planned to come as chaperones. Instead, she went alone while her father accompanied Mrs. Lindner to chemotherapy appointments. During that summer, her mother’s bedroom door, always open, stayed closed.

Now Deborah reminded her what she had always said about her chemotherapy. Her eyelashes, once long and curly, had been rendered short and stubby. Food tasted different. It had, in so many subtle ways, aged her.

“I don’t want that for myself,” Deborah said. “I don’t want to treat cancer. I just never want to get it.”

She began to seek support elsewhere. A genetic counselor gave her a brochure for Bright Pink, a group of young women who have tested positive for the BRCA genes. Lindsay Avner, its 24-year-old founder, lived in Chicago, and their meeting over coffee in the hospital lounge one evening in March lasted four hours. Ms. Avner had had a prophylactic mastectomy last year.

“You’ve got to see my breasts,” she told Deborah, escorting her into the bathroom.

Ms. Avner’s surgeon at Memorial Sloan-Kettering Cancer Center in Manhattan had used a technique that preserved the breast skin and nipples, leaving a scar only under the breast.

Deborah, still in her scrubs, said, “Wow.”

Mr. Zehr drove her to an appointment with Geoffrey Fenner, the chief of plastic surgery at Evanston Memorial Hospital one evening in mid-April. If she could find a surgeon to perform the mastectomy, Dr. Fenner said he would perform the reconstruction.

The nipple-sparing technique, the doctor explained, is not popular in the United States; a decade-old study suggested that leaving the nipple increased the risk of cancer. But more recent research indicated that the risk was perhaps only 1 percent greater than with traditional reconstruction.

“I can live with that,” Deborah said.

Mr. Zehr, a corporate insurance underwriter, waited outside. On the car ride home, Deborah lobbed her question into the darkness.

“Does the thought of plastic surgery bother you?” she asked.

A moment passed.

“It would if I thought the person I was with was doing it because they didn’t like the way they looked,” he said. “But that isn’t this situation.”

He looked at her. “So, no, it doesn’t bother me.”

Deborah announced her intention to have surgery in a long e-mail message to family members at the end of April.

“I want to share with you what I feel is the right answer for me,” she wrote.

Like anyone who carried the defective gene, she might never get cancer, she acknowledged. Or she might only get it when she was old. “But I’m not a gambler,” she wrote.

Her aunt, Gloria Spurlock, a music teacher in Louisville, Ky., immediately called Mrs. Lindner, her sister, at her home in Des Moines.

“How could you let her dismember her body?” she demanded. “You have to talk her out of it.”

Stung, Mrs. Lindner tried to defend her daughter. But Mrs. Spurlock was voicing some of her own worst fears.

“Gloria,” she replied. “This is Deb’s decision.”

It was the first of several heated phone calls between the sisters. Mrs. Spurlock had considered getting tested after Mrs. Lindner found out she had a BRCA mutation. The sisters knew the gene must have come from their mother, who had had ovarian cancer a decade earlier, and whose own mother had died of the same disease. But Mrs. Spurlock concentrated instead on a healthy diet, rest and positive thinking.

The medical profession, she had long believed, was far too eager to administer drugs and remove body parts that could be healed.

Mrs. Spurlock’s daughter, Lisa Spurlock, 24, also expressed dismay.

“I’m sorry you have to be so scared of this disease,” Ms. Spurlock wrote to her cousin.

The reactions gave Deborah pause. Then they made her angry.

“Why are they saying things like this to me?” she demanded of her mother.

From the Philippines, her sister suggested that Deborah was exposed to the worst-case scenarios as a doctor. Can’t breast cancer often be cured?

“You’re right, it can often be cured,” Deborah wrote back. “The problem is that the cure involves cancer, surgery, chemotherapy, sometimes radiation and the possibility of metastasis and death.”

When a second surgeon in Chicago gave the idea of the preventive mastectomy a lukewarm reception because of her age, Deborah flew to New York for a consultation with the doctor who had performed Ms. Avner’s surgery. She invited her mother to come with her.

On the plane, Deborah showed her mother a PowerPoint presentation she had created, making the case for preventive surgery. Mrs. Lindner listened. But mostly she watched the relief in her daughter’s face as she talked about escaping her genetic prognosis.

It was there again the next day in Dr. Patrick I. Borgen’s office on Park Avenue, when the doctor supplied the first unconditional medical affirmation of Deborah’s view.

“Maybe your grandchildren will have better options,” said Dr. Borgen, director of the Brooklyn Breast Cancer Project at the Maimonides Cancer Center. “But right now a draconian operation is the best thing we can do for you.”

Back home in Iowa, Mrs. Lindner asked her husband: “What would we have done? What if we had known when we were dating?”

“We would have done the same thing,” he said. “We would have wanted you to live.”

At Dr. Borgen’s recommendation, Deborah scheduled the double mastectomy with Dr. D. J. Winchester at Evanston Northwestern hospital for the last weekend in June, three days after her medical board exam. Her insurance agreed to pay after requesting a letter of support from her surgeons. There would be just enough time to recover before she began practicing in the fall.

A Glance in the Mirror

But with the date fixed, Deborah, for the first time in months, began to doubt her decision.

Glancing in the mirror on her way out for a run, she looked herself over.

“I was like, all right, there’s me, those are my breasts,” she told a friend. “That is what I see.”

It did not help that Mr. Zehr did not seem to quite understand what the surgery entailed. “I won’t be able to breast-feed,” she reminded him.

“I thought you were having reconstruction,” he said, puzzled.

“Yes,” she said, “but they’ll be silicone.”

With three days to go, Deborah met with a nurse to go over the details of the procedure she had discussed with the surgeon. She wanted to be sure about where the incisions would be, and the size of the implants.

“We had talked about the scars on the side,” she told the nurse, “and not touching the nipple.”

“Oh, you may have incisions everywhere,” the nurse said. “There may be one up the front and underneath and up the nipple.”

Deborah burst into tears.

“Am I doing the right thing?” she asked her mother from her cellphone after she left the office.

Mrs. Lindner, packing for the drive to Chicago to be with her daughter during her hospital stay, knew she was not just asking about the scars. And she had the answer.

“Yes,” Mrs. Lindner said. “You are doing what is right for you.”

On the morning of the surgery, Mr. Zehr was there, holding Deborah’s hand. “You look cute in your gown,” he told her.

In the lounge, Mrs. Lindner waited. The surgery and reconstruction took seven and a half hours, twice as long as the doctors had expected. The incisions were small, Dr. Winchester explained when he came out, and hidden under the breast, so it had taken a long time to scrape out all the breast tissue.

Then Mrs. Lindner rode up in the elevator with her daughter, still unconscious from the anesthesia. As they arrived at their floor, Deborah opened her eyes.

“Mom,” she said, and managed a small smile.

    Cancer Free at Age 33, but Weighing a Mastectomy, NYT, 16.9.2007, http://www.nytimes.com/2007/09/16/health/16gene.html?hp

Experts Question Study on Youth Suicide Rates

September 14, 2007
The New York Times
By ALEX BERENSON and BENEDICT CAREY

Last week, leading psychiatric researchers linked a 2004 increase in the suicide rate for children and adolescents to a warning by the Food and Drug Administration about the use of antidepressants in minors. The F.D.A. warning, the researchers suggested, might have resulted in severely depressed teenagers going without needed treatment.

But the data in the study, which was published in The American Journal of Psychiatry and received widespread publicity, do not support that explanation, outside experts say.

While suicide rates for Americans ages 19 and under rose 14 percent in 2004, the number of prescriptions for antidepressants in that group was basically unchanged and did not drop substantially, according to data from the study. Prescription rates for minors did fall sharply a year later, but the suicide rates for 2005 are not yet available from the Centers for Disease Control and Prevention.

“There doesn’t seem to be any evidence of a statistically significant association between suicide rates and prescription rates provided in the paper” for the years after the F.D.A. warnings, said Thomas R. Ten Have, a professor of biostatistics at the University of Pennsylvania.

In the report published last week, the authors analyzed data on suicides and antidepressant use over several years in the United States and the Netherlands. They argued that drug regulators may have created a larger problem by requiring pharmaceutical companies to place warnings on antidepressants, scaring away patients and doctors. The F.D.A. warning label says that a potential side effect in young people is an increase in suicidal thoughts and behavior.

“The most plausible explanation is a cause and effect relationship: prescription rates change, therefore suicides change,” said Dr. J. John Mann, a psychiatrist at Columbia University and a co-author of the study.

But Dr. Ten Have and other experts, while noting that it may still turn out that a reduction in prescriptions is leading to increased suicides among young people, said that the new study neither proved nor disproved this. Instead, some experts say, the study illustrates why suicide trends are so difficult to understand — and why this debate has been so polarizing and confusing.

In an interview, Robert D. Gibbons, a professor of biostatistics and psychiatry at the University of Illinois at Chicago and the lead author of the journal article, acknowledged that the data from the United States that he and his colleagues analyzed did not support a causal link between prescription rates and suicide in 2004. “We really need to see the 2005 numbers on suicide to see what happened,” he said.

But Dr. Gibbons defended the paper, saying that when taken in the context of previous studies that linked falling antidepressant use to increased suicide rates, “this study was suggestive, that’s what we’re saying.”

Other experts, however, said that the problem with such studies is precisely that they are suggestive rather than conclusive and are open to interpretation. Suicides are rare and uniquely personal events that can be driven by many factors: worsening depression or other mental illnesses, breakups or job loss, lack of drug or psychiatric treatment, even easy access to guns.

In calling for the labeling change on antidepressants, F.D.A. scientists based their decision on data from drug makers’ clinical trials, considered the gold standard in medical research. Those trials have shown that young patients who took antidepressants were about twice as likely than those on placebos to report suicidal thoughts or attempts, though the numbers in both groups were small.

Yet none of the youngsters in the trials, most of which ran for no more than a month or two, actually committed suicide. And most psychiatrists with long experience using antidepressants in children say the benefits far outweigh any risk.

In studies of data collected before 2004, Dr. Gibbons, Dr. Mann and others found clear associations between prescription patterns and suicide rates. For instance, prescription rates for patients from ages 10 to 24 rose steadily in the 1990s, while the suicide rate in that age group fell 28 percent from 1990 to 2003, according to a government report released last week.

In another study, researchers at Columbia University, analyzing data from 1990 to 2000, found that for every 20 percent increase in the use of antidepressants among adolescents, there were five fewer suicides per 100,000 people each year. Psychiatric researchers have found similar patterns among some age groups in other countries, including Sweden, Japan and Finland.

But many uncertainties remain. While the suicide rate for adolescents has fallen over the last decade, it has remained largely unchanged for the overall population, though prescriptions for psychiatric medicines have risen sharply in all age groups. Adjusted for the demographic changes, about 11 Americans per 100,000 killed themselves in 2004, the same as in 1994.

Demographics can play a role: White people kill themselves about twice as frequently as African-Americans and Hispanics, so as the population becomes more diverse, the suicide rate ought to drop, all else being equal. And suicide rates also appear to be negatively correlated with economic growth, which was exceptionally strong from 1994 to 2000. Advances in medicine also mean more lives can be saved now.

With so many potentially confounding factors at play, interpreting the relationship between prescription rates and suicides is difficult, said Andrew Leon, a professor of biostatistics at Weill Cornell Medical College who has served on F.D.A. panels studying suicide risk and antidepressants.

“These kinds of studies are very important in giving us a sense of the rates of disease and death in a population and how those may correspond to other things,” Dr. Leon said. “But what they don’t do is tell us whether the two trends are directly related.”

    Experts Question Study on Youth Suicide Rates, NYT, 14.9.2007, http://www.nytimes.com/2007/09/14/us/14suicide.html

San Francisco to Offer Care for Every Uninsured Adult

September 14, 2007
The New York Times
By KEVIN SACK

SAN FRANCISCO — Since contracting polio at age 2, Yan Ling Ho has lived with pain for most of her 52 years. After she immigrated here from Hong Kong last year, the soreness in her back and joints proved too debilitating for her to work.

That also meant she did not have health insurance. Not wanting to burden her daughter, who was already paying her living expenses, Ms. Ho delayed doctors’ visits and battled her misery with over-the-counter medications.

“Sometimes the pain was so bad, I would just cry,” she said. “I didn’t know what else to do.”

Last month, unable to bear her discomfort any longer, Ms. Ho went to North East Medical Services, a nonprofit community clinic on the edge of Chinatown, and discovered to her delight that she qualified for a new program that offers free or subsidized health care to all 82,000 San Francisco adults without insurance.

The initiative, known as Healthy San Francisco, is the first effort by a locality to guarantee care to all of its uninsured, and it represents the latest attempt by state and local governments to patch a inadequate federal system.

It is financed mostly by the city, which is gambling that it can provide universal and sensibly managed care to the uninsured for about the amount being spent on their treatment now, often in emergency rooms.

After a two-month trial at two clinics in Chinatown, the program is scheduled to expand citywide to 20 more locations on Sept. 17.

Whether such a program might be replicated elsewhere is difficult to assess. In addition to its unique political culture, San Francisco, with a population of about 750,000, has the advantages of compact geography, a unified city-county government, an extensive network of public and community clinics and a relatively small number of uninsured adults. Virtually all the city’s children are covered by private insurance or government plans.

At the bustling North East Medical Services clinic, where the staff and the signs are multilingual, doctors and nurses are trying to build trust with patients who may have last sought treatment from an herbalist. Families crowd the elevators, as teenagers help parents and grandparents navigate the system. Patients like Ms. Ho say they hope their access to the clinic’s services will bring them independence, and a chance to work.

Healthy San Francisco provides uninsured San Franciscans with access to 14 city health clinics and 8 affiliated community clinics, with an emphasis on prevention and managing chronic disease. It is, however, not the same as insurance because it does not cover residents once they leave the city.

After a phased start-up, the city plans to bring private medical networks into the program next year, expanding the choice of doctors. Until November, enrollment will be limited to those living below the federal poverty line ($10,210 for a single person; $20,650 for a family of four). Then it will open to any resident who has been uninsured for at least 90 days, regardless of income or immigration status.

Only then will city officials learn whether the program appeals to middle-class workers, who make up a growing share of the uninsured. And only then can they test whether San Francisco has the medical infrastructure to handle the desired increase in demand, and to do so without raising taxes.

So far, enrollment has exceeded expectations. The city projected that 600 to 1,000 people would sign up by the end of August. More than 1,300 did, even though officials have done little marketing. They hope to enroll about 45,000 people — more than half the city’s uninsured — in the first year. Some clinics are adding night hours and small numbers of workers.

“We really didn’t know what the interest level would be, so we’re very pleased,” said Mayor Gavin Newsom. “At the same time, we don’t want overexuberance yet because we don’t want to fall of our own weight.”

At the two pilot clinics, efforts are first made to qualify patients for Medicaid or other state and federal insurance programs. Those left over receive a Healthy San Francisco card that makes them eligible for primary care, dental exams, mental health and substance abuse services, hospitalization, radiology and prescription drugs.

Because the coverage is not portable, officials believe that people with private insurance will have little incentive to drop their policies to take advantage of the city’s cut-rate services.

Like Ms. Ho, many of those enrolling were already using the city’s health clinics — or the emergency room at San Francisco General Hospital — in times of acute need, like an asthma attack or stroke. About 57,000 of the 82,000 uninsured San Franciscans have used the city’s health system at some point.

But the new program hopes to persuade them to become regulars who regard their neighborhood clinic as a medical home. Once enrolled, patients are assigned a physician and encouraged to get blood pressure checks, mammograms and other screenings.

“We had a system that was not a system, and was based on episodic visits for chronic and acute care,” said Dr. Mitchell H. Katz, the city health director. “The idea that you should come get a cholesterol test, that didn’t happen.”

Nor was it uncommon for patients to ignore doctors’ orders because of cost. Before the program started in July, a clinic doctor had ordered X-rays and blood tests for Ms. Ho, but she never got them.

“Now I feel more comfortable coming in to get services and following the doctor’s instructions,” she said, speaking through an interpreter. She added that she recently had the recommended tests and is waiting for results.

The program was born of the city’s impatience with federal and state inaction, Dr. Katz said. In 1998, voters overwhelmingly endorsed universal access to health care in a citywide referendum. Over the years, city officials explored ways to provide universal insurance but, like other governments, could not figure out how to pay for it.

“What we did next was profound and simple,” said Mr. Newsom, who shepherded the program with Supervisor Tom Ammiano. “We asked a different question. We asked: How do we provide universal health care to all uninsured San Franciscans? And that one modest distinction allowed us to answer the question we hadn’t been able to answer for a decade.”

Tangerine M. Brigham, the program’s director, projects that it will cost $200 million the first year, and Mr. Newsom expects to finance it without a tax increase. The city already spends about that much on care for the uninsured, and that money will essentially be redirected to Healthy San Francisco.

The program was also selected by the state to receive a three-year federal grant worth $24 million a year for expanding access to care. And because enrollees are still uninsured, they remain eligible for state and federal benefits, like discounts on AIDS drugs.

Patients are asked to contribute nominal amounts through membership fees and co-payments that vary by income.

Those from families with incomes below the federal poverty line pay nothing. Those who earn more pay quarterly fees that range from $60 to $675, which is the rate for those with incomes above 500 percent of the poverty level ($51,050 for a single; $103,250 for a family of four). That is where the subsidy ends. The co-payments range from $10 to $20 for a clinic visit and from $200 to $350 for an inpatient stay.

A final financing mechanism has placed the program in legal jeopardy. To make sure the new safety net does not encourage businesses to drop their private insurance, the city in January will begin requiring employers with more than 20 workers to contribute a set amount to health care. The Healthy San Francisco program is one of several possible destinations for that money, with others being private insurance or health savings accounts.

Late last year, the Golden Gate Restaurant Association challenged that provision in federal court, arguing that it violates a law governing employer health benefits. A judge has scheduled a hearing for early November.

Mr. Newsom, a restaurateur and former member of the association, said the program would work only if accompanied by an employer mandate. But he said the city would have contingencies if it lost in court. “It may set us back,” he said, “but it’s not going to end this program.”

    San Francisco to Offer Care for Every Uninsured Adult, NYT, 14.9.2007, http://www.nytimes.com/2007/09/14/us/14health.html?hp

Rally at Ground Zero Aims to Build Support for 9/11 Health Care Legislation

September 9, 2007
The New York Times
By RAY RIVERA

Several hundred union workers and elected officials, including Senator Hillary Rodham Clinton, rallied near ground zero yesterday in support of federal legislation that would provide long-term monitoring and treatment for people exposed to dust in Lower Manhattan during the 9/11 cleanup.

“The fact that men and women are ill and not being helped here is a national disgrace,” Representative Carolyn B. Maloney said. “We are the wealthiest nation on earth; the least we can do is provide health care for the men and women who were there on 9/11. They were here for us. We need to be here for them.”

Mayor Michael R. Bloomberg and some members of New York’s Congressional delegation had been calling on the federal government to assume more of the financial burden of ground zero-related health problems.

Representative Vito Fossella, Republican of New York, who sponsored the bill with Ms. Maloney and Representative Jerrold L. Nadler, both Democrats, said the federal government had been reluctant to provide a steady flow of money. That reluctance seemed to be waning, he said, as more scientific evidence about the illnesses emerged.

“I think it’s gone from anecdotal individual stories of a diminished quality of life,” he said, “to stories of respiratory and pulmonary problems to hard and fast sets of data that point to the fact that there truly is a problem.”

The legislation, which will be introduced in the House on Tuesday — the sixth anniversary of the attacks — would require the federal government to collect data to better understand the extent of ground zero-related illnesses. It also would provide compensation to anyone exposed to asbestos and other contaminated dust, including rescue workers, office workers, students and even tourists who were in Lower Manhattan on Sept. 11.

Mrs. Clinton, taking time away from her presidential campaign to attend the rally, appeared to stake out a position similar to that of Rudolph W. Giuliani as the 9/11 candidate.

“From the first moment that I came to ground zero on the day after the attacks on our city and our country and saw the conditions under which the firefighters and police officers and E.M.T.’s and paramedics were laboring,” she told the crowd, which included many 9/11 first responders, “I knew we were going to have problems, that people would get sick, and that people would die from what they were exposed to.

“And I pledged to myself, and I pledge to all of you, that I will stay with you every step of the way until we get every single person the health care they deserve,” she said. Doing that, she added, “will be my highest priority, whether I am your senator or I am your president.”

Mrs. Clinton drew cheers from the crowd and posed for pictures with labor leaders before leaving the stage. Both she and Mr. Giuliani are expected to return to ground zero on Tuesday to commemorate the attacks.

In a day of fiery speeches, Mr. Nadler provided perhaps the harshest assessment of the government’s response to the problems of people who became sick in the aftermath of 9/11.

“Government officials at all levels took perilous shortcuts on workers’ safety,” he said. “Many of you toiled for months on that toxic pile at ground zero without proper protection. You were unnecessarily exposed to hazardous toxins because of what the government officials said and did.”

The rally also featured Carole King, who led the crowd in singing “You’ve Got a Friend.” Union leaders held the rally yesterday in lieu of the annual Labor Day parade.

Dr. Robin Herbert, the director of the World Trade Center monitoring and treatment program based at Mount Sinai Medical Center, said about 4 in 10 of its patients have had breathing problems like asthma, and many suffer mental health problems like post-traumatic stress disorder.

A task force appointed by Mayor Bloomberg has estimated that as many as 400,000 people might have been exposed to dust from the collapsed trade center towers. And in March, Mr. Bloomberg asked the Senate for at least $150 million a year for monitoring and treatment.

The new legislation takes elements from several bills that have failed to get through Congress. The City Council speaker, Christine C. Quinn, said she would make the legislation “the top priority” when she and other members of the Council visit Washington this month.

    Rally at Ground Zero Aims to Build Support for 9/11 Health Care Legislation, NYT, 9.9.2007, http://www.nytimes.com/2007/09/09/nyregion/09rally.html

California’s Ambitious Health Plan Stalls

September 9, 2007
The New York Times
By KEVIN SACK

SACRAMENTO, Sept. 7 — After losing much of August to a budget impasse, state lawmakers and Gov. Arnold Schwarzenegger have been unable to reach agreement on a proposal to extend health coverage to all uninsured Californians, raising the possibility of a special session of the Legislature and a statewide ballot measure.

Last January, in the afterglow of a triumphant legislative session and an easy election to a second term, Mr. Schwarzenegger proposed coverage for all 6.7 million uninsured Californians. Vowing that his state would lead the nation, the moderate Republican made his plan the centerpiece of a new “postpartisan” politics.

But with the Legislature speeding toward adjournment next week, enactment of Mr. Schwarzenegger’s proposal is far from certain. Though there is consensus on the issue’s urgency, there is no agreement on either the breadth or the financing of a health plan.

Given the national fanfare that accompanied Mr. Schwarzenegger’s announcement, and the sense that this nonelection year may afford a narrow window of opportunity, some experts say failure in California may arrest the national momentum behind health care reform.

“Failure to get something done here will have the effect of throwing a wet blanket on the national debate,” said Dr. Robert K. Ross, president of the California Endowment, a nonprofit health policy group.

Mr. Schwarzenegger, who vowed in last year’s campaign to resist tax increases, has added a late wrinkle by suggesting that he and the lawmakers should enact the outlines of a plan but leave the financing — i.e. the tax increases — to a ballot initiative.

A primary reason for doing so would be to circumvent lawmakers from the governor’s own party, whose votes would be needed to build the two-thirds majority required to raise taxes in California. It also would give Mr. Schwarzenegger a measure of political cover.

Asked in an interview whether he was prepared to renege on his tax pledge, Mr. Schwarzenegger said it would not be his doing if voters agreed to expand health coverage by raising a broad-based tax, like the sales tax.

“Not me, not me,” he said. “This is going to be one where we’ll let the people make the decision to fund this.”

Though polls indicate that Californians are fed up with the health care system, they may not be eager to vote for the substantial tax increases needed to pay for universal coverage. But the governor, who was rebuffed by voters in a series of 2005 ballot measures, sounded confident he could sell this one.

“I think the timing is right,” he said, seated in his cigar-smoking tent in the courtyard of the smoke-free Capitol. “And if you go out and explain it to the people, market it the right way, I think we have a shot at doing it.”

Would that not require campaigning for a tax increase?

“I would encourage the people to vote for our health care reform because it is the best investment they can make,” he said. “When you talk about spending a dollar to make two, this is the perfect example.”

Mr. Schwarzenegger’s proposal has always relied on contributions from employers, hospitals and doctors, though he has chosen to call them fees. Fee increases, unlike tax increases, do not require two-thirds approval.

His original plan would have raised $12.1 billion to provide free or subsidized insurance to those without it and to increase the state’s lowest-in-the-nation Medicaid reimbursement rates. The plan also includes financial incentives to encourage preventive care in an effort to contain rising health costs.

Mr. Schwarzenegger has emphasized the need for “shared responsibility” for universal coverage. He proposed to assess doctors 2 percent of their gross receipts and hospitals 4 percent of net patient revenue. Employers with more than 10 workers who did not offer health benefits would pay 4 percent of their payroll. By spreading the pain, the plan has made plenty of enemies.

This week, however, the California Hospital Association announced its support after calculating that most hospitals would gain more from increased reimbursement than they would lose from the 4 percent payments. The state medical association, which figures that almost all doctors would be net losers, has fought the plan.

Mr. Schwarzenegger, who never converted his proposal into a detailed bill, said he would insist that individuals be required to have insurance, thus expanding the risk pool, and that insurers be required to cover everyone regardless of health status. Of the four states that have passed plans with the goal of full coverage, only Massachusetts has mandated individual coverage.

Legislative lawyers shifted the political calculus in June when they concluded that Mr. Schwarzenegger’s proposed assessments on medical providers would qualify as tax increases. The Assembly speaker, Fabian Núñez, and the Senate president pro tem, Don Perata, both Democrats, then fashioned a bill that would require employers to spend at least 7.5 percent of their payrolls on health care.

Due to labor concerns about the cost of premiums for workers, the Democratic plan would not make insurance mandatory, and it would cover only 69 percent of the uninsured. With negotiations stalled, both chambers plan to pass the bill early next week, fully expecting Mr. Schwarzenegger to veto it before calling a special session, said Steven R. Maviglio, a spokesman for Mr. Núñez.

Mr. Núñez said he would prefer a legislative solution to a ballot initiative. “There’s no reason for a Democratic-controlled Legislature to pass a shell bill on the possibility that six months from now the voters would approve it,” he said, adding that a sales tax increase would be regressive and unpopular.

Mr. Perata described the discussions about broad-based taxes as “a fundamental shift in the governor’s position” and said pragmatism dictated incremental progress. “But this governor likes to play on a big stage,” he said, “and this is a big play.”

Mr. Schwarzenegger said he did not enter politics to think small.

“Why limit ourselves?” he asked. “Why should we say we are just like the rest of America, that we are not capable? California has always had the attitude that anything is possible, and let us lead and inspire the rest of the nation to follow us.”

    California’s Ambitious Health Plan Stalls, NYT, 9.9.2007, http://www.nytimes.com/2007/09/09/us/09health.html

American Girls' Suicide Rates Spike

September 6, 2007
By THE ASSOCIATED PRESS
Filed at 11:44 p.m. ET
The New York Times

ATLANTA (AP) -- The suicide rate among preteen and young teen girls spiked dramatically in a disturbing shift that federal health officials say they can't fully explain.

For all young people between ages 10 to 24, the suicide rate rose 8 percent from 2003 to 2004 -- the biggest single-year bump in 15 years -- in what one official called ''a dramatic and huge increase.''

The report, based on the latest numbers available, was released Thursday by the Centers for Disease Control and Prevention and suggests a troubling reversal in recent trends. Suicide rates had fallen by 28.5 percent since 1990 among young people.

The biggest increase was in the suicide rate for 10- to 14-year-old girls. There were 94 suicides in that age group in 2004, compared to 56 in 2003, a 67 percent increase. The rate is still low -- fewer than one per 100,000 population.

Suicide rates among older teen girls, those aged 15-19 shot up 32 percent; rates for males in that age group rose 9 percent.

''In surveillance speak, this is a dramatic and huge increase,'' Dr. Ileana Arias said of the overall picture. She is director of the CDC's National Center for Injury Prevention and Control.

More research is needed to determine whether this is a trend or just a blip, said one child psychiatrist, Dr. Thomas Cummins of Children's Memorial Hospital in Chicago. ''We all need to keep our eye on this over time to see if this is a continuing trend.''

Overall, there were 4,599 suicides among young people in 2004, making it the third-leading cause of death, surpassed only by car crashes and homicide, Arias said. Males committed suicide far more often than females, accounting for about three-quarters of suicides in this age group.

The study also documented a change in suicide method. In 1990, guns accounted for more than half of all suicides among young females. By 2004, though, death by hanging and suffocation became the most common suicide method. It accounted for about 71 percent of all suicides in girls aged 10-14; about half of those aged 15-19; and 34 percent between 20-24.

''While we can't say (hanging) is a trend yet, we are confident that's an unusually high number in 2004,'' said Dr. Keri Lubell, a CDC behavioral scientist who was one of the study authors.

Scientists speculated that hanging may have become the most accessible method.

''It is possible that hanging and suffocation is more easily available than other methods, especially for these other groups,'' Arias said.

The CDC is advising health officials to consider focusing suicide prevention programs on girls ages 10-19 and boys between 15-19 to reverse the trends. It also said the suicide methods suggest that prevention focused solely on restricting access to pills, weapons or other lethal means may be of limited success.

As for why rates are up, Richard Lieberman, who coordinates the suicide prevention program for Los Angeles public schools, said one cause could be a rise in depression during tumultuous adolescent years.

''There's a lot of pressure in and around middle school kids. They're kind of all transition kids. They're turbulent times to begin with,'' he said. ''The hotline's been ringing off the hook with middle school kids experimenting with a wide variety of self-injurious behavior, exploring different ways to hurt themselves.''

Arias said the declining use of antidepressants in those age groups might play a role. But it's ''not the only factor'' that health officials will be studying.

Four years ago, federal regulators warned that antidepressants seemed to raise the risk of suicidal behavior among young people, so black box warnings were put on the drugs' packaging.

When partial teen suicide data was published earlier this year, experts noted at the time that the drop in sales of the drugs corresponded with a rise in the suicide rate. Now there is concern that some children who need the medication aren't getting it.

''Suicide is a multidimensional and complex problem,'' Arias said. ''As much as we'd like to attribute suicide to a single source so we can fix it, unfortunately we can't do that.''

More education is needed, some specialists said, so that teachers, parents and others can quickly spot troubled teens.

''It underscores the need for more evaluation methods for school personnel and pediatricians to be able to better identify at-risk youth,'' said Dr. Alec Miller, director of the adolescent depression and suicide program at Montefiore Medical Center in New York. ''They are out there, and everyone needs to be better trained in identification.''

He said people who commit suicide tend to have a psychiatric condition, even if it has not been formally diagnosed.

Arias said warning signs include mental illness, alcohol and drug use, family dysfunction and relationship problems.

''For some, talking about suicide is awkward,'' she said. ''Our goal is to stop suicides, and to do that we need everyone's willingness to talk about it.

------

On the Net:

http://www.cdc.gov/ncipc/dvp/suicide

    American Girls' Suicide Rates Spike, NYT, 6.9.2007, http://www.nytimes.com/aponline/us/AP-Teen-Suicides.html

Bipolar Soars as Diagnosis for the Young

September 4, 2007
The New York Times
By BENEDICT CAREY

The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers report today in the most comprehensive study of the controversial diagnosis.

Experts say the number has almost certainly risen further since 2003.

Many experts theorize that the jump reflects that doctors are more aggressively applying the diagnosis to children, and not that the incidence of the disorder has increased.

But the magnitude of the increase surprises many psychiatrists. They say it is likely to intensify the debate over the validity of the diagnosis, which has shaken child psychiatry.

Bipolar disorder is characterized by extreme mood swings. Until relatively recently, it was thought to emerge almost exclusively in adulthood. But in the 1990s, psychiatrists began looking more closely for symptoms in younger patients.

Some experts say greater awareness, reflected in the increasing diagnoses, is letting youngsters with the disorder obtain the treatment they need.

Other experts say bipolar disorder is overdiagnosed. The term, the critics say, has become a catchall applied to almost any explosive, aggressive child.

After children are classified, the experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side effects like rapid weight gain.

In the study, researchers from New York, Maryland and Madrid analyzed a National Center for Health Statistics survey of office visits that focused on doctors in private or group practices. The researchers calculated the number of visits in which doctors recorded diagnoses of bipolar disorder and found that they increased, from 20,000 in 1994 to 800,000 in 2003, about 1 percent of the population under age 20.

The spread of the diagnosis is a boon to drug makers, some psychiatrists point out, because treatments typically include medications that can be three to five times more expensive than those for other disorders like depression or anxiety.

“I think the increase shows that the field is maturing when it comes to recognizing pediatric bipolar disorder, but the tremendous controversy reflects the fact that we haven’t matured enough,” said Dr. John March, chief of child and adolescent psychiatry at the Duke University School of Medicine, who was not involved in the research.

“From a developmental point of view,” Dr. March said, “we simply don’t know how accurately we can diagnose bipolar disorder or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness. The label may or may not reflect reality.”

Most children who qualify for the diagnosis do not proceed to develop the classic features of adult bipolar disorder like mania, researchers have found. They are far more likely to become depressed.

Dr. Mani Pavuluri, director of the pediatric mood disorders program at the University of Illinois, Chicago, said the label was often better than any of the other diagnoses often given to difficult children.

“These are kids that have rage, anger, bubbling emotions that are just intolerable for them,” Dr. Pavuluri said, “and it is good that this is finally being recognized as part of a single disorder.”

The senior author of the study, Dr. Mark Olfson of the New York State Psychiatric Institute at the Columbia University Medical Center, said, “I have been studying trends in mental health services for some time, and this finding really stands out as one of the most striking increases in this short a time.”

The increase makes bipolar disorder more common among children than clinical depression, the authors said. Psychiatrists made almost 90 percent of the diagnoses, and two-thirds of the young patients were boys, said the study, published in the September issue of The Archives of General Psychiatry.

About half the patients were identified as having other mental difficulties, mostly attention deficit disorder.

The children’s treatments almost always included medication. About half received antipsychotic drugs like Risperdal from Janssen or Seroquel from Astrazeneca, both developed to treat schizophrenia.

A third were prescribed so-called mood stabilizers, most often the epilepsy drug Depakote. Antidepressants and stimulants were also common.

Most children took a combination of two or more drugs, and 4 in 10 received psychotherapy.

The regimens were similar to those of a group of adults with bipolar diagnoses, the study found.

“You get the sense looking at the data that doctors are generalizing from the adult literature and applying the same principles to children,” Dr. Olfson said.

The increased children’s diagnoses reflect several factors, experts say. Symptoms appear earlier in life than previously thought, in teenagers and young children who later develop the full-scale disorder, recent studies suggest.

The label also gives doctors and desperate parents a quick way to try to manage children’s rages and outbursts in an era when long-term psychotherapy and hospital care are less accessible, they say.

In addition, drug makers and company-sponsored psychiatrists have been encouraging doctors to look for the disorder since several drugs were approved to treat it in adults.

Last month, the Food and Drug Administration approved one of the medications, Risperdal, to treat bipolar in children. Experts say they expect that move will increase the use of Risperdal and similar drugs for young people.

“We are just inundated with stuff from drug companies, publications, throwaways, that tell us six ways from Sunday that, Oh my God, we’re missing bipolar,” said Dr. Gabrielle Carlson, a professor of psychiatry and pediatrics at the Stony Brook University School of Medicine on Long Island. “And if you’re a parent with a difficult child, you go online, and there’s a Web site for bipolar, and you think: ‘Thank God, I’ve found a diagnosis. I’ve found a home.’ ”

Some parents whose children have received the diagnosis say that, with time, the label led to effective treatment.

“It’s been a godsend for us,” said Kelly Simons of Montrose, Colo., whose son Brit, 15, was prone to angry outbursts until given a combination of lithium, a mood stabilizer, and Risperdal, which was often given to children “off label,” several years ago. He now takes just lithium and is an honor roll student.

Other parents say their children have suffered side effects of drugs for bipolar disorder.

Ashley Ocampo, 40, of Tallahassee, Fla., whose 8-year-old son is being treated for bipolar, said that he had tried several antipsychotic drugs and mood stabilizers and that he had improved.

“He has gained weight,” Ms. Ocampo said, “to the point where we were struggling find clothes for him. He’s had tremors and still has some fine motor problems that he’s getting therapy for. But he’s a fabulous kid. And I think, I hope, that we’re close to finding the right combination of medications to help him.”

    Bipolar Soars as Diagnosis for the Young, NYT, 4.9.2007, http://www.nytimes.com/2007/09/04/health/04psych.html?hp

New Schizophrenia Drug Shows Promise in Trials

September 3, 2007
The New York Times
By ALEX BERENSON

In a clinical trial of about 200 patients, an experimental drug from Eli Lilly reduced schizophrenia symptoms without the serious side effects of current treatments, according to a paper published yesterday in the journal Nature.

The drug must still be evaluated on many more patients to test for the possibility of side effects that have not yet emerged, and it is at least three to four years from completing regulatory review.

But schizophrenia researchers said the trial’s results were surprising and impressive, especially since the drug works in a different way from existing antipsychotic medicines, all of which have serious side effects, including substantial weight gain and tremors.

Lilly will begin a larger clinical trial for the drug this month. If that trial confirms the results seen so far, the new drug could mark a breakthrough in the treatment of schizophrenia — and open the way to a broad new class of treatments for the disease. Schizophrenia, a devastating mental illness that affects 1 percent of adults, or about 2.5 million in the United States, usually begins in the late teens or 20s and is marked by psychotic delusions as well as social withdrawal and cognitive impairment.

“This is potentially one giant step forward for patients,” said Dr. Jeffrey Lieberman, chairman of the psychiatry department at Columbia and the lead investigator on a federally sponsored clinical trial of schizophrenia medicines. “This drug may turn out to be not just a comparably good antipsychotic agent, but a better antipsychotic agent.”

Dr. Lieberman has not been involved with the development of the medicine and does not receive any payments or consulting fees from Lilly.

The new drug also has the potential to be a blockbuster for Lilly. Medicines for schizophrenia and bipolar disorder are the fourth-best selling class of medicines in the United States, with sales of $12 billion in the United States and $18 billion worldwide last year.

The troubled history of Zyprexa, another antipsychotic medicine from Lilly, will lead regulators and psychiatrists to scrutinize the new medicine closely for hidden dangers, Dr. Lieberman said. When it introduced Zyprexa in 1996, Lilly hailed it as a breakthrough with fewer side effects than older drugs. But Zyprexa causes severe weight gain, and the American Diabetes Association has linked it to diabetes. Internal Lilly documents show that the company played down Zyprexa’s side effects, worrying they would hurt sales.

Despite that history, psychiatrists will be eager to see whether the new Lilly medicine works, since the existing drugs are of limited help for many patients. Existing schizophrenia medicines, whether older drugs such as Thorazine or newer medicines like Zyprexa, all work by blocking the brain’s dopamine receptors.

But the new Lilly drug does not directly affect dopamine. Instead, it modulates brain activity through a different set of receptors. As a result, it has the potential to be the first truly novel treatment for schizophrenia since Thorazine was introduced 1954, Dr. Lieberman and other researchers said.

Lilly’s new drug — which does not have a name yet and is referred to as LY2140023 — emerged from almost two decades of research by Dr. Darryle D. Schoepp, a toxicologist and pharmacologist who joined Lilly in 1988.

For decades, psychiatrists have known that users of PCP, a street drug sometimes called angel dust, have symptoms nearly identical to those of people with schizophrenia. By the 1980s, scientists had discovered that PCP blocked brain receptors that are triggered by an amino acid called glutamate. This led some companies and scientists to study ways to stimulate glutamate receptors as a treatment for schizophrenia.

But the brain has many different kinds of glutamate receptors, and figuring out how to stimulate or block them in medically beneficial ways has proved complicated. Instead of focusing on the receptors blocked by PCP, Dr. Schoepp concentrated on modulating the action of glutamate receptors in the brain’s prefrontal cortex, an area responsible for personality and learning.

“This is a system that is so fundamental to the function of your brain that it is quite powerful,” said Dr. Schoepp.

But because drugs that blocked dopamine had been the only successful schizophrenia treatments, many researchers viewed the glutamate pathway as unlikely to produce useful medicines, said Dr. P. Jeffrey Conn, director of the Vanderbilt University drug discovery program and an expert on glutamate research.

Dr. Schoepp deserved praise for persuading Lilly to invest in a field that appeared to be a long shot, Dr. Conn said, adding, “He locked in very early.”

As a result, Lilly appears to have a multiyear lead over its competitors in glutamate drugs, Dr. Conn said. Dr. Schoepp left Lilly in March to become the head of neuroscience research for Merck. Dr. Schoepp and Dr. Steven Paul, the president of Lilly Research Laboratories, both said that his departure would not hurt the development of Lilly’s new medicine

Dr. Joseph T. Coyle, a professor of psychiatry and neuroscience at Harvard Medical School, said the Lilly trial validated the theory that modulating glutamate receptors might control the symptoms of schizophrenia. Even if this drug fails in later trials, companies and scientists are likely to pursue glutamate research more aggressively, he said.

“When you see a company that comes up with something that’s completely different, completely out of the box, that attracts attention,” Dr. Coyle said.

Existing drugs are reasonably good at treating the hallucinations and delusions of schizophrenia. But they are far less effective at treating the so-called negative symptoms of the disease — the lack of motivation and emotion that leave many patients unable to work or have normal social relationships. The side effects of existing medicines, which affect nearly all patients, are also severe. Older drugs like Thorazine often cause tics and movement disorders, while newer medicines typically have fewer effects on movement but can cause weight gain and other metabolic changes.

In the clinical trial whose results were reported yesterday, LY2140023 had none of those side effects and appeared to work about as well as Zyprexa at reducing symptoms. In the trial, which was conducted in Russia from August 2005 to June 2006, patients were given the experimental drug, Zyprexa or a placebo. About 100 patients received the experimental medicine.

For the drug to be approved, Lilly will need to replicate the results in larger trials. This month, Lilly will begin a trial with 870 patients to determine the most effective dose of the drug. That trial is expected to be complete in January 2009, and if it is successful Lilly will probably start a large Phase III trial that could cover at least 2,000 patients.

“We have to confirm safety and efficacy with multiple studies,” Dr. Paul of Lilly said. He said he did not want to offer a prediction of when Lilly might ask the Food and Drug Administration for approval. But he said Lilly intended to develop the drug aggressively.

“We are very actively working on this target and related targets because we believe that this mechanism is now validated,” he said.

    New Schizophrenia Drug Shows Promise in Trials, NYT, 3.9.2007, http://www.nytimes.com/2007/09/03/business/03drug.html

Cancer Society Focuses Its Ads on the Uninsured

August 31, 2007
The New York Times
By KEVIN SACK

ATLANTA, Aug. 30 — In a stark departure from past practice, the American Cancer Society plans to devote its entire $15 million advertising budget this year not to smoking cessation or colorectal screening but to the consequences of inadequate health coverage.

The campaign was born of the group’s frustration that cancer rates are not dropping as rapidly as hoped, and of recent research linking a lack of insurance to delays in detecting malignancies.

Though the advertisements are nonpartisan and pointedly avoid specific prescriptions, they are intended to intensify the political focus on an issue that is already receiving considerable attention from presidential candidates in both parties.

The society’s advertisements are unique, say experts in both philanthropy and advertising, in that disease-fighting charities traditionally limit their public appeals to narrower aspects of prevention or education.

But the leaders of several such organizations, including the American Heart Association, the American Diabetes Association and the Alzheimers Association, said they applauded the campaign’s message that progress against chronic disease would be halting until the country fixed its health care system.

As in the past, the heart association is using its advertising dollars these days to promote more rigorous exercise and healthier diets. The most recent cancer society campaign encouraged screening for colon cancer, including a memorable commercial in which a diner plucked — and then ate — a lima bean polyp from the intestinal tract he had carved in his mashed potatoes.

But John R. Seffrin, the chief executive of the cancer society, which is based here, said his organization had concluded that advances in prevention and research would have little lasting impact if Americans could not afford cancer screening and treatment.

“I believe, if we don’t fix the health care system, that lack of access will be a bigger cancer killer than tobacco,” Mr. Seffrin said in an interview. “The ultimate control of cancer is as much a public policy issue as it is a medical and scientific issue.”

The two 60-second television commercials that form the spine of the campaign make that point.

One features images of uninsured cancer patients, appearing hollow and fearful. “This is what a health care crisis looks like to the American Cancer Society,” the narrator begins. “We’re making progress, but it’s not enough if people don’t have access to the care that could save their lives.”

The other commercial depicts a young mother whose family has gone into debt because her insurance did not fully cover her cancer treatment. “Is the choice between caring for yourself and caring for your family really a choice?” the narrator asks.

Census figures released this week show that the number and percentage of people in the United States without health insurance rose last year, to 47 million and 15.8 percent. A 2003 study estimated that one of every 10 cancer patients was uninsured.

Other surveys have found that one of every four families afflicted by cancer, which is projected to kill 560,000 Americans this year, is effectively impoverished by the fight, including one of every five with insurance.

The cancer society plans to buy time on network and cable channels from Sept. 17 to Thanksgiving, said Greg Donaldson, the group’s vice president for corporate communications. There will also be advertisements in magazines and on Web sites.

With nearly $1 billion in revenues, the cancer society is the wealthiest of its peers and has spent about $15 million annually on advertising since 1999. By comparison, Geico, the automobile insurer with the “Caveman” advertisements, spent about $14 million on network advertising in the first quarter of 2007, according to TNS Media Intelligence, a tracking firm.

Advertising about the health insurance crisis is not uncommon among more broadly based medical organizations and other interest groups.

Last week, the American Medical Association kicked off a three-year campaign called “Voice for the Uninsured” that will begin with $5 million in advertising in early primary states. AARP, in conjunction with the Business Roundtable and the Service Employees International Union, recently began a similar effort called “Divided We Fail.”

This year, the cancer society formed a collaborative with the heart, diabetes and Alzheimers associations, as well as AARP, to promote awareness of the health access problem. The group adopted as common principles that all Americans deserve quality, affordable health care with transparent costs.

But the cancer society is the only disease-focused group ever to have dedicated advertising resources to the topic, said officials with other charities and with trade groups.“I’ve never seen anything like it before,” said Bill Novelli, chief executive of AARP and, in a previous career, a co-founder of the Porter Novelli public relations firm. “It’s taking a different tack for them.”

That a charity like the cancer society felt compelled to join the access debate reflects both the urgency and the resonance of the issue. Nonetheless, Mr. Donaldson said it was “risky business” for the tax-exempt group.

It steered away, he said, from promoting solutions that could be viewed as partisan, like mandatory insurance or single-payer government coverage. Rather, he said, the commercials are intended to urge action by the next administration, and to drive viewers to a Web site linked to the group’s advocacy and lobbying arm.

“We very much see a moral imperative to raising the discussion,” Mr. Donaldson said, “but we understand there’s a need to be appropriate.”

Cancer society executives said they had heard little dissent from volunteers and donors, and several regional officials said they supported the new approach.

But others called the campaign misguided. Valerie C. Robinson, a longtime board member of the Jacksonville, Fla., chapter, said expanded access to insurance coverage was “not our fight.”

“To me, it’s throwing away money that we could have put into providing free mammograms or free PSA tests or free colonoscopies,” she said.

Mr. Seffrin initiated the advertising campaign after being pushed by the society’s board to make faster progress toward its goals of reducing cancer death rates by 50 percent and incidence rates by 25 percent from 1990 to 2015. If trends continue, the actual reductions are projected to fall well short, perhaps by as much as half.

While the decline in death rates is accelerating, studies have shown that if cancer was diagnosed more in its early stages, the rates would fall faster. And new research is confirming that insurance status often determines whether a person’s cancer is diagnosed early or late.

One study published this year found that uninsured breast cancer patients were more than twice as likely to have their cancer diagnosed in late stages as those with private insurance. Other studies have found similar results with cancers of the larynx and mouth.

“The truth is we know what’s going to happen with cancer if we don’t intervene,” Mr. Seffrin said. “It will become the leading cause of death in the world, needlessly.”

    Cancer Society Focuses Its Ads on the Uninsured, NYT, 31.8.2007, http://www.nytimes.com/2007/08/31/us/31cancer.html

Obesity Rates Climb in Most States

August 27, 2007
By THE ASSOCIATED PRESS
Filed at 4:30 p.m. ET
The New York Times

WASHINGTON (AP) -- Loosen the belt buckle another notch: Obesity rates continued to climb in 31 states last year, and no state showed a decline.

Mississippi became the first state to crack the 30 percent barrier for adults considered to be obese. West Virginia and Alabama were just behind, according to the Trust for America's Health, a research group that focuses on disease prevention.

Colorado continued its reign as the leanest state in the nation with an obesity rate projected at 17.6 percent.

This year's report, for the first time, looked at rates of overweight children ages 10 to 17. The District of Columbia had the highest percentage -- 22.8 percent. Utah had the lowest -- 8.5 percent.

Health officials say the latest state rankings provide evidence that the nation has a public health crisis on its hands.

Unfortunately, we're treating it like a mere inconvenience instead of the emergency that it is,'' said Dr. James Marks, senior vice president at the Robert Wood Johnson Foundation, a philanthropy devoted to improving health care.

Officials at the Trust for America's Health want the government to play a larger role in preventing obesity. People who are overweight are at an increased risk for diabetes, heart problems and other chronic diseases that contribute to greater health care costs.

''It's one of those issues where everyone believes this is an epidemic, but it's not getting the level of political and policymaker attention that it ought to,'' said Jeffrey Levi, the organization's executive director. ''As every candidate for president talks about health care reform and controlling health care cost costs, if we don't home in on this issue, none of their proposals are going to be affordable.''

At the same time, many believe weight is a personal choice and responsibility. Levi doesn't dispute that notion, but he said society can help people make good choices.

''If we want kids to eat healthier food, we have to invest the money for school nutrition programs so that school lunches are healthier,'' he said. ''If we want people to be more physically active, then there have to be safe places to be active. That's not just a class issue. We've designed suburban communities where there are no sidewalks for anybody to go out and take a walk.''

To measure obesity rates, Trust for America's Health compares data from 2003-2005 with 2004-2006. It combines information from three years to improve the accuracy of projections. The data come from a survey of height and weight taken over the telephone. Because the information comes from a personal estimate, some believe it is conservative.

Indeed, the Centers for Disease Control and Prevention released a study last year noting a national obesity rate of about 32 percent -- a higher rate than was cited for any of the states in the Trust for America's Health report. The CDC's estimate came from weighing people rather than relying on telephone interviews, officials explained.

Generally, anyone with a body mass index greater than 30 is considered obese. The index is a ratio that takes into account height and weight. The overweight range is 25 to 29.9. Normal is 18.5 to 24.9. People with a large amount of lean muscle mass, such as athletes, can show a large body mass index without having an unhealthy level of fat.

A lack of exercise is a huge factor in obesity rates. The Centers for Disease Control and Prevention found last year that more than 22 percent of Americans did not engage in any physical activity in the past month. The percentage is greater than 30 percent in four states: Mississippi, Louisiana, Kentucky and Tennessee.

Meanwhile, Minnesotans led the way when it came to exercise. An estimated 15.4 percent of the state's residents did not engage an any physical exercise -- the best rate in the nation. Still, the state ranked 28th overall when it came to the percentage of obese adults.

Another factor in obesity rates is poverty. The five poorest states were all in the top 10 when it came to obesity rates. An exception to that rule was the District of Columbia and New Mexico. Both had high poverty rates, but also one of the lower obesity rates among adults.

Poverty can lead to less safe neighborhoods, which deter children from playing. It can lead to fewer grocery stores offering fruits and vegetables, and it can lead to greater reliance on fast food, officials said.

''It seems the cheapest foods are the worst ones for you,'' Marks said.

Officials said the report is not designed to stigmatize states with high obesity rates but to stir them into action.

''These are the states where the urgency is the greatest. They need not to wait for others to lead. They need to become the leaders,'' Marks said. ''It's the only way that they can restore the health of their children and their families. It's the only way that they can improve their economic competitiveness.''

------

On the Net:

Trust for America's Health: http://healthyamericans.org

    Obesity Rates Climb in Most States, NYT, 27.8.2007, http://www.nytimes.com/aponline/us/AP-Obesity-Rankings.html

Senate Passes Children’s Health Bill, 68-31

August 3, 2007
The New York Times
By ROBERT PEAR

WASHINGTON, Aug. 2 — The Senate defied President Bush on Thursday and passed a bipartisan bill that would provide health insurance for millions of children in low-income families.

The vote was 68 to 31. The majority was more than enough to overcome the veto repeatedly threatened by Mr. Bush. The White House said the bill “goes too far in federalizing health care.”

But Senator Max Baucus, Democrat of Montana and chief sponsor of the bill, said, “Millions of American children have hope for a healthier future tonight.”

The bill would increase spending on the popular Children’s Health Insurance Program by $35 billion over the next five years.

“Covering these children is worth every cent,” said Senator Orrin G. Hatch, Republican of Utah, who helped create the program 10 years ago.

The House passed a much larger bill on Wednesday, presenting negotiators with a formidable challenge in trying to work out differences between the two measures.

Still, the strong commitment to the issue by Democratic leaders virtually guarantees that they can work out a compromise before Sept. 30, when the program is set to expire. But that compromise is likely to be unacceptable to Mr. Bush.

If Mr. Bush vetoes the bill, the future of the program would quickly become an issue in 2008 campaigns for Congress and the White House, in the context of a broader debate about universal coverage for health care.

The House bill, which passed on a vote of 225 to 204, would increase spending by $50 billion over the next five years. The Senate rejected a proposal by Senator John Kerry, Democrat of Massachusetts, to match that increase — and to cover the extra cost by raising taxes on people with incomes exceeding $1 million a year.

Both bills would raise tobacco taxes. The federal excise tax on cigarettes would rise to $1 a pack under the Senate bill and to 84 cents a pack under the House measure, from 39 cents a pack.

The House bill would sharply reduce federal subsidies paid to insurance companies offering private health plans to Medicare beneficiaries. Many Democrats say these plans, which serve nearly one-fifth of the 43 million Medicare beneficiaries, are overpaid. The Senate bill does not deal with Medicare.

Michael O. Leavitt, the secretary of health and human services, said Congress was jeopardizing health care for millions of needy children by passing bills that “the president will have no choice but to veto.”

Senator Charles E. Grassley of Iowa, a Republican who helped write the Senate bill, said he intended to try to persuade Mr. Bush to sign the legislation that emerges from Congress. But Mr. Grassley said that he would fight the proposed cuts in Medicare payments to private plans.

“It’s a question of equity for rural America,” Mr. Grassley said. “Before 2003, rural Medicare beneficiaries rarely had private Medicare plans to choose from. They did not have the same choices people have in urban America. These plans can be a good choice for people with a chronic illness, for lower-income people and for those who want extra benefits.”

Insurers say the private plans would disappear from many parts of the country if Medicare payments were cut as proposed by House Democrats.

But AARP, the lobby for older Americans, has endorsed the House bill. It says the “excess payments” to private plans cause higher premiums for all beneficiaries, including those in traditional Medicare.

In the final Senate vote, 18 Republicans and 2 independents joined 48 Democrats in supporting the legislation. All the no votes were cast by Republicans.

Senator Debbie Stabenow, Democrat of Michigan, set forth the case this way: “As lawmakers, we have a moral obligation to provide health care coverage for the millions of uninsured children. Health care should be a right, not a privilege, and covering every child is an important step toward this goal.”

But the Senate Republican whip, Trent Lott of Mississippi, said: “If you want to go to government-run, socialistic medicine, this is it, this is the way it’s going to happen. Even my colleagues on the Republican side of the aisle are buying this deal.”

Senator Baucus insisted that “this is not a huge massive expansion. This has nothing to do with national health insurance.”

Under the bill, states can use federal money to pay health care providers or to help families buy private insurance.

Senator Kent Conrad, Democrat of North Dakota, said, “To suggest that this is somehow socialized medicine is one of the most far-fetched arguments I have seen on the Senate floor. This care is provided by private physicians, using private insurance companies.”

Both bills would offer bonus payments to states as an incentive to find and enroll low-income children.

The Congressional Budget Office says the Senate bill would cover 3.2 million uninsured children, including 2.7 million who are currently eligible but not enrolled. The House bill, it said, would cover 4.2 million children, including 3.8 million already eligible for benefits. In addition, both bills would provide money to prevent 800,000 children now on the program from losing coverage.

The current allocations of federal money, totaling $5 billion a year, are not enough for states to maintain their current programs.

Senators of both parties said the bill would help Mr. Bush fulfill a promise he made at the Republican National Convention in New York City on Sept. 2, 2004.

“America’s children must have a healthy start in life,” Mr. Bush said then. “In a new term, we will lead an aggressive effort to enroll millions of poor children who are eligible but not signed up for the government’s health insurance programs. We will not allow a lack of attention, or information, to stand between these children and the health care they need.”

    Senate Passes Children’s Health Bill, 68-31, NYT, 3.8.2007, http://www.nytimes.com/2007/08/03/washington/03health.html

H.I.V. Patients Anxious as Support Programs Cut Back

August 1, 2007
The New York Times
By ERIK ECKHOLM

SAN RAFAEL, Calif. — In the golden hills of Marin County, it is hard to imagine that free food or emergency cab fares could matter much to anyone.

But for hundreds of people who were thrown into poverty by AIDS, like Wade Flores, 45, a former distributor for a chocolate company who lives alone and is getting sicker and weaker, recent cutbacks seem like a matter of life and death.

“These nonmedical services are what keep people like me alive,” Mr. Flores said.

Here and in many other cities, AIDS advocates say, changes in the distribution of federal assistance for indigent H.I.V. and AIDS patients are causing hardship and deep anxiety.

Congress rewrote the Ryan White Care Act in December in ways that expanded the regions eligible for money and allowed less assistance for support programs like meals and legal aid. Five new cities have joined the list of recipients, but without any increase in overall financing.

Because of strict limits on discretionary spending and the competing demands of other health initiatives, the Republican-led Congress and the Bush administration kept appropriations for the Ryan White program at about $2.1 billion over the last several years. At the same time, H.I.V., the virus that causes AIDS, spreads to an estimated 40,000 more people each year, more people are getting tested and seek care, and more patients live longer, requiring medicines costing thousands of dollars a month.

“We have a growing population of needy patients and a growing cost of care, and the funding is not keeping pace,” said Jennifer Kates, director of H.I.V. policy at the Kaiser Family Foundation. “If we have someone in South Carolina not getting medicines and someone in San Francisco not getting housing, how do we choose?”

But Republicans like Senator Tom Coburn of Oklahoma say that with the federal government spending more than $20 billion on AIDS treatment, prevention and research, a stronger focus on prevention and medical care is the main need, not more federal money.

Given the financing limits set by the White House and Congress, administration officials who run the program agree. “We want to make sure that the majority of Ryan White dollars are spent on medical services that can impact the clinical picture of people living with H.I.V.,” said Deborah Parham Hopson, associate administrator for H.I.V./AIDS at the Health Resources and Services Administration. Many regions face “tough decisions,” Dr. Parham Hopson acknowledged.

Patient advocates say that the Ryan White program meets vital needs that other programs do not — Medicaid coverage of care and drugs, for example, varies wildly among states — and that many of the imperiled side services are, as Mr. Flores suggested, nearly as important to patients as medicines.

Advocates say the program has been a godsend for hundreds of thousands of AIDS patients since it was established in 1990 as a “payer of last resort.” It provides aid to hard-hit cities for a wide range of medical and support services, and money to states to help pay for drugs.

“Ryan White is the safety net under the safety net,” said Murray Penner, deputy executive director of the National Alliance of State and Territorial AIDS Directors.

According to federal officials, nearly half the estimated 1.2 million people living with H.I.V. or AIDS are benefiting from Ryan White assistance, which is often passed to nonprofit groups, and one of every four people in antiviral therapy has some of the costs covered by them.

The reauthorization in December followed partisan and regional conflict over how to adjust to the changing nature of the AIDS epidemic, which affects more regions, increasingly afflicts women and members of minorities and has more long-term survivors needing aid.

Southern states with emerging problems argued that the cities where the epidemic began, like San Francisco and New York, were getting an unfair share. The new formula has spread money to five other cities — Baton Rouge, La.; Charlotte, N.C.; Indianapolis, Memphis and Nashville — for a total of 56.

With the pie sliced more thinly, 29 metropolitan areas lost money, compared with last year, while 27 are receiving more.

Among the major recipients, the San Francisco area, including Marin County, saw the greatest cut, 31 percent. Grants to New York City and Atlanta were cut by 7 percent and those for Newark, 9 percent. While the exact tally will change in August when money under a minority AIDS initiative is awarded, the dilution of money will remain.

On July 10, groups helping AIDS patients in New York received a letter from H.I.V. Care Services, which administers the city’s Ryan White money, detailing cuts in 14 activities including housing placement, legal services and nutrition aid.

In Connecticut, where Hartford and New Haven lost large sums, the state is providing some emergency help. But service groups have cut some 65 staff positions, said Shawn Lang, policy director of the Connecticut AIDS Coalition.

“It’s been pretty devastating,” Ms. Lang said.

San Francisco and Marin County have received temporary help from the state and local governments. Still, in Marin County food deliveries have stopped, money for emergency cab rides has shrunk and volunteer “buddy” programs are in danger, according to the Marin AIDS Project.

Mr. Flores, in San Rafael, has lived with H.I.V. for 20 years, but now the antiviral medicines have stopped working. The loss of food boxes and the cutbacks in free rides and other emergency money have left him poorer and more scared.

During his latest hospital stay the other day, he said, “If I decide to keep fighting this disease, I wonder if I’ll get the help I need.”

    H.I.V. Patients Anxious as Support Programs Cut Back, NYT, 1.8.2007, http://www.nytimes.com/2007/08/01/washington/01aids.html

Roberts Facing Medical Option on 2nd Seizure

August 1, 2007
The New York Times
By DENISE GRADY and LAWRENCE K. ALTMAN

Despite his quick recovery from the seizure he suffered on Monday, Chief Justice John G. Roberts Jr. faces a complex diagnosis and a difficult decision.

Because the seizure was his second — he had a similar one in 1993 — he meets the criteria for epilepsy, and he and his doctors will have to decide whether he should take medication to prevent further seizures, said neurologists not involved in his care. (Neither the chief justice nor his doctors would comment yesterday.)

The decision will involve weighing the risk of more seizures against the risk of side effects from the drugs. Major seizures can be a frightening and traumatic experience for patients and family members. Patients are advised to avoid heights and not to swim alone, and many states bar them from driving until they can provide evidence that the disease is under control.

But the drugs can have troubling side effects, including drowsiness or insomnia, weight loss or weight gain, rashes, irritability, mental slowing and forgetfulness. Many patients can be treated with minimal side effects, doctors say, but it may take trial and error to find the right drug.

The chief justice was released yesterday from Penobscot Bay Medical Center in Rockport, Me., one day after being rushed there from his summer home because of the seizure. A statement from the Supreme Court on Monday said that tests at the hospital had found “no cause for concern” and that the cause of the seizure was unknown.

Even though his two seizures occurred 14 years apart, they meet the criteria for epilepsy because they were “unprovoked,” meaning that they were not caused by a head injury, a drug reaction or another known factor.

About 2.7 million people in the United States have epilepsy, and in 70 percent of the cases the cause is unknown, according to the Epilepsy Foundation. Neurologists sometimes describe seizures as an electrical storm in the brain, a brief episode of heightened activity that can cause mild symptoms that are barely noticeable, or loss of consciousness and convulsions, as in the case of the chief justice.

“If he takes medication, he is likely to do fine and be seizure-free,” said Dr. Gregory L. Barkley, a neurologist who specializes in epilepsy and is clinical vice chairman of the neurology department at Henry Ford Hospital in Detroit.

Dr. Barkley said he did not expect the illness or the treatment to affect the chief justice’s ability to do his job.

But if Chief Justice Roberts’s two seizures were so far apart, is another really likely, or likely to occur soon enough to warrant taking a drug every day? Neurologists differ.

“I would recommend taking medication,” Dr. Barkley said. “The intervals tend to get shorter and shorter, and people tend to have recurrent seizures.”

He explained: “The brain learns from practice. The more you practice, the better you get, whether you’re playing the piano or having seizures. The more you have, the more you’re going to have. Most neurologists feel that the best way to intervene is to get the seizures under control as quickly as possible.”

Dr. Robert S. Fisher, director of the epilepsy center at Stanford University and a past president of the American Epilepsy Society, said: “In my view, it would be reasonable not to treat. It sounds like he went 14 years between seizures, and that’s a lot of pills to take to prevent the next seizure 14 years from now. The new ones are better than the old ones in terms of side effects, but they all have potential side effects and risks.”

Doctors say a complete medical workup is needed to find out if the two reported seizures were really the only ones that have occurred, because people with epilepsy can have mild seizures that they are not aware of. Neurologists often ask family members whether patients have certain symptoms, like daydreaming or blanking out for brief intervals, and not snapping out of it when others try to speak to them. Other symptoms may include dizziness, sensations in the stomach, feelings of déjà vu or noticing odd smells or tastes in the mouth — experiences that the patient may not recognize as seizures.

Often, Dr. Barkley said, a patient will report having had one seizure, but when asked about these other symptoms will say, “Oh, yes, that happens all the time.”

If such symptoms are frequent, it may sway the decision in favor of treatment.

Dr. Cynthia L. Harden, a professor of neurology at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, said it would be important to perform brain-wave studies to look for abnormal electrical activity in the brain, to get an idea of where the seizures may be starting and how frequent they are.

Dr. Harden said such studies during sleep were especially useful, and could help in making the decision about treatment. In people with epilepsy, Dr. Harden said, sleep deprivation can be a potent cause of seizures. The chief justice has had a busy schedule recently, including a two-week trip to Europe during which he attended conferences and taught.

Epilepsy is a common condition among Americans. The risk of having a single seizure in one’s lifetime is 9 percent. By Chief Justice Roberts’s age, 52, the risk is 7 percent to 8 percent. About 3 percent of patients have a recurrence, and 1 percent of Americans at any one time are under treatment for epilepsy.

Judd Jensen, a neurologist at Penobscot Bay Medical Center who officials said treated Chief Justice Roberts, declined to answer any questions late yesterday afternoon in his office, which he shares with two neurologists and two cardiologists. “I can’t answer those questions,” Dr. Jensen said.

Dr. W. Allen Hauser, a professor of neurology and epidemiology at Columbia University, estimated that the chief justice had about a 60 percent chance of having another seizure at some point, based on research on other patients who had had two seizures.

“I would say there is no standard recommendation,” Dr. Hauser said. “With multiple seizures, my recommendation generally is to put patients on antiseizure medication, and I think that would be the recommendation of most neurologists.

“That said,” he went on, “the reason one doesn’t immediately put everybody on the medications when they have seizures is that there are side effects to all the medications.”

“Fifteen percent will have some problem with the first drug that will lead to discontinuation and a different drug,” Dr. Hauser added. “Virtually everybody will have some side effects.”

Katie Zezima contributed reporting from Rockport, Me.

Roberts Facing Medical Option on 2nd Seizure, NYT, 1.8.2007, http://www.nytimes.com/2007/08/01/health/01seizure.html?hp